Notice of Assignment Date D D M M Y Y Y Y
To,
Reliance Nippon Life Insurance Company Ltd.
Unit Nos. 401B, 402, 403 & 404, 4th Floor, Inspire-BKC, G Block, BKC Main Road,
Bandra Kurla Complex, Bandra East, Mumbai - 400051. India.
All the information is to be filled in BLOCK LETTERS.
I/We (name of the assignor) F I R S T M I D D L E L A S T
as the owner/s of the policy no. issued by
Reliance Nippon Life Insurance Co. Ltd. hereby give you notice that I/We have absolutely/conditionally assigned the said policy to Mr./Mrs./Ms. (name of the assignee)
on D D M M Y Y Y Y as per the endorsement annexed to this notice.
We request you to register the assignment in your records and acknowledge the same to me/us and Mr./Mrs./Ms. (name of the assignee).
Details of the Assignee
Name of the Assignee F I R S T M I D D L E L A S T
Father's Name Date of Birth D D M M Y Y Y Y
Gender Male Female Transgender Marital Status Unmarried Married widower Divorced
Occupation Salaried Self Employed/Business Other Annual Income
Photo of Assignee
Nature of Duties_________________________________________________ Source of fund/Income___________________________________________
Residential status: Indian Non Resident Indian (NRI) Country, if NRI _________________________________
Residence for Tax purposes in Jurisdiction(s) outside India Yes No (If Yes, then mandatory to fill the FATCA/CRS declaration)
Residence Address F L A T N O.
B U I L D I N G R O A D N A M E / N O.
L A N D M A R K 1
D I S T R I C T / T A L U K A L A N D M A R K 2
C I T Y / V I L L A G E S T A T E Pin Code
STD ISD Code L A N D L I N E M O B I L E EMAIL ADDRESS
Permanent Address
M O B I L E 1 M O B I L E 2 EMAIL ADDRESS
PAN Number Provided Yes No
Relationship with Assignor
Immediate family Father Mother Spouse Son Daughter
Other Individual Friend Others Pl specify________________________
Institutional Entity Bank/Financial institute Society Trust Others Pl specify
Are Advisor/SMrelated to the Assignee? Yes No If Yes, to whom and what is the relationship? ______________________
Whether the Life to be Insured/Proposer/Nominee(s)/Appointee(s)/Premium payor is/are Politically Exposed Person(s)* Yes No
(*Politically Exposed Persons (PEPs) are individuals who are or have been entrusted with prominent public functions. PEP norms may also be applied to the accounts of the family members or close
relatives of the above referred individuals.)
Terms of Assignment
Future premium will be paid by Assignor Assignee (Premium Payor cannot be Bank/Financial Institute)
Mktg/Notice of assignment/V9/Mar022
Identity Proof Aadhar Card Passport Pan Card Others_____________________
Address Proof Electricity Bill Bank Statement Aadhar card Others_____________________
Income Proof_________________________________(as
Reliance Nippon Life Insurance Company Limited.per mentioned
IRDAI in AMLNo:
Registration KYC121.
Matrix)
Registered & Corporate Office: Unit Nos. 401B, 402, 403 & 404, 4th Floor, Inspire-BKC, G Block,
BKC Main Road, Bandra Kurla Complex, Bandra East, Mumbai - 400051. India. T +91 22 6896 5000. For more information or any grievance, 1. Call us between 9am to 6pm, Monday
to Saturday on our Toll-Free Number 1800 102 1010 or 2. Visit us at www.reliancenipponlife.com or 3. Email us at: rnlife.customerservice@relianceada.com. Trade logo displayed
above belongs to Anil Dhirubhai Ambani Ventures Private Limited & Nippon Life Insurance Company and used by Reliance Nippon Life Insurance Company Limited under license.
Beware of Spurious / Fraud Phone calls: IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving such phone
calls are requested to lodge a police complaint.
Page 1 of 3 CIN: U66010MH2001PLC167089
Notice Of Nomination
Dear Sir / Madam,
Please make the following changes
Appointment of Fresh Nominee(s)/Change of Existing Nominee(s) as given below
Name Of Nominee Date Of Birth Mobile No & E-Mail ID Communication Address Relationship With Assignee Share%
*In case the nominee is a minor, please fill appointee details Share% should total to 100
Appointees Details : Mandatory if Nominee is a Minor
The nominee(s) being a minor, I hereby appoint as the appointee(S) to receive the moneys secured by the policy during the minority of the nominee(s)
Name of
Name Of Appointee(s) Date Of Birth Mobile No & E-Mail ID Communication Address Relationship With Nominee Nominee
Name & Signature of Nominee Name & Signature of Appointee
Bank account details of Assignee (If Individual)
Bank Account Details
Policy Holder Name as per Bank Records
Bank Name Branch
Bank Account No IFSC Code
*Payment will be credited to the given bank account except in the case where the banks are not participating in Electronic Clearing
Signature of the Assignor Signature of the Assignee
Name Name
Date D D M M Y Y Y Y Date D D M M Y Y Y Y
Place Place
Instructions
1. A ll fields are Mandatory
2. All the information is to be filled in BLOCK LETTERS.
3. The term Assignor stands for the current policyholder, who intends to assign the policy, whereas the term Assignee stands for the person in whose favour the policy is to be
assigned
4. The Assignment of a policy shall automatically cancel any nomination made in the policy, except for assignment in favour of Reliance Nippon Life Insurance Company Limited
(wherever applicable) in which case the rights of the nominee would get affected to the extent of the Company s interest in the policy (Section 39(4)) of Insurance Act 1938)
5. The company expresses no opinion as to the legality or validity of the assignment
6. In case of Reassignment to the Life Assured, please ensure that a fresh nomination is made, since the original nomination stood cancelled at the time of assignment
7. This Assignment shall not be effectual against the company unless this Notice of Assignment and Endorsement are duly filled and completed in all respects and delivered
along with original policy document to nearest branch of Reliance Nippon Life Insurance Company Limited
8. In case the Assignment is in favour of a Financial Institution/Bank, please affix stamp of the Financial Institution/Bank and countersigned by the Authorised Signatory
9. In case the Assignment is in favour of a relative (i.e. the father, mother, spouse or child of the assignor), documentary proof (preferably ration card) mentioning the relation
therein should be produced along with this form
10. In case the Assignee is other than a Bank/Financial Institution/Relative, please furnish Identification Proof, Residential Proof and Income Proof of the proposed Assignee
11. The witness should be above 18 years of age and competent to contract
12. Self-attestation mandatory on KYC & Income Proof for assignor/Assignee
13. Post Registrations of Assignment, Assignee has to fill Nomination and bank account details separately
14. If Assignee wants to pay premium through our own business/firm's bank account, in that case we need to fill Third Party Declaration Form from customer for our
Mktg/Notice of assignment/V9/Mar022
record purpose.
15. Source of declaration required -if premium paid through cash or DD
Reliance Nippon Life Insurance Company Limited. IRDAI Registration No: 121. Registered & Corporate Office: Unit Nos. 401B, 402, 403 & 404, 4th Floor, Inspire-BKC, G Block,
BKC Main Road, Bandra Kurla Complex, Bandra East, Mumbai - 400051. India. T +91 22 6896 5000. For more information or any grievance, 1. Call us between 9am to 6pm, Monday
to Saturday (except public holidays) on our Toll Free Number 1800 102 1010 or 2. Visit us at www.reliancenipponlife.com or 3. Email us at: rnlife.customerservice@relianceada.com. 4.
Chat with us on our WhatsApp number (+91) 7208852700. Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited & Nippon Life Insurance Company
and used by Reliance Nippon Life Insurance Company Limited under license.
Beware of spurious phone calls and fictitious/fraudulent offers. IRDAI clarifies to public that: 1. IRDAI or its officials do not involve in activities like sale of any kind of insurance or
financial products nor invest premiums. 2. IRDAI does not announce any bonus. Public receiving such phone calls are requested to lodge a police complaint along with details of
phone call, number.
Page 2of 3 CIN: U66010MH2001PLC167089
Endorsement Form Date D D M M Y Y Y Y
I/We (name of the assignor) F I R S T M I D D L E L A S T
as the owner/s of the policy no. issued by
Reliance Nippon Life Insurance Company Limited on the life of Mr./Mrs. (name of the Life Assured)
with Sum Assured of Rs. hereby give you notice that I/We have assigned the said policy
to Mr./Mrs./Ms. (name of the assignee) on D D M M Y Y Y Y
Type of Assignment (Select whichever applicable)
I/We have Absolutely Assigned the policy to the assignee mentioned above Or
I/We have Conditionally Assigned the policy to the assignee mentioned above on the condition that in the event of (state the event on the happening of which, the assignment shall be
inoperative) , the said policy shall revert to me/us without any further act or deed on the part of the said assignee.
Consideration (Select whichever is applicable)
I/We have received a sum of Rs. as consideration from the said assignee with respect to the
referred assignment Or
I/We have assigned the policy out of natural love and affection only
Signature of the Assignor Signature of the Assignee
Name Name
Date D D M M Y Y Y Y Date D D M M Y Y Y Y
Signature of the Witness
Name
Date D D M M Y Y Y Y
Address
If the signature is in vernacular language, please complete the following declaration
I hereby declare that I have fully explained/translated the contents mentioned in the Assignment form to
F I R S T M I D D L E L A S T
and I further declare that he/she/they fully understood the meaning there of.
Signature of the Declarant Date D D M M Y Y Y Y
(Declarant should not be an employee/advisor of Reliance Nippon Life Insurance)
Name & Address of the Declarant F I R S T M I D D L E L A S T
Correspondence Address/ Usual place of residence F I R S T L A S T F L A T N O.
B U I L D I N G R O A D N A M E / N O.
L A N D M A R K 1
D I S T R I C T / T A L U K A L A N D M A R K 2
C I T Y / V I L L A G E S T A T E Pin Code
STD ISD Code L A N D L I N E M O B I L E 1 EMAIL ADDRESS
I hereby confirm that I have been explained the content in (Language) and have understood the same.
Signature of the Policyholder Date D D M M Y Y Y Y
--------------------------------------------------------------------- For office use ----------------------------------------------------------------------------
We Reliance Nippon Life Insurance Co. Ltd have recorded the assignment of policy no.
on the life of
by the policyholder
Mktg/Notice of assignment/V9/Mar022
with effect from D D M M Y Y Y Y (date of receipt of notice of assignment by the company)
In recording the assignment, the company does not express any opinion on the legality or validity of the assignment. For Reliance Nippon Life Insurance Company Limited
Authorised Signatory
Reliance Nippon Life Insurance Company Limited. IRDAI Registration No: 121. Registered & Corporate Office: Unit Nos. 401B, 402, 403 & 404, 4th Floor, Inspire-BKC, G Block, BKC Main
Road, Bandra Kurla Complex, Bandra East, Mumbai - 400051. India. T +91 22 6896 5000. For more information or any grievance, 1. Call us between 9am to 6pm, Monday to Saturday (except
public holidays) on our Toll Free Number 1800 102 1010 or 2. Visit us at www.reliancenipponlife.com or 3. Email us at: rnlife.customerservice@relianceada.com. 4. Chat with us on our WhatsApp
number (+91) 7208852700. Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited & Nippon Life Insurance Company and used by Reliance Nippon Life Insurance
Company Limited under license.
Beware of spurious phone calls and fictitious/fraudulent offers. IRDAI clarifies to public that: 1. IRDAI or its officials do not involve in activities like sale of any kind of insurance or financial
products nor invest premiums. 2. IRDAI does not announce any bonus. Public receiving such phone calls are requested to lodge a police complaint along with details of phone call, number.
Page 3 of 3
