Policy Cancellation Form ( Surrender Form )

PLEASE FILL THE FORM IN BLOCK LETTERS

Do you know by cancelling your policy you are losing on-
Your Life cover
Your Rider benefit
Opportunity of earning Long term return on your systematic planned investments.
To know more you can call us at 1800 200 5577 or SMS "RET"at 5424243 or get in touch with your Agent Advisor in case you
need any assistance in understanding your plan or our services.
Reason for Surrender
Financial reasons (Immediate Fund requirements,Purchase of Asset,etc.)
Unsatisfactory returns
Unsatisfactory services
Buying a new plan
Others,please specify
Did you consult any one before taking the decision to surrender:
Agent Friend Relative Others (pls specify)________________________________________
We regret your decision and hope you have evaluated all the benefits of continuing with your policy prior to making this application.We
thank you for choosing Max Life Insurance as your preferred insurance partner and hope that you will reconsider our products in the near
future.
Please Note:
Your request will be processed, provided the request form has been filled in complete and all mandatory documents have been submitted.
For Unit Linked Products if application is received up to 15:00 hrs IST on a business / working day, the same days NAV will be applicable. However, if
application is received after 15:00 hrs, then the next day declared NAV will be applicable
In case of address change or contact details change request, please fill up a separate Policy Service Request Form and submit with valid address proof.
Max Life Insurance shall not be held responsible for delay or non- receipt of the cheque in case the postal address is incomplete / incorrect in company's
records.
Max Life Insurance will not be responsible in case of non credit to your account or if transaction is delayed or not effected at all for reasons of incomplete/
Incorrect information provided or rejected by your bank. In case requisite information for direct credit is not received or transaction is rejected by bank the
payout will be made vide cheque
Mandatory Documents for processing payout
Original Policy document submitted by the Policy holder for Surrender request.
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INSURANCE
Do you know
New insurance is expensive than insurance purchased at a younger age.Don't surrender!
You can also opt for partial surrender to meet your immediate fund requirements and continue with your policy.
Low Charges: In Unit linked products, the charges come
down significantly after 3rd year resulting in more of your
premium being allocated towards your funds. ULIP thus help you
achieve long term goals.
Life Cover: Once the policy is surrendered the life cover ceases
and you may not get cover when you actually need it the most.
High Growth Potential: Unit linked products may be linked to
stock market and your investments grows at a fast pace as
compared to many other investments.
Tax Benefit: You can continue to avail tax benefits under the
applicable sections of the Income Tax Act, 1961 subject to any
amendment made there to from time to time.
Self attested valid copy of Photo ID proof, carry original for verification at Branch.
Original Cancelled Cheque with pre printed name & account number
Pass book copy / Bank statement having pre printed name & account number in case Cancelled cheque does not
have pre printed name and account number, carry original for verification at Branch.
Latest Contact Details. NRE bank statement reflecting any premiums paid from NRE account.
Policy No. Name of the Policy Holder_____________________________________________________
Mobile Number Alternate Mobile No.
Address 1 ____________________________________________________________________________________________________________________________
Address 2 _________________________________________________________________ Email ID__________________________________________________
City ______________________________________________ State ________________________________________________ Pin
Bank Details for NEFT
a) Pan Card
Declaration
.
I hereby submit that I amthe holder of an insurance policy no with Max Life Insurance Company Limited. I would
.
like to voluntarily surrender and terminate the a foresaid Policy I request you to please process the surrender request of my policy and pay the applicable
( ) ( ) . ____________________________________________________________ , surrender value if any after adjusting applicable charges if any I Mr Mrs / Miss . . / / o s
/ , w o__________________________________aged___________resident of______________________________________do hereby declare and affirmthat the d o /
. ,
details provided in this Formare correct and accurate I do hereby agree to receive the surrender value payable under the policy terms and conditions after
. , .
deduction of applicable charges Further I confirmthat the information provided by me herein is true and correct I confirmand stand indemnity towards Max
.
Life Insurance for any incorrect or wrongful refund obtained by me
.
I understand post processing the surrender request for my policy no my life cover for___________________
.
_________________________________________along with other benefits as mentioned in policy contract will cease to exist
______________________________
Signature of Policy Holder Date: Place:
Branch Mandatory checklist
All mandatory documents as listed above are collected.
All copies to be self attested by Policy Owner.
All documents are Original seen and verified by the Max Life Insurance Personnel.
Received Surrender request on at _______:______ am/pm
Retention Efforts made- Yes / No_______________ Reason for Surrender________________________
Pay out to the customer : 1) NEFT process 2) Cheque process
Acknowledgment Slip
We thank you for choosing Max Life Insurance as your preferred insurance partner and hope that you will reconsider our products in the near future. We regret your decision and hope you have evaluated all the
benefits of continuing with your policy prior to making this application. Your Request will be processed within 1 0 days of submission at our Branch office. In case you need any clarification or assistance
regarding your policy, please call 1800 200 5577 Or SMS 'RET' to 5424243.
Max LifeInsurance Co.Ltd.
3rd Floor, Operation Center, 90. A, Udyog Vihar, Sector-18, Gurgaon- 122015,Regd office: Max House 3rd Floor,1 Dr. Jha Marg, Okhla, New Delhi-110020,India Contact Details: Tollfree Customer Helpline:1800.200.55 77
e-mail: service.helpdesk@maxlifeinsurance.com Visit us at: www.maxlifeinsurance.com

b) Bank Account No...................................................................................
c) IFSC Code.............................................................................................d) Bank Name............................................................................................
e) Bank Address..........................................................................................f ........................................................................... ) Account Holder Name
Policy Number
Received by __________________________Date & Time of Receipt_________________
GO STAMP
Max Life Insurance/SUR/Version 2.2/June13
GO STAMP
Request Form
INSURANCE
SURRENDER REQUEST CUSTOMER ACKNOWLEDGEMENT SLIP
Policy Cancellation Form ( Surrender Form )

PLEASE FILL THE FORM IN BLOCK LETTERS
Note - Kindly attach a cancelled cheque bearing account number and policyholder name or copy of Bank Passbook along with this Form.
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