Registered Office: 6th Floor, Vaman Centre, Makhwana Road, Off Andheri - Kurla Road,

Andheri (E), Mumbai - 400 059. Call Centre: 1-800-22-7000 www.birlasunlife.com

Registration No. 109

POLICY SERVICE REQUEST FORM
[Kindly fill in BLOCK LETTERS only. ]

Policy No.

Client name
(Title) (First Name) (Surname)

1. PERSONAL DETAILS (Tick the relevant box)

A) Change of Address

Landmark

City State Pin code

(Mandatory)

B) Change in Contact details

Tel Tel
(Resi) (Off)
STD Code Tel No. STD Code Tel No.

Mobile E-mail
STD Code
C) Name Change*

Policy Owner Life Insured

From
(Title) (First Name) (Surname)

To
(Title) (First Name) (Surname)

*A certified true copy of the supporting document should be enclosed

2. CHANGE IN PREMIUM PAYMENT MODE/ METHOD (Tick the relevant box)

A) Premium Mode to Annual Semi Annual Quarterly Monthly #

B) Premium method to Direct Cheque Credit Card # E.C.S.#

#
Electronic Clearing Service (ECS) & Credit Card facility is available across all modes. Monthly modes are available only through ECS or credit card.
For availing these facilities, an ECS Mandate form with a cancelled cheque, or a Credit Card Authorisation form with photocopies of the front and
reverse of the Credit Card, will be required. You can download the forms from our website www.birlasunlife.com or call 1-800-22-7000 for the same.
3. INVESTMENT FUND SWITCH

A) Switch of Funds for Flexi Save Plus/Flexi Cash Flow/Flexi Life Line/Single Premium Bond: (Protector, Builder,
Enhancer)

From: To:

B) Switch of Funds for Flexi SecureLife Retirement Plan (Pension Plan): (Nourish, Enrich, Growth)

From: To:

C) Switch of Funds for ClassicLife (Protector, Builder, Enhancer, Creator, Magnifier)#

/ Flexi SecureLife II Retirement Plan (Pension Plan): (Nourish, Enrich, Growth)#

For ClassicLife / Flexi SecureLife II Retirement only

Name of the new fund
%
%
%
%
%
Total 100 %
# Switch of funds will be applicable to accumulated funds only and not for future premium allocation.
To change the distribution of future premiums, kindly fill in the below section.

4. DEPOSIT ALLOCATION (FUTURE PREMIUM)

Funds for ClassicLife (Protector, Builder, Enhancer, Creator, Magnifier)*

/ Flexi SecureLife II Retirement Plan (Pension Plan): (Nourish, Enrich, Growth)*
For ClassicLife / Flexi SecureLife II Retirement only
Name of the new fund
%
%
%
%
%
Total 100 %

* Change of allocation will apply to future premium only and will not change distribution of accumulated funds.

Please read all instructions before signing the form

• The switching of funds will be effected at unit prices of the same day provided the request is submitted and accepted at the
company's office before 4.15 pm and on the next working day's unit prices if the request is submitted and accepted at the
company's office after 4.15 pm.
• 2 Switches are free per policy year. For details on charges, please refer to policy contract.
• The total percentage allocation should add up to 100%. Any residual amount will be allocated to “Protector” / “Nourish”
Investment Fund depending on the plan
• The Minimum Values of a Policy are subject to the Investment Fund option opted at inception remaining unchanged through the
life of the policy, and other conditions as mentioned in the Minimum Values Pages.
• This application will be effective only if it is officially accepted by Birla Sun Life Insurance Company Limited.

I hereby declare that I understand and agree to all the conditions & information given above.

Signature of the Policy owner / Assignee/ Trustee

Date
d d m m y y y y