INSURANCE

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.
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.

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 High Growth Potential: Unit linked products may be linked to
down significantly after 3rd year resulting in more of your stock market and your investments grows at a fast pace as
premium being allocated towards your funds. ULIP thus help you compared to many other investments.
achieve long term goals.

Life Cover: Once the policy is surrendered the life cover ceases Tax Benefit: You can continue to avail tax benefits under the
and you may not get cover when you actually need it the most. applicable sections of the Income Tax Act, 1961 subject to any
amendment made there to from time to time.
 INSURANCE

Policy Cancellation Form ( Surrender Form )

PLEASE FILL THE FORM IN BLOCK LETTERS

Request Form

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 b) Bank Account No...................................................................................

c) IFSC Code.............................................................................................d) Bank Name............................................................................................

e) Bank Address..........................................................................................f ) Account Holder Name ...........................................................................

Note - Kindly attach a cancelled cheque bearing account number and policyholder name or copy of Bank Passbook along with this Form.

Declaration
I hereby submit that I am the 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./Miss/ Mrs. ____________________________________________________________s /o ,
d /o , w/o__________________________________aged___________resident of______________________________________do hereby declare and affirm that the
details provided in this Form are 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 confirm that the information provided by me herein is true and correct. I confirm and 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. GO STAMP
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

SURRENDER REQUEST CUSTOMER ACKNOWLEDGEMENT SLIP

Policy Number GO STAMP

Received by __________________________Date & Time of Receipt_________________

Max Life Insurance/SUR/Version 2.2/June’13