PSRF169219121808

Comp/Dec/lnt/4917
Acceptance of Surrender Value

To: HDFC Life Insurance Company Limited

Policy No.: <Policy Number> Plan: <Plan name> UIN: <UIN>

The surrender value is (INR) :

Declaration:

I/We hereby surrender the policy at the surrender value provided above, to HDFC Life Insurance Company Limited (hereinafter “Company”) in full and final settlement of all
my/our claims and demands under the given policy and the policy contract is hereby treated as cancelled with immediate effect. I/We understand that surrender of the policy
results in termination of the policy and that I am/We are required to return the original policy document to the Company. I/We hereby agree to indemnify the Company against
all liabilities that the Company may incur on account of any claim being made by any other person, howsoever, once the policy is surrendered as stated above. I/We understand
that policy payouts will be subject to TDS (Tax Deduction at Source) as applicable as per the Income-tax Act, 1961. I/We also understand that if TDS is applicable and a valid PAN
is not submitted as required by law, tax will be deducted at source from the policy payout at higher rate and the tax so deducted and paid to the Government will not be refunded
to the Payee by Company. I/We confirm that I/We have read the terms and conditions and I/We accept the same.

SIGN HERE SIGN HERE In case the policy is assigned, please SIGN HERE

provide signature of the Assignee with

seal (wherever applicable):

Signature of Policyholder 1 Signature of Policyholder 2 (Incase of Joint Life)

DD/MM/YYYY
Date : ________________________ Place : ________________________________________

Declaration made by third party where the Policyholder has affixed his/ her thumb impression/ has signed in vernacular:

The Policyholder has affixed his/her thumb impression/has signed in vernacular/has not filled the application. I hereby declare that the content of this application form has been
explained to the Policyholder in ___________________________ language and have truthfully recorded the answers provided to me. I further declare that the Policyholder has
signed/affixed his/her thumb impression in my presence.
SIGN HERE
Name: _______________________________________________________________________________________________
DD/MM/YYYY
Date: __________________ Place: ______________________________

Address: ______________________________________________________________________________________________ Signature of the Third Person

NEFT mandate already submitted NEFT mandate not submitted yet or if you wish to change the NEFT details (Please fill in the
NEFT Mandate
(Please do not fill in below details) details below for direct transfer of payouts into your bank account through the NEFT facility)

In case of children's plans, where the Beneficiary is a major, then please provide the Beneficiary's account details.

Bank Account No.:

Account Holder Name: _________________________________________________ IFSC (11 Characters)

Bank Name & Branch: __________________________________________________

Account Type: Savings Current NRO NRE

#
All premium(s) paid from NRE Account: ##
Proportion premium(s) paid from NRE Account:

IFSC^: ^11 digit alphanumeric code appearing on your cheque leaf.

NOTE:

A cancelled personalised cheque with account no. and IFSC should be submitted along with this NEFT Mandate. Where the cheque is not personalised, a latest bank statement
or copy of passbook where account number and IFSC are mentioned needs to be submitted with the mandate.
This mandate, upon processing, will override any of the previously tagged NEFT Mandates for all policies, held by the client with HDFC Life.
In case of NEFT failure or any further requirements pending on the mandate, payout will be kept on hold till a fresh NEFT mandate is received.
Intimation regarding the same will be sent to you.
#Refund to NRE account (full or proportionate) will be subject to ratio of premiums paid through NRE Account. Please submit a Bank Statement or Bank confirmation letter as
an evidence for premiums paid through NRE account.
##In case of proportionate payout, please provide two NEFT mandates i.e. for NRE account and non-NRE account.

Declaration:
I/We undertake to refund any amount that is credited to my/our account either in excess or which is not due to me/us at anytime, for any reason and to this effect, I/We confirm
that the particulars given here are true, correct and complete in all aspects. I/We understand and agree that submission of this form does not mean that the request will be
processed. I/We understand that any payout under the policy shall be strictly in accordance with the policy terms and conditions. Also, any payment shall be subject to
realisation of the last renewal premium payment. Further, I/We understand that the Company shall not be held responsible for any non-receipt of payment on account of
wrong/incorrect/incomplete information given by me/us in this form. If a transaction is delayed or has not come into effect at all, due to incomplete or incorrect information,
I/We shall not hold the Company responsible in any manner whatsoever.
SIGN HERE SIGN HERE

DD/MM/YYYY
Date : ________________________ Place : ________________________________________
Account Holder Signature Policyholder signature
(if different from policyholder)

NOTE:
With reference to recent regulatory changes, please submit PAN or Form 60 (if you do not have a PAN) with HDFC Life with immediate effect. Pls update via My
Account/service@hdfclife.com/18602679999/HDFC Life branch. Ignore if submitted.

HDFC Life Insurance Company Limited [Formerly HDFC Standard Life Insurance Company Limited] (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, Help line: 1860-267-9999. Local charges apply. DO NOT prefix any country code. E.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm |
Email: service@hdfclife.com / nriservice@hdfclife.com (for NRI customers only) | Website: www.hdfclife.com