REQUEST FOR CHANGE IN PERSONAL DETAILS

Change in Personal Details: Life Assured Proposer

Barcode
Policy Number Date D D M M Y Y Y Y
Name
Mr./Ms./Mrs. First Name Surname
Contact Nos.
STD Residence STD Office Ext. ISD Mobile

ISD Alternate Mobile

Address
Pin Code

E-Mail ID Alternate E-Mail ID

*CKYC Number/KIN (If available)
*To know your CKYC/KIN identifier visit the web Portal (www.karvykra.com or www.cvlkra.com)
All fields are mandatory. (Atleast one contact no. is mandatory for processing your request. The Contact details mentioned above will be updated for all future communication)
Note: If the life assured's details are being updated on account of auto-vesting,updation of the Life Assured's contact details, email ID and address is mandatory. The remaining details
need not be filled.
Aadhaar consent is mandatory in case of submission of masked Aadhaar copy for any servicing request.
Documents required: 1) Recent Photograph 2) PAN 3) Any of the (OVD) Officially valid document (List of OVDs is mentioned below)

Change in Name Proposer Life Assured Appointee Nominee (Please fill the Name as you want it to appear)

Mr./Ms./Mrs. First Name Middle Name Surname

Documents required:
1) Recent Photograph
2) Any of the (OVD) Officially valid document (List of OVDs is mentioned below)
3) Supporting proof ( Marriage Certificate / Gazette Copy / Adoption Deed / Divorce Deed)

Change in Address

Landmark Pin Code

Documents required:
1) Recent Photograph
2) PAN
3) Any of the (OVD) Officially valid document (List of OVDs is mentioned below)

Change in Date of Birth Proposer Life Assured Joint Life Assured Appointee Nominee DOB D D M M Y Y Y Y
GUIDELINES
• DOB change is allowed only once in a policy lifetime.
• DOB changes are subject to underwriting.
• Change in DOB may lead to change in charges.
• In case of corrections, the fluctuation in ULIP policies ( change in NAV) would be borne by the Company. In case of request from the customer for change in DOB, the fluctuation in
ULIP policies ( change in NAV) would be borne by the policy Holder.
• The increase in premium due to change in DOB, if any, has to be paid by the policy holder. The difference due to decrease in premium on change in DOB, if any, Shall be refunded
to the policy holder post deduction of applicable charges.
• The taxes on the above would be applicable at the prevailing tax rates.
• The funds in the contract may change on rectification of DOB.
• Post Dob changes, in case the customer is not eligible for the product, a suitable plan, if any, would be offered as per our underwriting norms. If it is not possible to grant any other
plan, Policy would be cancelled and would be refunded as per policy terms and condition.
• The above rules would be applicable to all other contracts held by the policy holder and changes would be effected in all, irrespective of specific request being received for these.

Request for Updating PAN

Kindly submit PAN/Form 60 (as defined under Income Tax Act, 1962), if not already submitted at the time of applying for the policy. Also PAN/Form 60 is mandatory where the
premium amount exceeds ` 50,000 in a Financial year. The premium payment can be done only through the acceptable premium collection modes. Where any
customer/policyholder wishes or proposes to make any payment in cash, it can be accepted up to the limit of ` 49,999/- only at the authorized collection points.
PAN eligible Yes No Reason of not being eligible for PAN
PAN Number
Name (as it appears on
the PAN Card)
Document Submitted: PAN Card Copy Form 60 Declaration in lieu of PAN

Request for updating GST (If available)

GST Number
Name (as it is
registered under GST)
Document Submitted: GST registration certificate
I confirm that the GST number provided by me is correct.

ACKNOWLEDGEMENT SLIP
This is to acknowledge the receipt of application for change in:

Name Address Contact Details Email ID Date of Birth Identity Proof Address Proof GST Number
Residential Status
STAMP
Policy Number Date D D M M Y Y Y Y &
TIME
Received By
Change in Residential Status
• Current residential status____________________ New Residential Status ____________________ for taxation purpose for the current financial
year_______________ and here onwards.
• Document submitted for current address __________________________________________________________________________________________________
Documents required:
1) Recent Photograph
2) Any of the (OVD) Officially valid document (List of OVDs is mentioned below)
3) Signed request letter
4) In case of residential status to be changed to NRI from Indian Resident then: NRI Questionnaire, self-attested passport copy,NRI address proof.

OVD Officially valid documents

- Passport
- Proof of possession of Aadhaar (First 8 digit of Aadhaar should be in the masked form)
- Driving License
- Voter ID card issued by Election Commission of India
- Job card issued by NREGA duly signed by an officer of the State Government
- Letter issued by the National Population Register containing details of name, address or any other document as notified by the Central
Government in consultation with the Regulator

I have voluntarily submitted my aadhaar card and hereby give ICICI Prudential Life Insurance Company Ltd. my consent to use and store my
aadhaar details for the purposes of processing/servicing this insurance policy. I was provided with options of submitting OVDs other than Aadhaar

Signature of Policy Holder (Proposer): _____________________ Signature of Assignee* / Trustee#: _____________________

(*Required in case of Absolute Assignment of Policy)
(#Required in case of Policy covered under MWPA)

Note: I have understood the meaning and scope of the change request form and take complete responsibility of the changes submitted by me. Any changes in the Policy
/ Personal Details are subject to the policy terms and conditions and relevant underwriting guidelines.

I/we agree that the PAN details and other information provided by me/us in this form maybe used by the Company to download/verify/ register/ update my/our KYC
documents on/from the CERSAI* CKYC portal for processing this request, any future applications, or any other requests. I/We understand that only the acceptable
officially valid documents would be relied upon for processing any requests/applications.(*Central Registry of Securitisation and Asset Reconstruction and security
Interest of India.)

DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any
changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that ICICI
Prudential reserves the right to take appropriate action.

Applicable when the Proposer is illiterate or suffering from disability due to which writing is restricted or the proposer has signed in vernacular language.
Note: Must be witnessed by someone other than the advisor/agent/employee of the Company.

COMP/DOC/Apr/2024/124/5857
I (Full name of Witness) _______________________________________________________ (Relation with Proposer) ____________________ adult and
inhabitant of (Address) _________________________________________________________________________________________________________________
do hereby declare that I have read and explained the contents of this form to the Proposer and he/she/they have understood the same.

____________________________
Signature of Witness
Comm/Form/Personal_Policy/1.7

FOR OFFICE USE ONLY:

ER Request submitted by C S CR CS
STAMP
Spaarc Call ID Date D D M M Y Y Y Y
&
Scanning Cabinet Received By TIME

Remarks

Kindly call our Customer Service Number 1800 2660 (toll-free)

Call Center timings: 10.00 A.M. to 7.00 P.M. Monday to Saturday (except national holidays)

Communication Address
ICICI Prudential Life Insurance Co. Ltd., Unit No. 901A, 901B, 1001A & 1002B, Prism Towers, Mindspace, Link Road, Goregaon (West), Mumbai-400104.