NOMINATION FORM

GUIDELINES:
• Please fill this form clearly in CAPITAL Letters.
• This form needs to be submitted along with the Notice of Nomination (Page 2), in accordance with the terms and conditions (Page 3) mentioned therein.
Policy Number

Name of Policy Holder:

Salutation First Name Surname

Contact Numbers

STD Residence STD Office Ext. ISD Mobile

Please tick the appropriate option and fill the details under their respective headings in the form.
Appointment of Fresh Nominee Appointment of Additional Nominee/s
Change of Existing Nominee/s Cancellation of Nominee/s

APPOINTMENT OF FRESH NOMINEE

I hereby nominate
Salutation First Name Surname

whose date of birth is (DD/MM/YYYY) and residing at

and who is my (relation, if any) to whom all the moneys secured

by the above mentioned policy shall be paid in the event of my death.

In case the nominee is a minor, please fill “Appointee Details” on page 2 of this form.

Signature of the Policy Holder

APPOINTMENT OF ADDITIONAL NOMINEE/S

I hereby nominate
Salutation First Name Surname

whose date of birth is (DD/MM/YYYY) and residing at

and who is my (relation, if any) in addition to the existing

nominee /s and to whom the moneys secured by the above mentioned policy shall be paid in the event of my death.

In case the nominee is a minor, please fill “Appointee Details“ on page 2 of this form.

Signature of the Policy Holder

CHANGE OF EXISTING NOMINEE/S

I hereby cancel the existing nomination in favour of

Salutation First Name Surname

and nominate
Salutation First Name Surname

whose date of birth is (DD/MM/YYYY) and residing at

and who is my (relation, if any) to whom

all the moneys secured by the above mentioned policy shall be paid in the event of my death.

In case the nominee is a minor, please fill “Appointee Details” on page 2 of this form.

Signature of the Policy Holder

Your request will be processed within 4 working days from the date we receive this form.
 CANCELLATION OF NOMINEE
I, hereby revoke the
Salutation First Name Surname
existing Nomination, which is in favour of

Salutation First Name Surname

executed at the day of ,20

Signature of the Policy Holder

APPOINTEE DETAILS: MANDATORY, IF NOMINEE IS A MINOR

The nominee being a minor, I hereby appoint

Salutation First Name Surname

Residing at , whose marital

Status is & date of birth is (DD/MM/YYYY), as the

appointee to receive the moneys secured by the policy during the minority of the nominee executed at

the day of ,20 In consent of

the above appointment I sign hereunder.

Signature of Appointee Signature of the Policy Holder

DECLARATION FOR SIGNING IN VERNACULAR LANGUAGE

Certification where the Life Assured has signed in vernacular or has affixed thumb impression:
Content of this form and its particulars has been explained by me in vernacular to the Executant.

Signature/Thumb impression of the Policy Holder

Name of Witness:
Salutation First Name Surname

Address:
Contact Numbers
STD Residence STD Office Ext. ISD Mobile

Signature of Witness

NOTICE OF NOMINATION
GUIDELINES: • Please fill this form clearly in CAPITAL Letters • This NOTICE needs to be submitted along with your Nomination / Appointee form.
To,
ICICI Prudential Life Insurance Company Ltd.,
Vinod Silk Mills Compound, Chakravarthy Ashok Road,
Ashok Nagar, Kandivali (E), Mumbai - 400 101.
Dear Sir / Madam,
Please effect the following change: (Tick and fill in the particulars for the chosen option in the Form)
Appointment of Fresh Nominee Appointment of Additional Nominee/s Change of Existing Nominee/s
Cancellation of Nominee/s Appointment of Appointee

Salutation First Name Surname

Salutation First Name Surname

Salutation First Name Surname

Salutation First Name Surname

Executed at the day of ,20

I have read and understood all the terms and conditions on Page 4.

Signature of the Policy Holder

 FOR OFFICE USE ONLY:
Spaarc Call ID Date D D M M Y Y Y Y STAMP
&
Scanning Cabinet Received By TIME

Remarks

TERMS AND CONDITIONS – NOMINATION

1. Either a fresh nomination or the existing nomination can be changed to a new nominee by the life assured at any time during the term of the
policy.
2. The registration of fresh / change or cancellation of nomination is subject to the receipt of notice and the form by ICICI Prulife.
3. Immediately after executing the cancellation of nomination the policy form and notice must be sent for registration to our Corporate Address.
4. If the life assured is not conversant with English or is illiterate, the form should be witnessed and the witness needs to certify before such
witnessing that the contents of the nomination form were explained by him to the named life assured in vernacular and that the life assured has
affixed his signature / thumb impression in his (witness’s) presence after thoroughly understanding the same.
5. On assignment of a policy the existing nomination automatically stands cancelled.
6. In case the policy is absolutely assigned to the life assured, then the life assured (assignee) can nominate / change or cancel the nomination
effected by him / her earlier.
7. If the nominee is a minor, an appointee must be appointed to whom the moneys secured by the policy shall be paid in the event of the
assured’s death during the minority of the nominee.
8. A nominee can be added to the existing nominee(s). In case of more than one nominee, a joint discharge voucher would be taken from all the
nominees and the claim proceeds would be paid to the nominee authorised by them.

ACKNOWLEDGEMENT SLIP
This is to acknowledge the receipt of application for: Appointment Of Fresh Nominee
STAMP
Appointment Of Additional Nominee/s Change Of Existing Nominee/s Cancellation Of Nominee &
Vernacular Cases Notice Of Nomination TIME

Policy Number Date D D M M Y Y Y Y

Received By

For any queries, please call Customer Service Number on 1860 266 7766
Call Center Timing 9.00 A.M. to 9.00 P.M. Monday to Saturday (except National holidays). Local charges apply.

Communication Address
ICICI Prudential Life Insurance Company Ltd., Vinod Silk Mills Compound, Chakravarthy Ashok Nagar,
Ashok Road, Kandivali ( E ), Mumbai 400 101.
Comm/Form/Nomination/2.1