LIC

LIFE INSURANCE CORPORATION OF INDIA

S.V. APPLICATION

HEA-M/ sodeoco Dor-|/ Bengaluru Division-ll

APPLICATION FOR SURRENDER VALUE

IraT ALfu/ SI Branch Address: fit/aOd Date :

FATT/ e|Place

uferft ter/902 So. / Policy No.

Name of Life AsSured
q a t / |Address

Name and Address of the Paying Authority

qGA/a | Designation

sor do. /Present Badge No. &Dept. No.

DeaS | JtAO | Last Premium Paid / Recovered

Previous Place of working

Designation, Badge No. and Dept. No.

with previous Employer

TDO dosoe ? / Is the Policy under Loan ?

BANK ACCOUNT DETAILS:
Name of the Bank: Branch :
Alc. No. Whether NEFT Form submitted

Idesire to surrender the above policy. Icertify that the information given above is true and correct.
2) Óu ATT/9dsPOB rdones seA | Give reasons for Surrender :

Signature of the Life Assured)

-a BsO8 /Cut Here

LIC
UFE INSURANCE CORPORATION OF INDUA

}G HT-|/3orteodo aar-ll/ Bengaluru Division-il

IrGT Atau/o | Branch Address:

yrfcit . / aÔN Jo.

Policy No. Application No. Date of Receipt

ees : 1) (ddodo) Fl for TeT/ Surrender Application

2) aO 2900/ eit qIAT/Policy Bond

DM/ 02-25 dotbo / Initials

 Form No. 3510/5074

LIC
LIFE INSURANCE CORPORATION OF INDIA
BENGALURUDIVISION -I|
Re. :Policy No.
IWe hereby declare that /We have not servedon any office of the Life Insurance Corporation of India, notice of
assignmernt or re-assignment in respect of the above policy except those, if any, already registered by the Life
Insurance Corporation of India, or the Insurer who issued the above Policy nor shall We serve on any office of
the said Corporation,any notice of assignment or re-assignment before payment of the Surrender Value.
Signature ofAssured
Signature ofAssignee(s).
Name ofAssured
(in BLOCK LETTERS)

Address

RECEIPT FORTHE SURRENDER VALUE OF POLIGY

Policy No.
On the Life of

for Rs. dated

I/We

do hereby acknowledge receipt fromLife Insurance Corporation of India, the sum of Rupees*

being the Surrender Value including Cash Value of Bonus of the above mentioned
Policy, which is herewith delivered upto the said Corporation to be cancelled. In witness whereof these presents
are subscribed by melus at
the day of 20
(Name of Place) (Date) (Month)

Surrender Value** (inclusive of Cash Value of Bonus) Rs.

Less:
Loan Rs.
Interest on loan upto Rs.

Premium due from to Rs.

Interest on overdue premium Rs.

Other Charges (to be specified) Rs. Rs.

NET PAYABLE: Rs.

English knowing Witness:

Signature Re. 1/
Revenue
FullName Stamp to be
affixed if
GROSS
Occupation : Surrender
Value exceeds
Address Rs. 500/

Signature
*Gross Amount of Surrender Value ** Delete where inapplicable [P.T.O.
 -2

NOTE: Illiterate persons must affix their thumb marks which should be identified by the attesting Magistrate
under the seal of his office or a Block Development Officer or a Gazetted Officer or a Principal/Head
Master of Local High School or Higher Secondary School run by the Government or an Agent of a
Nationalised Bankor a Class-| Officer of the Corporation or a Development Officer of the Corporation
with atleast 5 years service provided he/she is fully satisfied about the identity of the person/s
executing the form. Signatures in regional languages must be attested by respectable English
knowing persons. The witness attestingsuch signatures or thumb marks should sign the declaration
below.

"The contents of this discharge form have been explained to

and he/she/they has/have signed the same/put thumb impression afterfully understanding the same".

SEAL OFOFFICE (IFANY)

Signature of the Witness

"If the within written receipt is signed by more than one person and payment is desired to be made to only
one of them, then following Note ofAuthority must be completed and signed by all of them before a Magistrate or
a Justice of the Peace or a Gazetted Officer or a Block Development Officer or a Principal/Head Master of Local
High School or Higher Secondary School run by the Government or an Agent of a Nationalised Bank or a Class-I
Officer of the Corporation or a Development Officer of the Corporation with atleast 5 years service provided
he/she is fully satisfied about the identity of the executants. The Letter of Authority wil also be required if
paymentis to be made to a Bank.

IWe hereby authorise and request LIFE INSURANCE CORPORATION OF INDIA, to pay the above
mentioned amount of Rs. to
(Name of theauthorised Bank/ Person)

Signature by the party or parties

within-mentioned in the presence of :

(Signature in ful)

Signature of Magistrate or J.P. etc. with

Seal of the Office

" hereby certify that the contents of this Note of Authority were explained by me in vernacular to

and he/she they has/they have agreed to payment being made to

the party or parties authorised.

Magistrate or J.P. etc. with

Seal of the Office

*This Letter ofAuthoriy must be signed before aMagistrate or Justice ofthePeace or aGazetted Oficer ora
Block Development Officer ora Gazetted Oftcer or aPrincipa/Head Master ofLocal High School/Higher Secondary
School run by the Government or an Agent of a Nationalised Bank or a Class-I Officer of the Corporation or a
Development Officer of the Corporation with atleast 5years service when the Note of Authority is evecuted by an
illiterate or vernacular knowingperson/s.
DM/ 11-23
 LIC
LIFE INSURANCE CORPORATION OF INDIA
ANNEXURE I

BENGALURU DIVISION-I RETENTION OF INSURANCE COVER

Date

Questionnaire to be submitted by the Policyholder with Surrender Application / Discharge Form.

Policy No.
Name of the Policyholder
Question Question Exit interview undertaken by Branch Office
No.

1. Urgent financial need.

2. Not satisfied with Terms &Conditions of the Plan.
Reasons for Surrender of
1. 3. Not satisfied with service.
the LIC Policy ?
4. Any other reason:.

2.
Are you aware that Surrender of policy YES / NO
shall result into loss of Life Cover ?

3.
Are you aware that Surrender of policy YES / NO
may be financially disadvantageous ?

YES / NO
Are you aware of the apprOximate Rs.
4.
Surrender Value for your policy ?
Signature of the Policyholder
I hereby declare that I have understood the various aspects of Surrender of my policy and I am signing the
Discharge Form after understanding the same.

Signature of the Policyholder:

Name of the Policyholder :
Address:.

Mobile / Contact No.

E-mail Id: [P.T.O.
 LIC ANNEXURE II
LIFE INSURANCE CORPORATIONOF INDIA
BENGALURUDIVISION-II EXIT INTERVIEW Date

Certificate of Exit Interview conducted at Branch Office / Divisional Office

Policy No. : Name of the Policyholder :.

Date of Request for Surrender :
Question Question Exit interview undertaken by Branch Ofice
No.

1. Urgent financial need.

2. Not satisied with Terms &

Reasons for Surrender of Conditions ofthe Plan.
1
the LIC Policy ?
3. Not satisfied with service.

|4. Any other reason.

Is the Policyholder aware that

2. Surrender of LIC policy may incur YES /NO
a loss ofLife Cover ?

Is the Policyholder aware that

3. Surrender of LIC policy may be YES /NO
financially disadvantageous ?

YES /NO
Is the Policyholder aware of the
4. approximate Surrender Value?
SV Amount : Rs.

Iherebydeclare that I have conducted the Exit Interview (Personally / over Telephone) at.
.(Place), on. (date), at. Hrs.

Signature of the Official who conducted the Exit Interview :.

Name of the Official who conducted the Exit Interview:
S.R. No. Cadre:
DMJ02-25
Branch / Divisional Office
 9LIC NATIONAL ELECTRONIC FUNDS TRANSFER- MANDATE FORM

EINSURANCE CORPORATION OF INDIA

To / o t ,

LIFE INSURANCE CORPORATION OF INDIA /20d8eod Bes Ari

Branch / 3

Sub. : Receipt of policy payment through NEFT /.J.R.3. shoNE do D3 wn

lam giving below the details of my Bank Account for receiving policy payment through NEFT.

(1) Policy Nos. / DORrie tos, :

1 4

2 5

3 6

Name of policy holder/claimant /l oORTDDo/ odd ido

(2) Bank Name /2208 Btdo:
(3) Bank Branch Address / wotJ OHOt SOT

(4) Account Type / sD`o aDO:(Mention the type of your Account -Ja Odob dododb 2dobo)
Savings / Current /Cash Credit / NRI eNOOO/230O/ nio zOO/NW•R OUBeos •T

(5) Account No. I oatO3:

(Bank AcCOunt No. should be written from left to right / Jt WOoJ IOo)

(6) IFSCode / SA OBE :

(7) Mobile No. / sdoio zo, :

(8) E-mail ID / - e g SOK

(9) Are you willing to receive SMS /E-mail, on matters related to your LIC policies : YES/ NO

Ihave enclosed the following document to this effect. (PleaseVappropriate item)

(A) Cancelled Cheque Leaf / daioRd eat ot.

(B) If cheque is not having the name of Bank Account holder, then Photo Copy of the
page of Bank Pass Book containing details of Bank Accounts No., IFS Code

DM / 02-25 Signature of the policy holder / 90ROO r

 Branch/TOI:

LIC
FE I N S U R A N C E C O R P O R A n O M T 4
LIFE INDIA

BENGALURU DIVISION -II

SDd^ SDF JE3 (NEFT - NATIONAL ELECTRONIC FUND TRANSFER) 70ads ,0E° D`Otb tdriso

1) Reado odas ap srDFB (NEFT) JOdBesto?

2) o.J.R.J. (NEFT) Sod OBOJOn/J8doD / 3osðOdOR Gros sROBoeieo:

3) .a.J.3. (NEFT) odotbsWd SsNDNSeTDd tozdsne:

aAOGDI`0Odortzseeo. 3d0 drRrds sd, Jortbas oBries. 8) RoR odBeatbd so`rio FEMA

(P.TI.O.
 LIFEINS URANCE CORPORATION OF INDIA
(sec-285BAof the income tax act 1961 relating to FATCA/CRS reporting)

*Tax Reside ncy Is your country of Tax Residency outside India ? Y/ N

pol nu Imber.e ooos Name of policyholder

If yes,
6l the Self Certification Form I hereby declare that the detall furnís hed above is true and
correct to the best of my kaowiedge and belief and Iundertake to inform you of any
change therein immediately. In case the above information is found to be false or untrue
or misleading or misrepresenting, Iam aware that Imay be held liab le for it. Mobile
mumber of the Proposer/ Life to be assured: E mail id of the Proposer/ Life to be assurd:
Signature / Thunb inpression of the Life to be assured

Signature othe policy hokder/assignee