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Surrender Request Form

This document is a surrender request form for a life insurance policy from Bajaj Allianz Life Insurance Company. It requests information to identify the policy such as the policy number, policy holder name, whether the policy has been assigned, and assignee details if applicable. It also requests the number of years premiums were paid, the reason for surrender, and surrender request date. The form must be signed by the policy holder and assignee if applicable. It is accompanied by the policy bond. The document also contains an electronic payment section to select a payment method of NEFT, ECS, or direct credit and provide bank account details for electronic fund transfers.

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528 views

Surrender Request Form

This document is a surrender request form for a life insurance policy from Bajaj Allianz Life Insurance Company. It requests information to identify the policy such as the policy number, policy holder name, whether the policy has been assigned, and assignee details if applicable. It also requests the number of years premiums were paid, the reason for surrender, and surrender request date. The form must be signed by the policy holder and assignee if applicable. It is accompanied by the policy bond. The document also contains an electronic payment section to select a payment method of NEFT, ECS, or direct credit and provide bank account details for electronic fund transfers.

Uploaded by

ranjitkunu
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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BAJAJ ALLIANZ LIFE INSURANCE COMPANY LT

GE Plaza, Airport Road Yerawada, Pune 411006

SURRENDER REQUEST FORM

1. Policy Number ____________________________________

2. Name of Policy Holder ____________________________________

3. Is the Policy Assigned Yes / No

4. Name of Assignee (if (2)above is Yes) _____________________________________

5. Number of years Premium Paid _____________________________________

6. Reason for Surrender _____________________________________

7. Surrender Request Date ____DD____MM_____YYYY

Enclosure : Policy Bond

Signature of Policy Holder Signature of Assignee

Name Name

Date :___DD____MM_____YYYY Date :___DD____MM_____YYYY

Contact No _________________ Contact No _________________

PFOO5
Branch Address & Contact Numbers
BAJAJ ALLIANZ LIFE INSURANCE COMPANY LT
GE Plaza, Airport Road Yerawada, Pune 411006
Electronic Payment:

This mandate is a standing instruction to Bajaj Allianz Life Insurance Co Ltd, to transfer the amount to pe paid to the policy
holder electronically into his bank account.

Electronic Payment Fund Transfer will be applicable to Surrenders, Partial Withdrawal, Cancellation of Proposal, Annuity,
Loans Survival Benefits and Maturity.

Electronic Payout Methods:

Please Tick one of the Options:

National Electronic Fund Transfer (NEFT)

Electronic Clearing System (ECS)

Direct credit (Select Banks)

Note: Cancelled copy of Cheque/ Bank Statement/ Bank Passbook Copy not more than 6 months old as on date to be submitted along
with Electronic Payout Request.

Account Holder Name:

Bank Name:

Branch Name:

Bank Account Number:

Type Of Account: Savings Current

MICR Code

IFSC Code:

The payout mode selected in the Form will be used by company to generate any payouts to the policy holder (Claimant). Payouts
would be done in accordance and subject to terms and conditions of the policy

_____________________________ ___________________________________
Signature of Policy Holder Signature of Bank Account Holder

Banks Verification

Stamp & seal of Bank for Verifying Customers Bank Account Number
PFOO5
Branch Address & Contact Numbers

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