8/3/2019 Payout Request

http://slidepdf.com/reader/full/payout-request 1/2

PAYOUT REQUEST

• The power of compounding:10% return, at t he end of 10 years you w ill have over Rs. 17.5 lakh. If youcontinue investing for another 10 years you end up with over Rs. 63 lakh!

• Superior risk-adjusted returns: We are committed to giving you superiorreturns without taking undue risks. Please visit our website and get thelatest copy of ‘Ensure' to see how well your funds have performed.

If you invest Rs. 1lakh every year and get a • Charges reduce every year: The longer you continue to invest, thelower your average charges turn out to be. Our policies are designedthis way!

• Your policy is a goal based investment: Investments are made toachieve long term goals such as your child's education or building aretirement kitty. Using such investments for immediate needs should

only be a last resort.

Before you fill up this form, please consider these interesting facts:

Name of ProposerFirst Name Middle Name Surname

Policy Number

PRE-ISSUANCE CANCELLATIONApplication Number

FREELOOK

In case of Product & Feature change, please complete the table below :

Change in Product Change in the Policy Feature Policy cancellation & RefundFreelook opt ion executed for:

(Incase of this option please complete thepayment details on the reverse side of the form)

Name of New Product Sum Assured Term Premium Premium Payment Mode

Funds Requir ed:

Name of t he New Fund(s) Percentage

100%Total

Documents Submitted: Welcome Kit / Policy Certificate OR Indemnity Bond (Accepted in case the policy document is lo st/misplaced

by the policy holder)

All fields are mandatory. (Atleast one contact no . is mandatory for pro cessing your request)

Reason for Pre-issuance cancellat ion

Reason for Freelook cancellation

ACKNOWLEDGMENT SLIP

This is to acknowledge the receipt of application for:

Pre-Issuance Cancellation Freelook Cancellation Partial Withdrawal (Amount. Rs.____________________) Surrender/Full Withdrawal

Name of Proposer

Policy Number

Received By

Documents Submitted Welcome Ki t / Policy document Indemnity Bond (Accepted in case the policy

document is lost/misplaced by the policy holder)

IMPORTANT GUIDELINES:• It is mandatory to fill in t he payment details section on the reverse of this form.

• If application for Unit Linked Product is received up to 3:00 pm IST on a weekday (Mon-Fri), the same day’s unit value wil l be applicable. However, if the applicat ion is received after 3:00 pm IST, then the next declaredNAV will be applicable.

• If the policy has been assigned, the request would be accepted on receipt of lett er from the Assignee of the policy.• All communication wi ll be sent to the mailing address registered wi th us. The Company w ill not be liable for any loss arising from non receipt of communication.• Documents required for ANY wi thdrawal transaction: 1. Self attested photo ID proof, 2. Copy of cancelled cheque 3. In case of Partial W ithdrawal, a self attested copy of Policy Certificate is required and in case o

original Policy Certificate is required.In case of application for Surrender along with Reinstatement, the reinstatement is processed on the same working day while the Surrender will be processed on the next working day and the NAV of the date of

processing will be applicable.

f

Freelook or Full Surrender, the•

I understand that my request w ill be processed as per prevailing terms andconditions which might require underwr iting and might result in

postponement, decline, extra premium or additional requirements on mypolicy. Any NAV fluctuations as a result of the freelook change/ refund w illbe passed on to the poli cyholder.

E-Mail ID

Contact Nos.

MobileISDExt. OfficeSTDSTD Residence

Cancelled Cheque Self Attested Photo ID

1

STAMP&

TIME

Date  D D M M Y Y Y Y

Date  D D M M Y Y Y Y

8/3/2019 Payout Request

http://slidepdf.com/reader/full/payout-request 2/2

PAYOUT REQUEST

 _____________________ Signature of Proposer

Note: Request will be processed if the withdrawal requested is greater than or equal to the minimum withdrawal amount mentioned in the policy document

PARTIAL WITHDRAWAL

ICICI Prudential Life Insurance Company Ltd., Vinod Silk Mills Compound, Chakravarthy Ashok Nagar, Ashok Road, Kandivali ( E ), Mumbai 400 101.

Kindly call our Custom er Service T

Call Center t imings: 9.00 A.M. to 9.00 P.M. M onday t o Saturday (except national ho lidays)

oll Free Number 1-800-22-2020 from your MTNL or BSNL line

Communication Address

PercentageName of the Fund(s) Amount (Rs.)

Please select one of the follow ing payout opt ions:

Direct Credit (This will be a direct transfer to your bank account) Cheque Dispatch (Will be sent to the com munication address as per Company records)

FULL SURRENDER

Documents Submitted: Welcome Kit / Policy document OR Indemnity Bond (Accepted in case the policy document is l ost/misplaced

by the policy holder)

Reason for Full sur render ____________________________________________________________________________________________________________ 

Note:units results in termination of the contract and all rights / title and interest under the policy shall stand extinguished.

Amount payable on Surrender/ Full Withdrawal of the units is as per the policy terms & conditions. The Surrender / Full Withdrawal of the

Name of Bank Account Holder

Bank Name

Branch Name

Bank Account Number

Bank Account Type Savings Current

MICR Code (You can get this code from your cheque book)

(You can get this code from your bank)IFSC Code

NOTE:I understand and agree that the submission of this form does not mean that the request will be processed.? I understand that any payout under the policy shall be strictly inaccordance with the policy terms and conditions. Also any payment under shall be subject t o realisation of the last renewal premium payment.?I hereby declare that the particulars given in this form are true, correct and complete in all aspects.?I take full responsibility of genuineness and correctness of t he details filled herein.?If the t ransaction is delayed or not effected at all for any reasons due to incomplete or incorrect information, I shall not hold the company responsible in any manner whatsoever.?Further, I understand that the company shall not be held responsible for any non receipt of payment on account of w rong/ incorrect/ incomplete information given by me in this form.?I also understand and agree that the Company reserves the right to use any alternative payout opt ion.

Reason for Part ial Withd raw al ________________________________________________________________________________________________________ 

2

PAYMENT DETAILS

 _____________________ 

Signature of Assignee

Please affixRe.1 Revenue

Stamp &Sign across

the stamp

Please affixRe.1 Revenue

Stamp &Sign across

the stamp

STAMP&

TIME

     C    o    m    m     /     F    o    r    m     /     P    a    y

    o    u     t     /     1 .     2

 _____________________ Signature of Proposer

(Required in case of Absolute Assignment of policy)

 _____________________ 

Signature of Assignee