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Payout Form

Policy No.: Date:

Dear Sir,

With reference to the above policy please process (Tick the appropriate, below)

1) n ULIP-Surrender n Traditional Surrender (Tick Appropriate)2) Partial Withdrawal Amount `

3) Refund - Excess money paid

4) Loan Maximum loan available / Amount `

5) Re-Issue / Revalidate the cheque (Enclose stop payment indemnity / stale cheque)

*For ULIP products NAV, please refer point no. 2 of terms and conditions section on page 2.

Name of the Policy Holder:

Address:

City: State:

Mobile No: Landline: Email ID:

n Signature proof attachedn Surrender charges informed to the customer from LA (For surrender of ULIP policy)n Request received time stamp to be affixed

In case of ULIP surrender

Current Fund value (Indicative)

Surrender charges

*Surrender value (Indicative)

*This is an indicative surrender value depends on the effective NAV rates, please refer point no. 2 of T&C section on page 2.

Signature of Policy holder Date

Selection of Payment option (Tick Appropriate)

n Direct Transfer to my bank account. (Cancelled cheque is mandatory)1.n Remit payment through cheque (Cheque will be sent to the communication address as per company records).

1Further the cheque should bear the name of the policyholder/account holder's name and IFSC / RTGS / NEFT Code. In the eventthe details are not appearing on the cheque leaf, the applicant needs to submit a recent statement from the bank issuing thecheque where all such details are available. The bank a/c number should be clear & visible (please do not cross on a/c no.). In case,such details are not available, the payment would be released by cheque. Policy holders signature to be taken on cancelled cheque.

A Reliance Capital Company

Attach Cancelled Cheque Here

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Policy holders name as per bank records:

Bank Name:

Branch Name:

Bank Account Number:

IFSC Code: (Mandatory only for bank Transfer)

Please verify that account number matches with the cancelled cheque/bank statement attached and counter sign.

Name & Sign of CE Branch Stamp & Date

Terms & Conditions (T&C):

1. Incase of Surrender/Partial Withdrawal Certain charges will be deducted as mentioned in the terms & condition in the policydocument.

2. For ULIP Products, if the request is received:

2.1 Before 3.00 p.m, NAV of date of application shall be applicable.

2.2 After 3.00 p.m, NAV of the next working day shall be applicable.

3. The contract shall conclude upon payment of the surrender money and the same shall be treated as valid discharge forcompany (RLIC)

4. RLIC shall not pay any money against surrender, partial withdrawal, refund of excess money or loan amount in the form of Cash.

5. If the electronic credit is not effected, delayed or credited to a wrong account on account of incorrect or incompleteinformation provided, RLIC shall not be held liable now or in future for such losses.

6. In the event the credit is not effected by your Banker for any reason, RLIC reserves the right to make the payment throughcheque/DD.

7. All the above requisitions shall be processed as per the terms and conditions as laid in the policy contract and will be binding.

I understand and agree to all the above terms and conditions as referred above.

Signature of Policyholder with Date

Customer Acknowledgement

Policy No.: Date: Service Request No:

In case of ULIP surrender

Current Fund value (Indicative): Surrender charges: Surrender value (Indicative):

Name & Sign of CE Branch Stamp & Date

A Reliance Capital Company

Reliance Life Insurance Company LimitedRegistered Office: H Block, 1st Floor, Dhirubhai Ambani Knowledge city, Navi Mumbai, Maharashtra-400710, India

Reliance Life Insurance Company Limited is a licensed life insurance company registered with the Insurance Regulatory and Development Authority(Registration No: 121) in accordance with the provisions of the Insurance Act 1938

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(Tear here)