Please call 18002660282 to get the ticket no.

______________

Policy Surrender Form

PLEASE FILL THE FORM IN BLOCK LETTERS

Name of the Policyholder: ________________________________________________________________________________

Policy No.: _____________________________Alternate Mobile No.: ____________________________________

Email:
I accept to receive all future communication from Max Life Insurance vide email ID only (strike if you want to continue by hard copies).

Aadhaar No.:
I hereby authorise Max Life to process my payouts to my Aadhaar linked bank account and to use the same to validate/update my KYC details.

C KYC:

Bank Details for NEFT

Account Holder Name: ________________________________________ Bank Name: ______________________________
Bank Account No.: ________________________________________________
IFSC Code: _________________________ PAN Number: ____________________
TDS will be applicable in accordance to Section 194DA of Income Tax Act prevailing at the time of payment. If you
are an NRI, please fill up NRI declaration available at the end of this form and TDS will be governed in accordance to
Section 195.
.
Declaration
I am the policyholder of above mentioned policy. I request you to please process the surrender request and pay the
applicable surrender value post deduction of charges (if any). I do hereby declare and affirm that details provided
herein are true and correct. I understand that that on payment of surrender value my policy along with associated
benefit will cease to exist.
Date: D D M M Y Y Y Y

Place: ________________________________________ Signature of Policyholder

No Objection Certificate from Life Insured (applicable only if Life Insured has turned major)
I, ________________________________________________; hereby confirm the valid discharge of the requested payout
towards the above Policy and will not hold Max Life Insurance liable for any further claim in future.

Place: ________________________________________ Signature of Life Insured

Customer Acknowledgement Slip

We thank you for choosing Max Life Insurance as your preferred insurance partner and hope that you will reconsider
our products in the near future. We regret your decision and hope you have evaluated all the benefits of continuing
with your policy prior to making this application. Your request will be processed within 10 days of submission at our
branch office. In case you need any clarification or assistance regarding your policy, please reach us at the details
given below.

Date: D D
GO Stamp
M M Y Y Y Y
Please Note:
•Your request will be processed; provided the request form has been filled in completely and all mandatory documents have
been submitted
•For Unit Linked Products, if application is received up to 15:00 hrs IST on a business/working day, the same days NAV will be
applicable. However, if application is received after 15:00 hrs, then the next day declared NAV will be applicable
•In case of address change or contact details change request, please fill up a separate Policy Service Request Form and submit
with valid address proof
•Max Life Insurance shall not be held responsible for delay or non-receipt of the cheque in case the postal address is
incomplete / incorrect in company’s records.
•Max Life Insurance will not be responsible in case of non credit to your account or if transaction is delayed or not effected at
all for reasons of incomplete/incorrect information provided or rejected by your bank. In case requisite information for direct
credit is not received or transaction is rejected by bank the payout will be made vide cheque

Mandatory Documents Required for Processing Payout

Original policy document submitted by the policyholder for Surrender request
Self-attested valid copy of Photo ID proof (carry original for verification at Branch)
Original cancelled cheque with pre-printed name & account number
Pass book copy/Bank statement having pre printed name & account number in case cancelled cheque does
not have pre printed name and account number (carry original for verification at Branch)
Latest contact details & NRE bank statement reflecting any premiums paid from NRE account

Branch Mandatory Checklist

All documents are original seen and verified by the Max Life Insurance personnel
Received surrender request on ___________________ at am/pm ________________
Retention efforts made Yes No
Reason for surrender ______________________________________________________
Payout to the customer NEFT Cheque

Max Life or IRDAI, does not call/sms/e-mail, asking you to change your policy to other insurers, promising high returns. Stay Alert & Safe.

Helpline
1860 120 1122

Max Life Insurance Co. Ltd. 3rd Floor, Operation Center, 90-A, Udyog Vihar, Sector-18, Gurugram -122015 (Haryana).

Did you know? Buying a new insurance is expensive than insurance purchased at a younger age. Don't
surrender! You can also opt for partial surrender or loan facility, to meet your fund requirements and continue with
your policy, subject to the terms of your Policy document.

Low Charges: In the Unit Linked Products, the

` charges reduce gradually over the years leading to
High Growth Potential: ULIPS provide the option
Ver: 1.0 Mar 2017

to invest in equity, which provides potential for

a higher proportion of your premium being
higher growth of your funds
invested in the fund.

Life Cover: Once the policy is surrendered the life Tax Benefit: You can avail tax benefit under the
cover ceases thus depriving you of the benefit when section of the Income Tax Act 1961, subject to any
you actually need it. further any amendment
 NRI Declaration Form

If Non Resident (NR) as per Indian Income Tax Act 1961, please fill this form.

Particulars Details

Country of residence

If PAN is available (please provide)

If Tax Residency Certificate

(Certificate issued by Govt. of respective country)

Signed form 10F (format attached)

Permanent Establishment declaration (format attached)

NOTE:
1. TDS would be applicable as per prevailing rate basis country of residency submission of above and
compliance under provision of Section 10 (10D)/Section 10(10A) of the Income Tax Act,1961.
2. In case of non-availability of PAN, no TDS certificate will be issued.

Date: D D M M Y Y Y Y

Place: ________________________________________ Signature of Policyholder

 “FORM NO. 10F”

[See sub-rule (1) of rule 21AB]

Information to be provided under sub-section (5) of section 90 or sub-section (5) of section

90A of the Income-tax Act, 1961

I. . . . . . . . . . . . . . . . . . . *son/daughter of Shri. . . . . . . . . . . . . . . . . . . in the capacity of . . . . . . . .

. . . . . . . . . . . (designation) do provide the following information, relevant to the previous year. .
. . . . . . . . . . . . . . . . . *in my case/in the case of. . . . . . . . . . . . . . . . . . . for the purposes of sub-
section (5) of * section 90/section 90A:—

SI.No. Nature of information : Details#

(i) Status (individual; company, firm etc.) of the assessee :

(ii) Permanent Account Number (PAN) of the assessee if allotted :

(iii) Nationality (in the case of an individual) or Country or specified territory :

of incorporation or registration (in the case of others)

(iv) Assessee’s tax identification number in the country or specified territory :

of residence and if there is no such number, then, a unique number on the
basis of which the person is identified by the Government of the country
or the specified territory of which the assessee claims to be a resident

(v) Period for which the residential status as mentioned in the certificate :
referred to in sub-section (4) of section 90 or sub-section (4) of section
90A is applicable

(vi) Address of the assessee in the country or territory outside India during :
the period for which the certificate, mentioned in (v) above, is applicable

2. I have obtained a certificate to in sub-section (4) of section 90 of sub-section (4) of section

90A from the Government of . . . . . . . . . . . . . . . . . . . (name of country or specified territory
outside India)

Signature: . . . . . . . . . . . . . . . . . . .

Name: . . . . . . . . . . . . . . . . . . .

Address: . . . . . . . . . . . . . . . . . . .

Permanent Account Number: . . . . . . . . . . . . . . . . . . .

 Verification

I. . . . . . . . . . . . . . . . . . . do hereby declare that to the best of my knowledge and belief what is

stated above is correct complete and is truly stated.

Verified today the . . . . . . . . . . . . . . . . . . . day of. . . . . . . . . . . . . . . . . . . .

...................

Signature of the person providing the information

Place: . . . . . . . . . . . . . . . . . . .
 TO WHOMSOEVER IT MAY CONCERN

This is to certify that –

1. The amounts being remitted to us by Max Life Insurance Company Ltd. in <name of the
currency in which remittance is to be made> are in respect of the <nature of business, services
rendered etc.> underlying the scope of agreement between Max Life and us.

2. The amounts are to be remitted to us on our account in <name of the country where the account is
held> and we are beneficiaries thereof.

3. We are a resident in <name of the country> as defined in <give reference of the Article> of the
Double Taxation Avoidance Agreement (treaty) entered into between India and <name of the
country>.

4. It is our firm interpretation that we do not have any Permanent Establishment in India as defined
in the <give reference of the Article> of the treaty rendering <nature of business, services
rendered etc in India, for example Recruitment services, Human Resource services etc>

5. The amounts receivable from Max Life Insurance Company Ltd. is in the nature of “nature of
business, services rendered etc “ and falls under the Articles of the treaties.

6. The place of world assessment of our income is <name of the country>.

Authorized Signatory :

Date:
Place: