REQUEST FOR CHANGE IN POLICY DETAILS

Policy Number Date D D M M Y Y Y Y Barcode

Name of Proposer
Mr./Ms./Mrs. First Name Surname

Contact Nos.
STD Residence STD Office Ext. ISD Mobile

E-Mail ID

All fields are mandatory. (Atleast one contact no. is mandatory for processing your request. The Contact details mentioned above will be updated for all future communication)

Change in Premium Payment Frequency

Monthly Half Yearly Yearly (This change will be applicable from the next premium payment date)
Note: • This change will be applicable from the next premium payment date • For monthly mode, standing instructions is mandatory. Please fill the NACH Direct Debit form and submit the same along with
this form. • Change in premium frequency will have an impact on change in premium.

Change in Premium Payment Mode

Cheque Direct Debit/ECS (NACH) Bill Desk Bill Junction
Note: • If payment through Direct Debit / ECS (NACH) is selected, mandate needs to be filled and submitted at the nearest ICICI Prudential Life Insurance branch.

Change in Insurance amount (Sum Assured)

From Rs. Required Rs.
Note: In case of increase in Sum Assured, a Personal Health Declaration Form (PDR) will have to be submitted along with this form.

Change in Annual Premium

From Rs. Required Rs.

Note: • Any change in the premium that needs to be paid can only be done at Policy Anniversary • Change in premium contribution can be made subject to terms and conditions

Request for Policy Statements / Receipts

E-Welcome Kit Unit Statement Premium Paid Certificate Others _______________________(Please specify)

From D D M M Y Y Y Y To D D M M Y Y Y Y

ECS Preferred Date:

Premium Due Date D D M M Y Y Y Y Preferred Account Hit Date : D D
Preferred due date can be any day between your premium due date and the next 11 days.
Please Note:
1. This is a servicing request only
2. The preferred account hit date is for purpose of premium debit only.
3. NAV applicable on the account hit date would allotted to the policy account
4. All policy benefits would be applicable as per the premium due date mentioned in the policy document
5. All account details related to ECS debit would remain the same (as provided in the ECS mandate)

Signature of Policy Holder (Proposer): _____________________ Signature of Assignee* / Trustee#: _____________________

(*Required in case of Absolute Assignment of Policy)
(#Required in case of Policy covered under MWPA)
Note: I have understood the meaning and scope of the change request form and take complete responsibility of the changes submitted by me. Any changes in the Policy /
Personal Details are subject to the policy terms and conditions and relevant underwriting guidelines.

ACKNOWLEDGEMENT SLIP
This is to acknowledge the receipt of application for change in:

Identity Proof Premium Payment Frequency Premium Payment Mode Insurance amount (Sum Assured)

Annual Premium Request for Policy Statements / Receipts ECS Preferred Date Policy Discontinuance

Request for Foreclosure Reversal Cover Continuance Option Consent for sharing Policy Details
STAMP
Policy Number Date D D M M Y Y Y Y &
TIME
Received By
Policy Discontinuance
I am fully aware that I will not be entitled to any policy benefit after Discontinuing it. I will only receive the Discontinuance Policy Fund Value after deduction of applicable
charges, upon completion of the fifth policy year.

Request for Foreclosure Reversal

I hereby request you to revive my policy number which has been foreclosed
DECLARATION:
i. I understand that the Company has accepted my request for foreclosure reversal of the above policy purely as a gesture of goodwill.
ii. I undertake to pay regular premiums and keep the policy in force so that I can continue to enjoy the benefits available under the same.
iii. I agree and undertake that I will not surrender the above policy at least for a period of one year from the date of this request. Further, I also agree and undertake that I
will not assign the above policy for a period of one year to any individual entity.
iv. I agree and understand that if I submit any request for (i) surrender or (ii) assignment of the policy to any individual entity, within one year from the date of this request
then the Company will not be under any obligation to process my request and I shall not hold the company liable for the same.

Cover Continuance Option (CCO) / Automatic Premium Payment (APP)

Register for CCO / APP Deletion of CCO / APP
Note:
• Cover Continuance gives you the option of continuing your life cover and the rider cover even if you stop paying premiums. If the fund value reaches the minimum requirement, the
policy would be foreclosed and surrender value would be paid to you. • During cover continuance period the mortality and policy administration charges will be deducted via
cancellation of units. • Future premiums for this policy will not be accepted once the cover continuance option is activated.
• On activation of APP, premium will be collected through cancellation of units. • APP can be availed once if term less than 15 years and twice if term is greater than 15 years. • APP
facility is available only in Investshield Cash (U28),Investshield Life (U29),Investshield Pension (U30) and Investshield Gold (U34). • APP facility can be deleted only if the same has
been registered but not activated.

Consent for sharing Policy Details

I/We provide consent for sharing policy details with my/our servicing agents.
I/We do not wish to share my/our policy details with my/our servicing agents.
Note: Policy details includes fund value, unit statement and portfolio statement details, bonus amounts, etc.

DECLARATION
Applicable when the Proposer is illiterate or suffering from disability due to which writing is restricted or the proposer has signed in vernacular language. Note: Must be witnessed by
someone other than the advisor/agent/employee of the Company.

I (Full name of Witness) _______________________________________________________ (Relation with Proposer) ____________________ adult and inhabitant of (Address)
______________________________________________________________________________________________________________________________________
do hereby declare that I have read and explained the contents of this form to the Proposer and he/she/they have understood the same.

____________________________
Signature of Witness

Signature of Policy Holder (Proposer): _____________________ Signature of Assignee* / Trustee#: _____________________

(*Required in case of Absolute Assignment of Policy)

Comp/doc/Dec/2017/0680
(#Required in case of Policy covered under MWPA)
Note: I have understood the meaning and scope of the change request form and take complete responsibility of the changes submitted by me. Any changes in the Policy /
Personal Details are subject to the policy terms and conditions and relevant underwriting guidelines.

FOR OFFICE USE ONLY:

Comm/Form/Personal_Policy/1.7

ER Request submitted by C S CR CS
STAMP
Spaarc Call ID Date D D M M Y Y Y Y
&
Scanning Cabinet Received By TIME

Remarks

Kindly call our Customer Service Number 1860-266-7766 (local charges apply)
Call Center timings: 10.00 A.M. to 7.00 P.M. Monday to Saturday (except national holidays)

Communication Address
ICICI Prudential Life Insurance Co. Ltd., Unit No. 1A & 2A, Raheja Tipco Plaza, Rani Sati Marg, Malad (East), Mumbai 400097.