POLICY SURRENDER FORM

PLEASE FILL THE FORM IN CAPITAL LETTERS

Policyholder’s Name:

Policy No.: Mobile No.:

Email ID:

Nationality: Indian Foreign National NRI PIO

I accept to receive all further communication from Max Life Insurance through E-mail ID only (strike if you wish to continue with hard copy).
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.

Bank Details for NEFT

Account Holder Name:

Type of Bank Account: Savings Current NRO NRE

MICR Code: Bank Name:

Bank Account No.:

IFS Code: PAN:

TDS will be applicable in accordance to Section 1940A of Income Tax Act prevailing at the time of payment. If you are an NRI, please fill up the
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 on payment of surrender value my policy along with
associated benefit will cease to exist. “I/we understand that, I/we have disclosed my/our personal information (which
may include Aadhaar related information) with Max Life for the purpose of providing insurance and related services
and I/we hereby consent and authorise Max Life to use, store and/or share the same with government/regulatory/
statutory bodies, Insurance repositories, reinsurers/hospitals or diagnostic centers/other Insurance companies for
the purposes of underwriting assessment, claim investigation/settlement, KYC and policy servicing purposes, as per
applicable law.”

Date: D D M M Y Y Y Y
Place: Signature of Policyholder/Assignee:
Note: In case, policy is issued under Married Women Property Act (MWPA, Section 5 & 6 ), please share the consent
from Wife /Husband/Trustee/Legal heir.
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 15 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 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 day’s
NAV will be applicable. However, if application is received after 15:00 hrs IST, 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 the company’s records
• Max Life Insurance will not be responsible in case of non-credit to your account or if your transaction is delayed
or not effected at all, for reasons of incomplete/incorrect information provided or rejected by your bank. In case
the requisite information for direct credit is not received or transaction is rejected by the bank, the payouts will be
made vide cheque

Mandatory Documents Required for Processing Payout

Self –attested copy of official valid document such as “Aadhar , Voter ID , DL or Passport or NAREGA Job Card”
( Carry Original for Branch Verification as well)”.
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 all premiums paid from NRE account.

Branch Mandatory Checklist

All documents are original seen and verified by the Max Life Insurance personnel.

Retention efforts made Yes No

Reason for surrender

1. Stated policy benefits and returns, as per the policy contract, vary from those understood by me at the time
of purchase
I thought that I need to pay premiums for lesser years / only 1 year
I thought I will get higher returns
The maturity period is different from what I understood
Other reasons
2. I cannot afford to pay the premium for this policy
I have a medical emergency I have a financial emergency
I am getting better benefits from another insurer
I am getting good returns based on my fund value and I want to withdraw the money
I want to withdraw my funds as the lock-in period is over
Payout to the customer NEFT Cheque

Did you know? Buying a new insurance is more 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 and conditions of the policy.
Low Charges: In the Unit Linked products, the charges reduce gradually over the years leading to a higher
proportion of your premium being invested in the fund.
High Growth Potential: ULIPs provide the option to invest in equity, which provides potential for higher growth
of your funds.
Life Cover: Once the policy is surrendered, the life cover ceases thus depriving you of the benefit when you
actually need it.
Tax Benefit: You can avail tax benefit under the section of the Income Tax Act 1961, subject to any further
amendment.
 To be Filled only if Nationality is Other than Indian.
Important Instructions:
• All fields are compulsory • Please fill in capital letters
• Attach documentary evidence as marked (*)

Client ID: Policy No.:

Policyholder’s Name:

Father’s/Husband’s Name:
Nationality: Indian Foreign National NRI PIO

Citizenship: Indian Others, please specify

Gender: Male Female Others

Date of birth: D D M M Y Y Y Y City of birth:

Country of birth:

*INDIAN ADDRESS:

Flat No./Building No.:

City: State: PIN Code:

Mobile No.: Tel. No.:

Address Type: Residential Business Registered Office Unspecified

*OVERSEAS ADDRESS:

Flat No./Building No.:

City: State: PIN Code:

Mobile No.: Tel. No.:

Address Type: Residential Business Registered Office Unspecified

Policyholder’s Name:

Request Received Date: D D M M Y Y Y Y Request No.: GO Stamp

Name of Branch Official:

Employee Code of Branch Official:

Signature::
OCCUPATION:

Salaried Self-employed Business Retired Housewife

Others, please specify

Passport No.: Passport Issuing Country:

*
PAN.:

*Foreign Tax Identification No. ( or Functional Equivalent):

Country:

*Country of Residence as per tax laws:

(If more than one country of tax residence, provide Tax I dentification No./Functional Equivalent: on all countries of tax residence)

ID Proof submitted:

Election ID Valid Driving License Valid Passport AADHAAR Card

NAREGA Job Card Any Other Government Agency Issued Document

I do hereby certify that above stated information is correct in all respects and may be used for all purposes, including
reporting to statutory authorities & compliances, and understand that it is my responsibility to report the changes, if
any, to Max Life within 2 weeks of occurrence of such change.

Policyholder’s Signature:

For Office Use Only

Request Received Date: D D M M Y Y Y Y

Branch Name and Code:
Certified that th is form
Employee Code: is complete in all respects
and all relevant documents
are obtained and verified.
Signature: