Surrender/PartialWithdrawalApplicationForm

PLEASE CONSIDER THE BELOW FACTS BEFORE YOU SIGN THIS FORM:

LifeCover:IncaseofSurrenders,yourPolicywillnolongerbeinforce.Nolifecoverwillremainonyourpolicy.
ExpectBetterReturns:ItisadvisabletopayallyourpremiumsandremaininvestedfortheentiretenureoftheULIPpolicy.Youcanexpectbetter
returnsinthelongrun.
SurrenderCharges:Surrenderchargesareapplicableonthesurrenderofapolicy.Thiswillreduceyourfundvalue.
Ifthereisurgentmoneyrequirement,werequestyoutogoforPartialWithdrawal,ifavailable,ratherthansurrender.
FormoredetailsonpartialwithdrawalpleasecontactyourAdvisor/CIForyoucancallusonourtollfreenos1800222123or18004259010.
SBI Life Policy No.

Surrender:
I / We _______________________________ wish to surrender my above
mentioned policy and request you to settle the surrender value against my

policy.FurtherI/Weherebydeclarethat

Policyisnotassignedtoanyone

Yes/No

PolicywasissuedundertheprovisionsofMWPAct/HUF
Yes/No

PartialWithdrawal:
I/We_____________________________wishtowithdraw
an amount of Rs.________ (In words Rupees
_______________________________
____________________________ only) under my above
mentionedpolicy.

I/ We understand that if fund value after the partial

PolicyhasbeenattachedbyanyAuthority/Court
Yes/No
withdrawal
goes below Rs.10000/ or one annualized
MyBankAccountDetails(Mandatory)
Thereareencumbrancesagainstthepolicy

Yes/No
premium (whichever is applicable), the policy will be

foreclosedaspertheterms&conditionsofthepolicy.

SignatureofWitness:

SignatureofPolicyholder/Assignee
(Assigneessignatureincasepolicyisassigned)

Name:Name:.

PresentAddress:.........PresentAddress:.

....
...

ContactNumber:.....ContactNumber:...
(CompleteaddressandcontactnumberisMandatory)(CompleteaddressandcontactnumberisMandatory)

I/We do hereby acknowledge receipt from SBI Life Insurance Co. Ltd., a sum of Rupees (in figures) ____________/, (Rupees
______________________only),beingtheSurrenderValue/PartialWithdrawalamounttowardsthepolicy.
Affix
One
Rupee
Revenue
stamp & sign
across

(Ifpolicyholderisanilliterateorsigninginvernacularlanguage,his/herthumbimpression/signaturemustbe
attestedbyanygazzettedofficer,notary,hisbankerwithhisofficialsealorbyanOfficialofSBILifenotbelow
theRankofAMafterexplainingthecontentsofthisapplication)
Name:

Designation:
Address:

Signature:

Date:
Place
NOTE:
In case of address other than the one mentioned in SBI Lifes records, please submit the request along with ID
proof&addressproof.
SBILifereservestherighttoreverseanypaymentmadeerroneouslyintoyouraccount.

SBILifeInsuranceCo.Ltd
CorporateOffice:"Natraj",M.VRoad&WesternExpressHighwayJunction,Andheri(East),Mumbai400069
CentralProcessingCenter:KapasBhavan,PlotNo.3A,SectorNo.10,CBDBelapur,NaviMumbai400614
PS12/Ver1.8/29.05.2012Page1of2

Surrender/PartialWithdrawalApplicationFormPage2

DIRECTCREDITMANDATE
To
SBILifeInsuranceCoLtd.
Branch:__________________________

Sub:ReceiptofpolicypaymentthroughNEFT

IamgivingbelowthedetailsofmyBankaccountforreceivingpolicypaymentthroughNEFT.

(1) PolicyNo.

Nameofpolicyholder/claimant:__________________________________________

(2)BankName:_______________________________________________________
(3)BankBranchAddress:_______________________________________________
(4)AccountType:Savings/Current/CashCredit/NRI/NRE______________________
(5)AccountNo.

(Bankaccountnumbershouldbewrittenfromlefttoright)

(6)IFSCode:

(7)MobileNumber:

+ 9 1

(8)EMailId:_________________________@________________________

Ihaveenclosedthefollowingdocumenttothiseffect.(Please3appropriateitem)

Cancelledchequeleafalongwithpreprintedname.

IfChequedoesnotcontainpreprintednamethenpleasesubmitselfattestedcopyofBankPassbookshowing

preprintedbankaccountno.,accountholdername&IFSCodealongwithacopyoftherecenttransactions(notmore
than6monthsold).

NOTE:

ForNRI/NREaccount,letterfromthebankisrequiredforthedirectcreditofthesurrenderproceeds.

_________________________
SignatureofthePolicyholder

Date:
SBILifeInsuranceCo.Ltd
CorporateOffice:"Natraj",M.VRoad&WesternExpressHighwayJunction,Andheri(East),Mumbai400069
CentralProcessingCenter:KapasBhavan,PlotNo.3A,SectorNo.10,CBDBelapur,NaviMumbai400614
PS12/Ver1.8/29.05.2012Page2of2