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Date: 24/04/2014 To, Mr.SHAREEF S/O ABDUL AZIZ MOH MIRDGAN BIJNOR BIJNOR UTTAR PRADESH 246701 Ref: Policy No: LN130900002522 on the life of Mr/Mrs/Ms Mr.SHAREEF Dear Sir / Madam, Surrender Request Reg. We are in receipt of your request for Surrender of the above mentioned policy. The surrender quotation is given below. The Surrender value mentioned below is as on the date and may vary depending on the date of the Surrender application. processing of NEAR MADINA PRESS MIRDGAN
Quotation:
Plan:
Fund SHRI PLUS No of Units NAV(10/03/2012) Fund Value
` 4133.67
Maximus ULIF00301/07/06MAXIMUSFND128
253.8750
16.2823
Fund Value = No: of Units in the Fund A/c x N.A.V as on the date of surrender quotation = ` 4,133.67 /Basic Fund Value TopUp Fund Value Less : Basic Surrender Charges @25.00% on Base Fund Value TopUp Surrender Charges Other deductions Total deductions O/S Policy Deposit Top Up Amount Not Underwritten Net Amount of Surrender Value Payable Yours Sincerely,
` 1,033.41 ` 0.00 `0 ` 1,033.41 ` 0.00
4,133.67 0.00
0.00
` 3,100.26
[AUTHORISED SIGNATORY]
Date: 24/04/2014
RUPEES
THREE
satisfaction of all my claims and demand in respect of surrender value against the above mentioned policy.
Note: The Surrender value as mentioned above may vary depending on the date of request, monthly processing charges till the date of processing the application, N.A.V as on date of acceptance or approval of a surrender request etc.
Declaration :
I/We hereby declare that I/We have not served on any office of the Shriram Life Insurance Co. Ltd., any notice of assignment/reassignment in respect of the above policy except those if any, already registered with Shriram Life Insurance Co. Ltd., nor shall I/We serve on any office of the said company any notice of assignment or reassignment before payment of the surrender.
t Present address to which cheque is to be sent: t Payee details to issue Account Payee cheque:
Bank A/c No: Name of the Bank:
Dated at
this
day of
20
1. 2.
. .
Please affix
` 1 Revenue Stamp and sign across the
If the application is signed in a vernacular language and with the help of a scribe, then please fill & sign the following:
DECLARATION BY PERSON FILLING THE FORM (For form filled in by a scribe for forms signed in vernacular languages)
I of
having known the policyholder for a period (Yrs / Months) do declare that "I have explained the nature of contents of this form to the policyholder, which forms the basis for
In case if the policy is conditionally assigned, then the policy holder as well as the assignee(s) should sign the Discharge Form.