Freelook Cancellation form

Policy Number
First name*
Last Name*
Address 1
Address 2
City_______________________State_________________________________________Pin

Contact Number

Email ID____________________________________________

*Reasons for Cancellation (To be filled by Policyholder)

Financial Problem

Tampering, Corrections, forgery of proposal or related papers

Personal Reason

Product differs from what was requested or disclosed

Policy Pack Delayed

Policy Pack not received

Obligation Sale

No requirement
Please specify reason for cancellation as ticked above by you________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
I hereby submit that I am the Policyholder of an insurance policy number
I understand
that as per the terms and conditions of the policy contract, I can avail freelook cancellation of the policy within 15 days of the receipt
of the policy contract. I request you to please process the cancellation of the policy under the freelook option, after adjusting the
applicable charges and stamp duty in accordance with the policy contract.
I understand that cancellation of the Policy results in termination of the insurance contract and all rights/ titles and interest under
the Policy shall stand terminated or misrepresentation in the information furnished by me in this Form Postal Address* (where the
cheque would be dispatched), incase address is different from the policy, attach the address proof (mandatory)
Address 1
Address 2
City_____________________________State__________________________________________________Pin

DISCLAIMER Max Life Insurance Company shall not be held responsible in case the premium refund is not credited to your bank account or
if the transaction is delayed or not effected at all for reasons of incomplete/incorrect information provided by you in this Form. Further, Max
Life Insurance reserves the right to use any alternate option to pay you including demand draft/cheque inspite of your opting for direct credit
option. Credit will be effected based solely on the policyholder account number information provided by the policyholder and the
policyholder name particulars will not be used thereof.
Please Note : The relevant NAV and processing of the Policy will be applicable post receipt of all the requirements/documents
received by Max Life Insurance

I Mr./ Mrs/ Miss ______________________________________ s/o, d/o, w/o of____________________________________aged _____,

resident of address as mentioned above do hereby declare and affirm that the details provided in this Form are correct and accurate.
I do hereby agree to receive the premium refund under the policy terms and conditions, after deduction of applicable charges.
Further, I confirm that the information provided by me herein is true and correct. I confirm and indemnify Max Life Insurance
Company against all losses/damages incurred by it due to any wrongful refund obtained by me.
Signed at ............(Place)

Signature / Thumb Impression of Policy Holder :

Date............................

Ver 1.1

06/2013

Vernacular Declaration(To be filled if Customer has signed in language other than English / Affixed Thumb Impression)
I hereby declare that I have explained the contents of Freelook cancellation form/request letter to the Policyholder Mr/Mrs/Ms
______________________________in___________________ Language and that the policy holder has affixed the thumb
impression(s)/signed in language other than English in my presence after fully understanding the contents thereof. . I further
declare that I am not related with the Company in any manner, whatsoever

.........
(Name and Signature of the Declarant)

...........
(Date)

Desired Mode of payment

Cheque

Direct transfer to My Account (not applicable for NRE a/c)

Please provide details If Direct Transfer to my Account Selected (Kindly Fill in BLOCK LETTERS only

II. Bank Details of the Policy Holder - Mandatory

a)

Bank Account No............................................................ b)

Account Holder Name.....................................................................................................

c)

IFSC Code........................................................................ d)

Bank Name.......................................................................................................................

e)

Bank Address.....................................................................................................................................................................................................................

Note - Kindly attach a cancelled cheque bearing account number and policy holder name or copy of Bank Passbook.
I agree to save and hold Max Life Insurance Company Limited harmless and indemnified against any and/or all losses, claims, liabilities, legal
proceedings (including attorney fees), expenses or damages suffered by or taken against Max Life Insurance Company Limited arising on account
of any error or misrepresentation in the information furnished in this EFT mandate by me
DISCLAIMER:.Max Life Insurance shall not be held responsible In case the premium refund not credit to your bank account or if the transaction is
delayed or not effected at all for reasons of incomplete/ncorrect information, Further Max Life Insurance reserves the right to use any alternative
payout option including demand draft/ payable at par cheque inspite of you opting for Direct Credit option. Credit will be effected based solely on the
Policy Holder account number information provided by the Policy Holder and the Policy Holder name particulars will not be used thereof.
Please Note : The relevant NAV and processing of the Policy will be applicable post receipt of all the requirements/documents received by Max
Life Insurance
* Mandatory Information

For Office Use Only (All fields are mandatory to be filled)

Retention by CSE ______________________________________________________________________

Name of Receiver: _______________________________________________Employee Code: ____________________________________________
Phone Number: __________________________________________________GO Code: __________________________________________________
Request received Date: ___________________ Time___________________ (to be filled Manually)
Signature verified:

Yes

No

Policy Pack Received:

Yes

No
Max Life Insurance Co. Ltd.

3rd Floor, Operation Center, 90-A, Udyog Vihar, Sector-18, Gurgaon-122015, Regd office: Max House, 3rd Floor, 1 Dr. Jha Marg, Okhla, New Delhi-110020, India Contact Details: Tollfree Customer
Helpline:1800-200-5577 (from MTNL/BSNL),Other Networks: 2542001 (Dial STD Code 95124<from Delhi>, +0124<from other cities>).Tollfree Claims Helpline: 1800-103-5678 (from MTNL/BSNL) Fax:
4239683 (Dial STD Code 95124<from Delhi>, +0124<from other cities e-mail: service.helpdesk@maxlifeinsurance.com Visit us at: www.maxlifeinsurance.com

CUSTOMER ACKNOWLEDGEMENT SLIP

Policy Number

Type of request________________________________________________________________________

GO STAMP

Received by _____________________________________ Date & Time of receipt _________________

Employee Code _____________________________________ Signature _________________________
Ver 1.1

06/2013