PIWC Mismatch Verification Form

(This form is to be used only for obtaining confirmation from the Customers marked under PIWC
Mismatch Category during Pre-Issuance Welcome calls)

Please provide the following information*:

1. Proposal Number: _______________________________________________________________

2. Premium amount to be paid is Rs. __________________________________________________

3. Frequency of premium payment: - Single Monthly Quarterly Half Yearly Yearly

4. Premium is payable for ______ Years and term of policy is _____ Years.

5. Life Insurance Cover (Sum Assured) is (in Rs):________________________________________

________________________________________________________________________________

Declaration from the proposer

I declare that the policy benefits & terms and conditions of the policy are clearly explained to me. I also
declare that the details furnished above are provided by me and I have understood the questions
completely.

Name _____________________________ Signature: __________________________

Date: _____________________________ Place: __________________________

I hereby confirm that customer has signed in presence of me.

Name _________________________ Signature: __________________________

(To be signed by UM/BDM and above)

Confirmation from the Supervisor (BSM/ Sr./AM /Supervisor) :

1. PIWC Calling Remarks: __________________________________________________________

_______________________________________________________________________________

2. Did you speak to the customer on the above mismatch Yes No

3. Whether customer agrees to Premium/ Frequency/Payment Term/ Benefit Term/Sum Assured as

mentioned above from point 1 to point 5: Yes No

Name: _________________________________ Signature:: ___________________________

Place: _______________ Date:______________ Designation: ___________________________

Note: A scanned copy of this document duly signed by the signatory mentioned above is to be uploaded on
Image View Module.

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* This information should be filled by the customer. In case of vernacular declaration, the concerned channel representative
should explain to the customer clearly before obtaining confirmation.

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