PSRF540823021605 Comp/feb/Int/4631

For Official Use Only

Specimen Signature Form Branch:
Received at branch on:
(Applicable for all Policies)
Received by:

Personal Details

Name of the Policyholder: ______________________________________________________________________________________________

Policy No.: ____________________________ Client ID: ________________________

Aadhaar No.:

PAN :

Email ID*: ___________________________________________________________________________________________________________

Contact* No. : (Mob)_______________________/(Res)_____________________________/ (Off)______________________ (Mobile number is preferable)

*Contact details provided herein will be updated for all future communications. For customers registered under National Do Not Call Registry, this will be considered as consent
to communicate with him / her on the contact details provided herein.

Declaration for Specimen Signature

<Name of the Policyholder>

I, _________________________________________________________ hereby declare that my specimen signatures in sshort, ffull, vernacular language

y
and in all different styles are as mentioned below.
I hereby hold HDFC Standard Life Insurance Company Limited and its agents, employees
es or directors,
tors, harmless, from all losses
loss oro damages suffered by

op
them, on reliance of the provided details.

SIGN HERE SIGN HERE

ERE SIGN HERE
tC
Specimen 1 Specimen
men 2 Specimen 3

(DD/MM/YYYY)
Date: __________________________ Place: ____________________________
______________
_________________________

Declaration made by third party where the Policyholder

cyholder has signed in vernacular:
af

I hereby declare that the content of this application

pplication form has been explained
exp to the Policyholder in ___________________________
ecorded the answers provided
language and have truthfully recorded pro me I further declare that the Policyholder has signed/affixed his/her
to me.
sence.
thumb impression in my presence.

Name ___________________________________________________________________
______________________________
_______________________ SIGN HERE
Dr

_____________________
____________________________
Address: _________________________________________________________________

DD/MM/YYYY ___ Place: _________________

Date: __________________ ___________
___ Signature

Customer Acknowledgement Copy (Specimen Signature Format)

Policy No.: Policyholder Name: _________________________________

(DD/MM/YYYY)
Branch Stamp
Customer Relations Officer: ___________________ Date: _____________________ Time: _________________

Call 1860-267-9999 (local charges apply). DO NOT prefix any country code e.g. +91 or 00.
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