Policy Servicing Request Form

Please remember to collect Acknowledgment letter on submission of this form.

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Policy Number. Date :

Life Assured’s Name : _________________________________________________________

Policy Owner’s Name : _________________________________________________________

Contact no: E-mail ________________________________________________________

Electronic Payment Mandate:

This mandate is a standing instruction to Bajaj Allianz Life Insurance Co Ltd, to transfer the amount to be paid to the policyholder
electronically into his bank account.

Electronic Payment Fund Transfer will be applicable to Surrenders, Partial Withdrawal, Cancellation of Proposal, Annuity, Loans
Survival Benefits and Maturity.

Bank Name Branch Name

Bank Account No. Account Type Savings Current

IFSC MICR Code

The payout mode selected in the Form will be used by company to generate any payouts to the policy holder (Claimant).
Payouts would be done in accordance and subject to terms and conditions of the policy
Note: Cancelled copy of Cheque/ Bank Statement/ Bank Passbook Copy not `more than 6 months old as on date to be submitted along with
Electronic Payout Request.
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OPIN / MOBILE / E- Mail Registration Mandate

I would like to avail following value added services provided by Bajaj Allianz Life Insurance Co Ltd:

E-mail _____________________________________________ Mobile No.

By signing below, that above mentioned mobile and email address belongs to me and is authentic .Based on the above
mentioned information I hereby wish to apply for Bajaj Allianz Life Insurance company ltd’s (BALIC’s) Mobile Registration
Service, as may be made available to me by the BALIC from time to time.
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Frequency Change

From _________________________ To ___________________________ SSSiiigggnnnaaatttuuurrreeeooofffPPPooollliiicccyyyhhhooollldddeeerrr///A

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Addition / Deletion of Rider

Name of Rider for Addition / Deletion: ___________________________ Effective From_________________________
Note: Any addition of rider is subject to the company underwriting the risk and the company shall not be liable until such time it has
underwritten the risk and issued intimation to the policy holder and any addition of rider for a traditional policy will be effective from next
policy anniversary SSSiiigggnnnaaatttuuurrreeeooofffPPPooollliiicccyyyhhhooollldddeeerrr
/Assignee
Change In Sum Assurance
I wish to Increase / Decrease Sum Assurance from ___________________ to ________________
Note: Increase in SA is subject to Policy Conditions
• Increase of SA is subject to the company underwriting the risk and the company shall not be liable until such time it has underwritten
the risk and issued intimation to the policy holder
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Change In Fund Apportionment (Allocation of Future Premiums)*

I wish to allocate my future premiums as indicated : Name of the Fund Percentage

Note:
• The allocation totals to 100%
• Fund Apportionment doesn’t guarantees fund switching
•
For any Query Reach Us at 020-30587888 or Mail to life@bajajallianz.co.in SSSiiigggnnnaaatttuuurrreeeooofffPPPooollliiicccyyyhhhooollldddeeerrr///A
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 Policy Servicing Request Form

Fund Switch (Allocation of Existing Funds)*

I wish to switch the value of units credited to this policy as indicated below:

From Fund To Fund No Of Units Amount ( Rs)

Note:
• This Fund Switching transaction would be applicable only to the existing funds, and the future premiums shall continue to be apportioned in the same
proportion, as it exists today.
• The selected fund is applicable for the particular product
• Switching Charges would be levied as per policy condition
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Top- Up
Fund Percentage
Top-Up Amount :

Note:
• Minimum amount of Top-Up is Rs.5000/-
• Max Amount is governed by respective policy conditions SSSiiigggnnnaaatttuuurrreeeooofffPPPooollliiicccyyyhhhooollldddeeerrr///A
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* If the application for fund switch / Allocation is received up to 3 pm on a weekday (Mon – Fri), the same day’s unit value will be applicable. However, if the application is
received after 3 pm on a weekday, then the next working day’s unit value will be applicable (when the applicable day is not a valuation day, NAV of the next immediate
valuation day would be considered)

Declaration: I /We hereby request the policy particulars be changed in accordance with the above information furnished by me/us. Further I We agree that company may
not be able to process the request if I / We provided any incorrect/incomplete/inconsistent information.

Partial Withdrawal

I/we. The policy owner/trustee/assignee wish

Name of the Fund No Of Units Amount (Rs) to apply for partial withdrawal of the
amounts indicated below from the units
credited to my policy, in the proportion given
below.

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Declaration: I/We, the policy owner/trustee/assignee in the title of the above policy authorize and request that the above policy
be changed in accordance with the above particulars (partially surrendering the units). I/We further agree that any alteration or
variation shall not take effect until the Company is approving the request.

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Signature of Witness
________________________________________
Surrender

I / we, _____________________________________________________________do hereby acknowledge receipt from

Bajaj Allianz Life Insurance Company Limited of the sum of Rupees__________________________________________

I/ we have enclosed the policy document Yes No / we understand that the surrender of the policy
or full withdrawal of units result in the termination of the policy. I / we also understand and agree that the policy
shall be deemed to have been duly surrendered and the company discharged of all liabilities under it upon payment
of the surrender value. I / we also understand that the contract of insurance shall be deemed to have been duly
terminated on my/our signing this application form for surrender of the policy.

Rs.1 Revenue Stamp

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For any Query Reach Us at 020-30587888 or Mail to life@bajajallianz.co.in