Request For Change In Personal/policy Details
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2PSRF631022081602 / Comp/Aug/Int/4704
Request For Change In Personal/Policy Details
(* Indicates Required Fields)
Policy Number*:
E-Insurance Account No.:
Name of the Policyholder*:
PAN (Permanent account No.)
Aadhaar No.
Change in registered contact details and Email ID
Email ID:
Alternate Email ID:
Office No.
Mobile No.
Residence:
Alternate No.
Contact details provided herein will be updated for all future communications. The above mentioned contact number will be considered as consent to communicate with him / her
on the contact details provided herein.
Name Change
Policyholder
Life Assured
Nominee/Beneficiary
Appointee
Name to be changed to*:
__________________________________________________________________________________________________________________
If you are a married woman with a change in surname, please submit a copy of your marriage certificate. For any other request involving significant changes in the name, please
submit a ‘Gazette Copy’ .
Address Change
Policyholder
Life Assured
Nominee/Beneficiary
Appointee
Address*: House/Flat No.:
Street/Area:
City/District:*
State:*
Pin Code:*
Note:
a. This change is applicable to all policies held under your client ID.
b. If the nominee’s/beneficiary’s address is different from the address of the Life Assured, then please use a separate form.
Addition or Change of Nominee/Beneficiary
Nominee/Beneficiary Name*:
Nominee/Beneficiary Name*:
Date of Birth*:
Date of Birth*:
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Relationship with the Life Assured*:
Relationship with the Life Assured*:
Address for correspondence*:
Address for correspondence*:
Percentage of Entitlement*:
Percentage of Entitlement*:
Note: 1. Beneficiary should be a blood relative. 2. Change in beneficiary is not allowed for specific products in the Children’s plan and Young Star plan categories. It will be
allowed for demise or divorce cases only. 3. If the nominee/beneficiary is a minor, please fill in the appointee section below. 4. If the Nominee is other than blood relative, then
Moral Hazard Questionnaire is required. 5. In case of more than 02 Nominees, please fill in a separate form.
Addition or Change of Appointee
Appointee Name *:
Date of Birth*:
D
D
M
M
Y
Y
Y
Y
Relationship with the nominee/beneficiary *:
Address:
Declaration of Appointee: I hereby accept my appointment as an appointee to receive the proceeds under the policy on behalf of the
beneficiary/nominee who is a minor.
SIGN HERE
DD/MM/YYYY
Appointee Signature *:
Date *: __________________________
Place *: _______________________________
Change in Date of Birth of Nominee/Beneficiary/Appointee/ Proposed Policyholder
Name: __________________________________________________________________________________________________________________
Change in DOB required for:
New DOB:
Nominee/Beneficiary
Appointee
Proposed Policyholder
D
D
M
M
Y
Y
Y
Y
Customer Acknowledgement Copy (to be filled by Customer Relations Official only)
Policy No.: _______________________ Policyholder Name: __________________________________________________
PS Request: ___________________________________________ Interaction ID No.: ______________________________
Branch Stamp
Documents accepted: ________________________________________________________________________________
Customer Relations Officer:
Branch Name:
Date:
Time:
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