Policy Servicing Request Form - Health Plans-1 printable pdf download

HPSF110003081212/Comp/Nov/Int/1635

Policy Servicing Request Form-Health Plans - 1

For Official Use Only

Alteration Done

Branch Name:

Alteration Denied

Receipt Date & Time:

Employee Code: _______________________

Received by:

Signature: ___________________________

Interaction ID:

Policy Number ________________________ Email ID * _____________________________________________________________________________

(First Name)

(Middle Name)

(Last Name)

Policyholder's name _________________________________________________________________________________________________________

Contact* No.: (Off)_________________________/ (Res)_____________________________ /(Mob)___________________

(Mobile number is preferred)

*Contact details provided herein will be updated for all future communications. For the customers registered under National Do Not Call Registry, this response will be treated as valid discharge.

The request for change/ correction in name and change in address would be effected for all the policies linked to the client id. Policy servicing charges may be levied as applicable. Please refer to

your policy document for details.

CHANGE/ CORRECTION IN NAME (Tick One)

Life Insured

Nominee/ Beneficiary

Appointee

Policyholder

General Rules

1. The change will be effected in all the Policies where the client exists. 2. For married women with a change in surname, only a declaration for

a change in maiden name is required. For complete name change Marriage certificate is required. 3. For all other requests involving significant

name change a Gazette copy is required. 4. All the supporting documents should be countersigned by the Life Insured / Policyholder.

Name to be changed to: _________________________________________________

CHANGE IN ADDRESS (Tick One) (Multiple selections allowed in case of common address)

Life Insured

Nominee/ Beneficiary

Appointee

Proposer

General Rules

1. The change will be brought into effect across all the Policies where the client code exists. 2.Self-attested documentary proof of the new address

is mandatory. Contact us for the list of acceptable address proofs.

Correspondence address

Permanent Address (Please tick one option)

House / Flat No. __________________________Street/Area _______________________________________________________________________

Landmark _____________________________________________________ City / District ________________________Pin Code ________________

Contact No. ____________________________/_____________________________

CHANGE OF NOMINEE/ BENEFICIARY

CHANGE OF NOMINEE/ BENEFICIARY DATE OF BIRTH

General rules

Incase the nominee/ beneficiary is a minor, please fill up the Appointee details below. For change of DOB of nominee/ beneficiary, a valid age proof

should be submitted.

Nominee/Beneficiary Name Mr/Mrs/Ms __________________________________________________________________________________________

House/Flat No ______________________ Street/Area _____________________________________________________________________________

DD MM

YYYY

City / District ______________________________ Pin Code _______________________________ Date of Birth ____/____/______

Contact No. _________________________/____________________________ Email Id __________________________________________________

Nominee/ Beneficiary Relation to the Life Insured: __________________________________

In case of change in DOB of Nominee or Beneficiary Old Date of Birth: ____/____/______ (dd/mm/yyyy) Revised Date of Birth:____/____/_______

DD MM

YYYY

DD MM

YYYY

DECLARATION OF NEW APPOINTEE (TO BE FILLED INCASE OF CHANGE 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

Date _______________________ Place __________________________ Appointee's Signature:

(No thumb impression)

IRDAI Registration No. 101.

HDFC Standard Life Insurance Company Limited.

In partnership with Standard Life Plc.

CIN:U99999MH2000PLC128245.

Regd. Off: Lodha Excelus, 13 Floor, Apollo Mills Compound, N. M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.

CUSTOMER ACKNOWLEDGEMENT COPY (POLICY SERVICING FORM FOR HEALTH PLANS)

Policy No. ________________________________ Policyholder Name _________________________________________________________________

PS Request _____________________________ Documents accepted

Original Policy Document

Others (specify) ______________

Customer Relations Officer:

Date:

Time:

Branch Stamp

For queries or more information, call us on 1860-267-9999 (Local charges apply). DO NOT preﬁx any country code e.g. +91 or 00. Available all days from 9 am to 9 pm |

Email - |NRI (For NRI customers only) | Visit -

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Policy Servicing Request Form - Health Plans-1

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