Policy Servicing Request Form-Health Plans - 1
For Official Use Only
Receipt Date & Time:
Employee Code: _______________________
Policy Number ________________________ Email ID * _____________________________________________________________________________
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)
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)
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.
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
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 _____________________________________________________________________________
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:____/____/_______
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.
Date _______________________ Place __________________________ Appointee's Signature:
(No thumb impression)
IRDAI Registration No. 101.
HDFC Standard Life Insurance Company Limited.
In partnership with Standard Life Plc.
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:
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