Change In Specimen Signature Form printable pdf download

PSRF540823021605 Comp/feb/Int/4631

For Official Use Only

Change in Specimen Signature Form

Branch:

Received at branch on:

(Applicable for all Policies)

Received by:

Personal Details

Name of the Policyholder: ______________________________________________________________________________________________

Policy No.: _________________________________________

Aadhaar / PAN Number: ____________________________________________

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 Change in Specimen Signature

I, _________________________________________________________ wish to inform you that I have changed my signature as stated below:

SIGN HERE

Existing Signature

New Signature

I hereby hold HDFC Standard Life Insurance Company Limited and its agents, employees or directors, harmless, from all losses or damages suffered by them,

on reliance of the above details.

Yours faithfully,

SIGN HERE

(Signature of the Policyholder)

(DD/MM/YYYY)

Date: __________________________

Place: ____________________________

Banker's Verification format

I/We confirm that Mr. / Ms.__________________________________________________________________________________________________

Operates the Savings / Current Bank Account No.

and the above signature matches with our records.

Name of the Officer: ______________________________________________ Name of the Bank: ________________________________________

Branch Name: __________________________________.

Signature & Seal of the

Confirming Authority

Declaration made by third party where the Policyholder has signed in vernacular:

I hereby declare that I have explained the contents of this application form to the Policyholder in _______________ language and have truthfully

recorded the answers provided to me. I further declare that the Policyholder has signed / affixed his / her thumb impression in my presence.

(DD/MM/YYYY)

Name: _______________________________________________________ Date: __________________ Place: ______________________________

Signature: ________________________ Address: ______________________________________________________________________________

HDFC Standard Life Insurance Company Limited. In partnership with Standard Life Plc. CIN:U99999MH2000PLC128245. IRDAI Registration No. 101.

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

Customer Acknowledgement Copy (Change in Specimen Signature Format)

Policy No.:

Policyholder Name: _________________________________

Branch Stamp

(DD/MM/YYYY)

Customer Relations Officer: ___________________ Date: _____________________ Time: _________________

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

from 9am to 9pm | Email – | NRI (For NRI customers only)

Visit –

Change In Specimen Signature Form

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