Life Insurance Signature Specimen Form

SSF20024011209

For O cial Use Only

Specimen Signature Format

Branch Name:

Received at branch on:

(A single request form will apply to all Policies)

Received by:

PERSONAL DETAILS

Policy Number: ________________________ Email ID *:_____________________________________________________________________________

(First Name)

(Middle Name)

(Last Name)

Policyholder's name:_________________________________________________________________________________________________________

Contact* No.: (Res) ________________________ / (O ce) ________________________ / (Mobile)________________________

(Mobile No is preferable)

* 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.

Declaration of Life to be Assured/Life Assured

I hereby declare that my specimen signatures in short, full, vernacular language and in all di erent styles are as under.

English (Full) :

English (Short) :

1. _______________

1. _______________

Vernacular :

1. _______________

Other Styles :

1. _______________

2. _______________

3. _______________

Yours

faithfully

SIGN HERE

SIGN HERE

(Signature of the Life Assured)

(Signature of the Life Assured-Joint life only)

DD/MM/YYYY

DD/MM/YYYY

Date: ___________________ Place: ___________________

Date: ___________________ Place: ___________________

Declaration of the CFC/BDM/CAM

I Mr. /Ms. ____________________________________________________________________________, Agency code __________________________

hereby attest and declare that the Life Assured/Life to be Assured has signed in my presence.

DD/MM/YYYY

Attestation by CFC/BDM/CAM

Date: __________________________ Place: _________________________________

Declaration to be made by a third person where:

The Life to be Assured/Life Assured has a xed his/her thumb impression; OR



The Life to be Assured/Life Assured has signed in vernacular; OR



The Life to be Assured/Life Assured has not lled the application.



I hereby declare that I have explained the contents of this application form to the Life to be Assured/Life Assured in ______________________language

and have truthfully recorded the answers provided to me. I further declare that the Life to be Assured/Life Assured has signed/a xed his/her thumb

impression in my presence.

SIGN HERE

DD/MM/YYYY

Date: _____________ Declarant Address: ___________________________________________________________________

____________________________________________________________________________________________________

Declarant Signature

________________________________________________________________________________________________________________________

IRDAI Registration No. 101.

In partnership with Standard Life Plc.

CIN:U99999MH2000PLC128245.

HDFC Standard Life Insurance Company Limited.

th

Regd. Off: Lodha Excelus, 13 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

Customer Relations O cer

Date:

Time:

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