Faidey ka insurance

SURRENDER FORM
INSTRUCTIONS : 1. The policyholder must sign any cancellation/alteration. 2. Surrender or withdrawal will be done by liquidating the required number of units of the Fund at the prevailing Unit Price.
3. In case of complete application received by the Branch / Head Office of the insurer up to 3 p.m. on a working day, the same day’s closing NAV will be applicable. If application received after 3 p.m.,
units will be redeemed at the next working day’s unit prize. 4. This application will not be effective until it is officially accepted by Kotak Mahindra Old Mutual Life Insurance Ltd.
5. Please refer to the policy contract for terms & conditions regarding Partial Withdrawal/Surrender. 6. Please note that in case any of your premium cheque is yet to be cleared, surrender proceeds shall
be processed but be paid out only after clearance of premium cheque. 7. Account no. is MANDATORY for all type of payments. Request you to submit the original cancelled cheque. 8. NAV will be paid
for the date on which the complete surrender request requirement is received. 9. Please note that for full surrender of policy, the policy document/certificate of life insurance cover must be returned
together with the application. 10. If cheque is not personalised please provide copy of latest bank statement/passbook 11. This form can be sent to "The Policy Servicing Department, Kotak
Mahindra Old Mutual Life Insurance Ltd., Kotak Tower, 7th Floor, Building No.21, Infinity Park, Off Western Express Highway, Goregaon Mulund link Road, Malad (E), Mumbai- 400097.

1. PARTICULARS OF THE POLICYHOLDER

a) Policy Number MWP Case Yes No

b) Full Name : Title Surname First Name Middle Name

c) Contact No : STD Mobile

d) Address:

City: State : Pin : MA ND AT OR Y

Email Address

Do your bit for green world & Switch to e-communication. Kindly mark if you would like to receive your communication through electronic mode.

2. DECLARATION BY THE POLICYHOLDER

I wish to withdraw the amount indicated below from units credited to my policy. I understand and agree to all information and terms and conditions given above and in my policy contract.

Place
Signature of the Policy holder or Guardian (if life insured is minor)
or Assignee (if policy is Assigned)
Date D D M M Y Y Y Y

3. DETAILS REGARDING WITHDRAWAL

Name of the Plan

For KRIP 2/3 Annuity payout (Choose any of the following option)
LIC of India ICICI Pru Birla Sun Life MetLife SBI Life Bajaj Allianze Life

Reliance Life Max New York Life Aviva Life TATA Aig Life Bharti AXA Life Shriram Life

Other Insurers offering annuity plans

4. SETTLEMENT OPTIONS (Pay directly to my bank account mentioned here, please attach an Original cancelled cheque for any payment type)
Payment remittence type Cheque Direct credit
Name of the Policy holder as per Bank record

Bank Name Account No:

& Address
IFSC Code
Account Type Savings NRE* Others (if any)
MICR Code
*Credit to NRE account can be given only if premium are received from NRE account

5. DECLARATION BY THE PERSON FILLING IN THE FORM 6. For Office only (Affix date and time stamp here)
(For form filled in by a scribe or for forms signed in vernacular languages)

I_____________________________________________, residing at ___________________

having known the proposer for a period of ________________ do declare that I have explained the
nature of the questions contained in this form to the proposer. I have also explained that the
answers to the questions form the basis for accepting this request for Partial Withdrawal/Surrender.

Date D D M M Y Y Y Y

Signature of Scribe

DOCUMENT RECEIVED
Surrender form Original Policy Document Original Cancel Cheque Others (if any)

Kotak Mahindra Old Mutual Life Insurance Ltd. Regn. No. : 107, Regd. Office: 4th Floor, Vinay Bhavya Complex, 159-A, C.S.T. Road, Kalina, Santacruz (E), Mumbai-400 098
http://insurance.kotak.com/ Insurance is the subject matter of the solicitation.
1.7/052008

ACKNOWLEDGEMENT
We acknowledge the receipt of request for partial surrender/full surrender for Policy no.: ____________________.

Branch Name Documents received with this request

Date D D M M Y Y Y Y Time H H M M

Name of branch co-ordinator Signature of branch co-ordinator

Kotak Mahindra Old Mutual Life Insurance Ltd. Regn. No. : 107, Regd. Office: 4th Floor, Vinay Bhavya Complex, 159-A, C.S.T. Road, Kalina, Santacruz (E), Mumbai-400 098
http://insurance.kotak.com/ Insurance is the subject matter of the solicitation. 1.7/052008