POLICY SURRENDER FORM
PLEASE FILL THE FORM IN CAPITAL LETTERS
Policyholder’s Name:
Policy No.: Mobile No.:
E-mail ID:
Nationality: Indian Foreign National Non-Resident Indian Person of Indian Origin
I accept to receive all further communication from Axis Max Life Insurance through E-mail ID only (strike if you wish to
continue with hard copy). I hereby authorise Axis Max Life Insurance to process my payouts to my Aadhaar linked bank
account and to use the same to validate/update my KYC details.
Bank Details for NEFT
Account Holder Name:
Type of Bank Account: Savings Current NRO NRE
MICR Code: Bank Name:
Bank Account No.:
IFSC Code: PAN:
TDS will be applicable in accordance to Section 1940A of Income Tax Act prevailing at the time of payment. If you are an NRI,
please fill up the NRI declaration, available at the end of this form and TDS will be governed in accordance to Section 195.
Declaration: I am the Policyholder of above mentioned policy. I request you to please process the surrender request and pay
the applicable surrender value post deduction of charges (if any). I do hereby declare and affirm that details provided herein
are true and correct. I understand that on payment of surrender value my policy along with associated benefit will cease to
exist. “I/we understand that, I/we have disclosed my/our personal information (which may include Aadhaar related
information) with Axis Max Life Insurance for the purpose of providing insurance and related services and I/we hereby consent
and authorise Axis Max Life Insurance to use, store and/or share the same with government/regulatory/statutory bodies,
insurance repositories, reinsurers/hospitals or diagnostic centers/other Insurance companies for the purposes of underwriting
assessment, claim investigation/settlement, KYC and policy servicing purposes, as per applicable law.”
Date: D D M M Y Y Y Y
Place: Signature of Policyholder/Assignee:
Note: In case, policy is issued under Married Women Property Act (MWPA, Section 6), please share the consent from Wife/
Husband/Trustee/Legal heir.
No Objection Certificate from Life Insured (applicable only if Life Insured has turned major)
I, , hereby confirm the valid discharge of the requested payout towards
the above policy and will not hold Axis Max Life Insurance liable for any further claim in future.
Place: Signature of Life Insured:
Customer Acknowledgement Slip
We thank you for choosing Axis Max Life Insurance as your preferred insurance partner and hope that you will reconsider our
products in the near future. We regret your decision and hope you have evaluated all the benefits of continuing with your
policy prior to making this application. Your request will be processed within 15 days of submission at our branch office. In
case you need any clarification or assistance regarding your policy, please reach us at the details given on the last page
Date: D D M M Y Y Y Y
Please Note:
• Your request will be processed provided the request form has been filled in completely and all mandatory documents
have been submitted;
• For Unit Linked products, if application is received up to 15:00 hrs IST on a business/working day, the same day’s NAV
will be applicable. However, if application is received after 15:00 hrs IST, then the next day declared NAV will be
applicable;
• In case of address change or contact details change request, please fill up a separate policy service request form and
submit with valid address proof;
• Axis Max Life Insurance shall not be held responsible for delay or non-receipt of the cheque in case the postal address is
incomplete/incorrect in the company’s records;
• Axis Max Life Insurance will not be responsible in case of non-credit to your account or if your transaction is delayed or
not effected at all, for reasons of incomplete/incorrect information provided or rejected by your bank. In case the
requisite information for direct credit is not received or transaction is rejected by the bank, the payouts will be made vide
cheque.
Mandatory Documents Required for Processing Payout
Self–attested copy of official valid document such as Aadhar, Voter ID, DL or Passport or NAREGA Job Card
(Carry Original for Branch Verification as well);
Original cancelled cheque with pre-printed name & account number;
Pass book copy/bank statement having pre-printed name & account number in case cancelled cheque does not
have pre-printed name and account number (carry original for verification at branch);
Latest contact details & NRE bank statement reflecting all premiums paid from NRE account.
Branch Mandatory Checklist
All documents are original seen and verified by the Axis Max Life Insurance personnel.
Retention efforts made Yes No
Reason for surrender
1) Stated policy benefits and returns, as per the policy contract, vary from those understood by me at the time
of purchase
I thought that I need to pay premiums for lesser years/only 1 year
I thought I will get higher returns
The maturity period is different from what I understood
Other reasons:
2) I cannot afford to pay the premium for this policy
I have a medical emergency I have a financial emergency
I am getting better benefits from another insurer
I am getting good returns based on my fund value and I want to withdraw the money
I want to withdraw my funds as the lock-in period is over
Payout to the customer NEFT Cheque
Did you know? Buying a new insurance is more expensive than insurance purchased at a younger age. Don’t surrender!
You can also opt for partial surrender or loan facility, to meet your fund requirements and continue with your policy,
subject to the terms and conditions of the policy.
Low Charges: In the Unit Linked products (ULIPs), the charges reduce gradually over the years leading to a higher
proportion of your premium being invested in the fund.
High Growth Potential: ULIPs provide the option to invest in equity, which provides potential for higher growth
of your funds.
Life Cover: Once the policy is surrendered, the life cover ceases thus depriving you of the benefit when you
actually need it.
Tax Benefit: You can avail tax benefit under the section of the Income Tax Act 1961, subject to any further
amendment.
To be Filled only if Nationality is Other than Indian
Important Instructions:
• All fields are compulsory • Please fill in capital letters
• Attach documentary evidence as marked (*)
Client ID: Policy No.:
Policyholder’s Name:
Father’s/Husband’s Name:
Nationality: Indian Foreign National NRI PIO
Citizenship: Indian Others, please specify
Gender: Male Female Others
Date of birth: D D M M Y Y Y Y City of birth:
Country of birth:
*INDIAN ADDRESS:
Flat No./Building No.:
City: State: PIN Code:
Mobile No.: Tel. No.:
Address Type: Residential Business Registered Office Unspecified
*OVERSEAS ADDRESS:
Flat No./Building No.:
City: State: PIN Code:
Mobile No.: Tel. No.:
Address Type: Residential Business Registered Office Unspecified
Policyholder’s Name:
Request Received Date: D D M M Y Y Y Y Request No.: GO Stamp
Name of Branch Official:
Employee Code of Branch Official:
Signature:
OCCUPATION:
Salaried Self-employed Business Retired Housewife
Others, please specify:
Passport No.: Passport Issuing Country:
*
PAN.:
*Foreign Tax Identification No. (or Functional Equivalent):
Country:
*Country of Residence as per tax laws:
(If more than one country of tax residence, provide Tax Identification No./Functional Equivalent: on all countries of tax residence)
ID Proof submitted:
Election ID Valid Driving License Valid Passport Aadhaar Card
NAREGA Job Card Any Other Government Agency Issued Document
I do hereby certify that above stated information is correct in all respects and may be used for all purposes, including
reporting to statutory authorities & compliances, and understand that it is my responsibility to report the changes, if
any, to Axis Max Life Insurance within 2 weeks of occurrence of such change.
Policyholder’s Signature:
For Office Use Only
Request Received Date: D D M M Y Y Y Y
Branch Name and Code:
Certified that this form
Employee Code: is complete in all respects
and all relevant documents
are obtained and verified.
Signature:
axismaxlife.com/customer-service
For more details, visit us: axismaxlife.com/contact-us
Axis Max Life Insurance Limited (formerly known as Max Life Insurance Company Limited) is a Joint Venture between Max Financial Services Limited and Axis Bank Limited. Important: DO NOT believe
in calls, SMSes or e-mails offering discounts. For NEFT Payments, please transfer only to "HSBC Bank A/C No. 1165 <Followed by 9 digit Policy No> IFS Code: HSBC0110002". Axis Max Life Insurance
does not collect Premium in any other account. Axis Max Life Insurance Limited (formerly known as Max Life Insurance Company Limited): Plot No. 90 C, Sector 18, Udyog Vihar, Gurugram, Haryana - 122
015. Regd. Office: 419, Bhai Mohan Singh Nagar, Railmajra, Tehsil Balachaur, District Nawanshahr, Punjab - 144 533. CIN: U74899PB2000PLC045626 | Customer Helpline Number: 1860 120 5577
The Brand Ambassadors (if depicted herein), have endorsed only the Axis Max Life Insurance Products and are not in any manner endorsing Axis Bank Limited and do not have any kind of association or
relationship with Axis Bank Limited.
IRDAI Registration No. 104
BEWARE OF SPURIOUS/FRAUD PHONE CALLS!
• IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums
• Public receiving such phone calls are requested to lodge a police complaint
