PAYOUT REQUEST FOR
SURRENDER / PARTIAL WITHDRAWAL
Before you fill up, please consider these interesting facts:
Beat Inflation: Reduced Charges in the Long Run:
Inflation destroys the value of your savings. You can In most ULIP's, premium allocation charges come down over
beat inflation by staying invested for a long term a long term, so more of your premium is allocated towards
horizon. ULIPS have the potential to provide better your fund. ULIPS are thus designed to secure long term
returns over a long term. goals. Incase you choose to surrender your existing ULIP
policy to re-invest in another ULIP plan, you may have to pay
the initial charges once again.
Achieve your Lifes Goals: Pay Premiums Regularly:
Cost of all major expenses are constantly rising. A You can choose from a large variety of options to pay your
long term financial plan with disciplined investment will premium. Log on to www.iciciprulife.com for a complete list.
help you realize all your goals such as your childs You may also visit our website and get the latest copy of
education or building a retirement kitty. Ensure to know more about fund performance.
Policy Number : 02680416 Date : 03/11/2016
Name of Proposer : Ronny Rozario Jose Fernandes
No:: 9820834708
Contact No
Id:: fern.ronny@gmail.com
Email Id
Is this Policy Assigned? YES NO
Assignee Name
ENTITY DETAILS
Entity Type: Individual Non Individual
Entity Regulations: Non Profit Organization Regulated by RBI / SEBI / IRDAI Others Not Applicable
IMPORTANT GUIDELINES:
1. The Policyholder is required to personally visit the branch for submitting this request.
2. If the request under the Unit Linked Product is received up to 3:00 pm IST on a weekday (Mon-Fri), the same days NAV will be applicable. However, if the
application is received after 3:00 pm IST, then the next declared NAV will be applicable.
3. Where the policy is assigned, this request would be processed only on receiving consent / no objection from the Assignee of the policy.
4. All communications will be sent to the mailing address registered with us. The Company will not be liable for any loss arising from non-receipt of communication.
5. If the application for re-instatement/renewal premium and surrender is received on the same day, first the policy will be re-instated/Premium allocation will be
done and then the surrender will be processed on the next working day and the NAV of the date of processing will be applicable.
6. Amount payable on surrender/ partial withdrawal of the units shall be net of all charges, Service tax and Swachh Bharat Cess (SBC). Service tax and SBC will be
charged as per prevailing tax laws.
7. TDS (Tax deducted at Source) provisions are applicable on all taxable payouts under section 194DA (Resident Indians) and 195 (Non-residents) subject to
conditions under section 10(10D) for life insurance policies,10(10A) for commutation and other provisions of Income Tax Act, 1961. TDS credit will not be
available to you if valid PAN is not submitted with us.TDS rate u/s 194DA is 1% if valid PAN is available with us else 20% on total payout under all your taxable
policies aggregating Rs.1, 00,000 or more in a financial year. TDS rate u/s 195 is 30.9% +12% surcharge (if applicable) on tax, applicable on income arising to a
non-resident policyholder.
8. Amount payable on Surrender/ Full Withdrawal of the units shall be as per the policy terms & conditions. The Surrender / Full Withdrawal of the units will result in
termination of the policy and all rights / title and interest under the policy shall stand extinguished.
FULL SURRENDER
Documents Submitted: Welcome Kit / Policy document
Reason for Full Surrender : I have an urgent financial requirement
Note: Amount payable on Surrender/ Full Withdrawal of the units shall be as per the policy terms & conditions. The Surrender / Full Withdrawal of the units will result in
termination of the policy and all rights / title and interest under the policy shall stand extinguished.
PARTIAL WITHDRAWAL
Documents Submitted (mandatory): Welcome Kit / Policy document
Reason for Partial Withdrawal
Name of the Fund(s) Percentage Amount (Rs.)
Note: Request will be processed if withdrawal requested is greater than or equal to minimum withdrawal amount mentioned in the policy document. Partial withdrawal not allowed in case of Pension products.
ACKNOWLEDGEMENT SLIP
This is to acknowledge the receipt of application for: Partial Withdrawal (Amount. Rs.____________________) Surrender/Full Withdrawal
Policy Number 02680416 Form Generation Date 03/11/2016
Validity Date
STAMP
Spaarc Call ID Surrender Request Date &
TIME
Documents Submitted Welcome Kit / Policy document Self Attested Photo ID Signed Cancelled Cheque
Received By
PAYMENT DETAILS :
1. Please take due care and caution to ensure that the bank related information is filled correctly.
2. Payout will be done through Direct Credit (direct transfer to your bank account)
3. This electronic mandate request will apply to all policies held by you with ICICI Prudential where no mandate is currently attached.
Name of Proposer: Ronny Rozario Jose Fernandes
* Where the policy is absolutely assigned the payout will be processed in favor of the Assignee
Bank Name: STATE BANK OF INDIA
Name:: THANE (THN)(0489)
Branch Name
Number:: 31628268398
Bank Account Number
Bank Account Type : S
Code:: 400002094
MICR Code
(You can get this code from your cheque book)
IFSC Code
(You can get IFSC code from your bank)
Bank Proof Submitted
Note:
1. Please take due care and caution to ensure that the bank related information is filled correctly.
2. Payout will be made in Savings Account only.
3. Bank account number provided in this form should match with the account number appearing on the cheque. The account number must be pre-printed
4. This electronic mandate request will apply to all policies held by you with ICICI Prudential where no mandate is currently attached
5. Any payout under the policy shall be made after realization of the last renewal premium payment.
6. If the transaction is delayed or not effected at all or is effected in some other account for any reasons due to incomplete or incorrect information, I shall not
hold the company responsible in any manner.
7. I/We further confirm that the account details provided herein are not pertaining to NRE account and NRE payouts will be processed by cheque only
8. I/We understand and agree to inform ICICI Prudential with an advance notice of 6 weeks;in case I/we desire to change my bank details or withdraw the
current mode of payment due to any reason, however,ICICI Prudential shall retain the right to accept/reject this in case the revised bank details are not
enabled under this NEFT Framework.In case details are not submitted 6 weeks in advance, then the interim payments will be processed by way of cheque
and will be sent at your registered communication address.This mandate shall be used for future payments, if any.
9. I hereby declare that the particulars given in this form are true, correct and complete in all aspects. I take full responsibility of accuracy and correctness of
the details filled herein.
10. Further, I undertake that I shall not hold the Company responsible for non-receipt of payment due to wrong/ incorrect/ incomplete information given by me
in this form. I also understand and agree that the Company reserves the right to use any alternative payout option.
Signature of Proposer Signature of Assignee
DECLARATION
Applicable when the Proposer is illiterate or suffering from disability due to which writing is restricted or the proposer has signed in vernacular language. Note: Must be
witnessed by someone other than the advisor/agent/employee of the Company.
I (Full name of Witness) (Relation with Proposer)
adult and inhabitant of (Address) do hereby declare
that I have read and explained the contents of this form to the Proposer and he/she/they have understood the same.
Signature of Witness Mobile Number of Witness
FOR OFFICE USE ONLY: Form Spaarc Call ID Surrender Spaarc Call ID
Form Generation Date 03/11/2016 Validity Date Surrender Request Date
Received by
STAMP
MANDATORY DECLARATION BY BRANCH OPERATIONS & SALES EMPLOYEE: &
TIME
I hereby confirm that I have explained the benefits of policy continuance & the implications of surrender of the
aforementioned policy to the policy holder.
BRANCH OPERATIONS EMPLOYEE DETAILS:
Ops Employee Name and ID
(Signature of specified person)
SALES EMPLOYEE DETAILS:
Sales Employee Name and ID
(Signature of specified person)
REASON FOR NON-AVAILABILITY OF SALES PERSONNEL:
Not present in branch Attending other customer(s) Others (please specify)
Kindly call our Customer Service Number 1860-266-7766 (local charges apply)
Call Center timings: 9.00 A.M. to 9.00 P.M. Monday to Saturday (except nationalholidays)
Communication Address
ICICI Prudential Life Insurance Company Ltd., Raheja Tipco Plaza, Rani Sati Marg, Malad ( E ), Mumbai 400 097.
