Freelook Cancellation Form
Policy Number:
Name:
Address:
City: State:
Pin: Contact Number*:
Email ID:
Reasons for Cancellation
Financial Problem Tampering, Corrections, forgery of proposal or related papers
Personal Reason Product differs from what was requested or disclosed
Policy Pack Delayed Policy Pack not received
No requirement Obligation Sale
Please detail out reason for cancellation ______________________________________________________
____________________________________________________________________________________________
Desired Mode of payment
Cheque Direct transfer/NEFT
Bank Details of the Policyholder
Account Holder Name: ______________________________ Bank Name: ______________________________
Bank Account No.: ________________________________________________
IFSC Code: _________________________ PAN Number: ____________________
Note - Kindly attach a cancelled cheque bearing account number and policy holder name or copy of Bank Passbook.
*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.
CUSTOMER ACKNOWLEDGEMENT SLIP
Policy Number
Type of request_________________________________________________________________
Received by ________________________ Date & Time of receipt ______________________ GO Stamp
Employee Code _________________________________ Signature _____________________
• I am the Policyholder of an insurance policy number as mentioned above and have requested Max Life
Insurance Co. Ltd (“Company”) to process the cancellation of the policy under the freelook option, after
deducting the proportionate risk premium for the period of cover, charges of stamp duty paid and the expenses
incurred on medical examination of the Life Insured, if any, in accordance with the policy contract.
• I am aware that the cancellation of the Policy results in termination of the insurance contract and all rights/
titles and interest under the Policy shall stand terminated.
• The payment of the premium refund amount by Max Life in accordance with the terms hereof shall constitute a
full and final discharge of the obligations of Max Life under the policy and I shall not claim/demand anything
thereafter.
• The details provided in this Form are correct and accurate to best of my knowledge and records and I will hold
the Company harmless and indemnified against any and/or all losses, claims, liabilities, legal proceedings
(including attorney fees), expenses or damages suffered by or taken against the Company arising on account of
any error or misrepresentation in the information furnished in this Form by me or any wrongful refund obtained
by me.
Place: _____________________
.
Signature of the Policyholder Date: D D M M Y Y Y Y
DISCLAIMER:
• The Company shall not be held responsible in case the premium refund is not credited to your bank account or if the
transaction is delayed or not effected at all for reasons of incomplete/incorrect information provided by you in this Form.
Credit will be effected based solely on the policyholder account number information provided by the policyholder and the
policyholder name particulars will not be used thereof. The Company may also pay you via any mode like demand
draft/cheque etc.
• The relevant NAV and processing of the Policy will be applicable post receipt of all the requirements/documents received by
the Company.
For Office Use Only (All fields are mandatory to be filled)
Retention by CSE: ___________________________________________________________________________
____________________________________________________________________________________________
Name of Receiver: Employee Code:
Phone Number: GO Code:
Request received Date: D D M M Y Y Y Y Time: H H M M
V2.0/ FLF/Ideas/Oct '17
Signature verified: Yes No
Policy Pack Received: Yes No
Important: DO NOT believe calls, SMS, emails offering discounts. Please pay only to HSBC Bank A/c no. <1165your policy no.> IFSC code - HSBC0110002
Toll-free Helpline
Max Life Insurance Co. Ltd. Plot No. 90A, Sector 18, Gurugram, 122015, Haryana.
IRDAI Registration No. 104
