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sDP 50.000-12/12 eTrlrs?T i5fteq sqrLIFE INSURANCE
CORPORATION
ctrt ri,/Form No. 5074/351 0frrrqOF INDIAffi qusa/Delhi Division
-lll
eicqdq/wrqd loq d meiil qtApptication for Surrender /Discounted
ValueqRG6 Irail gr*I?FThe Sr. Branch Managerrrrr&q Eft{q Sqt
ntrqLIFE INSURANCE CORPORATION OF INDIAyrsr rrrq|oq ri./B ranch U n
it No,..................frq rTdqq/rr*{ql,Dear Sir/Madam, _o r
:{fttrq: qrFRft d........... rgdlqq rR........-.
* cil en1 q d eri tnrc dI* Delete where Inapplicable
**
Re.: Policy No. Fvg.ti erq-4 qrffi q,T enqfq $it=rr qrHr Rr
qrrqr eruftr TRI EFI Urrgrq mt d t+ff s.r*w qTtrRft frqi-6. .6]
qR,q{ffi znl srq d {fl t I .rqT C nr6'tEr6rqrl Te{r tnq iF'it=TI
qrgtrl Rt qqqr f* strol gqdn env t I* | intend to surrender my
above Policy. Kindly pay me the same*' My above mentioned policy
will mature on........ ...1 intend to have it dicounted value.
Kindly pay methe same. ' rr{ftq ,/ Yours faithfullY,ff*renrZSi
gnatu re.................".'..T{r =Trq/ Full Name
........:.......qil / Address..
M : qR qrRnff tnr rfirgtyn S gtrT d d 5gr nef+ vaq{ rrr{tRff d
rwren dli ilRq INote : In case the policy is assigned, the
application must be signed by the assignee.
(qsi t6 {\s{FTt End* t)(at which cheque is to be Posted)
61 qrfl d.r{....................... .............scn d crFi6
{........................6 rrqf{'d lga d y-61q o,1 *tqBeceipt or
the Surr
grE arrl qndrq Gftfi 61 ftrs C lr$-ffi qTRFff d qtn Tfl r{trd
(sr
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surrender/Discounted value (inclusive of case Value of
Bonus)D.A.B. Refund
TOTAT Rs.frtiT vrft mre aft rr$lless-1P1/Loanqrq/Loan lnteresttq
frKZPremium Dueq.S. g.?. q qqrril/Apl Debiter;q rtrii /x-
charge
illw va-E arql $R-c o-csr d,/ore d fr ftrd sc dFs si uf.s6-{
(qfr ih)d d) Gfr qrlfrq d-fi ffql ftqq grerqrscslw qftr$ irr0 o-{i
sre Aqr srgqd dm q-6e fl duffefl inr $ .d d {iZ es+ sqEffi crfu{ff
+vrer+tii srqdq fl al$+Es qrftq+{i +ql furq+ffi{,rqi-irqSilqcnQ rfi
er& t gtt{cf VEq rq $q ffRff1tu d g'rcrt d wd qaa{q qI Xflq{q
6r ?i{ *eT{ s?f, ft{rq d ffi orqldq d crq qro 6'{ian//6ii t ffi qmi
qrd$: "l/ We hereby declare that lA ,le have not assigned the above
Life Insurance Policy to any one nor l^^,e have dealtwiththe same
in any manner, except tor any AssignmenvReassignment already
registered as on date by the Life InsuranceCorporation of India
orthe Insurer who insured the above policy upon due Notice. lrlA/e
hereby further Declare that l^/ve have notserved on any office
ofthe Lile Insurance Corporation of India any other or further
notice ofassignment or reassignment in respectof above policy, nor
shall l/vve serve on any office of the said Corporation any notice
of assignment or reassignment betorepayment of Loan/Su rrender
Value/Su rvival Benefit"WITNESS: qR E-c{ ro-q 500 in'.
t3Trffid*1n.mrsfi-fr
Fd'e ffnilRupee One Revenue Stampto be alfixed if
GrossSurrenderValue is Rs.500
lgl ilt{/Full
(fiqrq! d Wsrqn/Signature of Life assured)Son of/Wife of
NEFT MANDATE FORMa(tIO
AccountType: Savings/ CurrenU Cash CrediVNRlAccount No.(Bank
account number should be written from left to right)MICR No.IPS
Code:Mobile Number:+ l9 1r Emailid :
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cte: iiliqfuyefuid rri w-* oqql drn-{ qtRs ffi Rrcrqd olqltrq d
*t-g d r{trd }rqrFrd qffie.e Sdrtlqr!ilfus 3ffq ft{t rn su's
ft-6r{r 3{D-6Rii rn v-oqFs orfffi qr r-r,F.rr ETs ii"rkd errfiq.-
a*;';; J mqYRT S curnrqd/qqntqrqo qr vsrrq-d +cF S \'+ qI Farq S
celq shff 3Tfuqr{ qr frqq d ft-6r{eifM, cfr oq fr oq qis s{ +{..f,
iE_g6r e|*{ *'r{ rri u'A 1Fr d reer< ; *t S Ei# *g* d d am d
wSerRs r ffi d irdrqr s|-q,{IqI { ERrerffi r}i qq s ffi cRs6 H qr{i
ard qfu d am cqrn-d o-rfl qGc r i-iEwnan ar oiSor Rvm ol sqrFr.
6-{i qre rrres of frq q}qsn { rwren o-gi qrRq;Note: llliterate
persons must atfix thumb marks ivhich should be identilied by
attesting Magistrate underthe sealof his office by aJustice of the
Peace or a Block Development officer or a Gazetted ofticer or a
principal/Headmaster of Local High School orHigher Secondary School
run by the Government or an agent of Nattnatised ulnk oi a class I
officer of the corporation or aP::"!?,i:" qftigor of the
corporalion with at least five y6ars service or by an Agent of rhe
corporation who is a member ot rheuluo aI rne level ol Divisional
Manager and above provided he/sho is lully satisfieJ about the
identity of the person (s) executing .the form Signature in
Regional Languages must be attested by a respectabte English
Knowing person. The witness aitesting thesrgnalures orthumb marks
should sign the Declaration bslow:gd{ 3?TSn q:I
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f,/sq gff{ rmr qrrfrq ftrq qq11}rr:n qll sTForr fur Ven t fr
sq$-ffi;; ;;; ;;;;; ;;; ;; ;n",n""I"fl;;;; ;; ;;;;;,; ;;;;;; ;;;;
;T*"ffi"il;lRsAddress5 arfrn ?Tr aTMl i f{-{.frlcrqRerft il fwrerq
friq rWitness: (See introduction below)T{r qrq/Fuil
Name-TrlOccupationtrcn/Address----------:----------
(cd}$'rt srcil frf gq arftf, sT =Trq)EnKilqN//Signatureg3r
oTrq,/FullName-TsII/Address-------
qfur*e q qftgs ouo'fts $ rwrer*t cclFrd 6rdt Efr W qQ-6R rrr ftl
F-flur d//rffi..........................:.............
..................;.........oi s+dam ycfrqd qrdqrqr { qrrw Rqr"m er
gkT6/i sfi-q-dqfuqr qeilqt of voa orgr6pq5q qri+frcc-6qdt rI hereby
certify that the contents of this Note of Authority were explained
by me in vemacular to Shri/agreed to payinent being made
the party or parties authorised
Signature of Witnesstl F
