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POLICY
DETAILS
I request Exide Life Insurance Company Limited to release my survival benefit amount for the below mentioned policy.
Policy Number*:
ADDRESS
Address*:
City*:
State*:
PIN*:
Landline*:
Mobile*:
PREMIUM
ADJUSTMENT
E-mail*:
Renewal Premium adjustment*
BANK ACCOUNT
DETAILS
TAX DEDUCTIONS
Yes
No
I hereby agree for the installment premium which is due on the benefit due date (current and future), to be adjusted from the proceeds.
Bank Name*:
Bank Branch*:
Account Number*:
IFSC Code*:
Savings
Current Account
NRO
In case the IFSC code is not provided or if the same is not enabled for NEFT, then the payout will be made by A/c payee special crossed cheque. Direct credit is
not possible for NRE accounts.
No
As per Finance Act 2014, payments made under Life Insurance policies which are not exempt under the Income Tax Act are subject to tax deduction at source @ 2%
(Under Section 194DA). In case the payee does not furnish valid PAN details, the rate of tax deduction will be 20%.
No
DOCUMENTS REQUIRED
Note: In case you are not a Resident of India, then tax deductions will be applicable as per beneficial provisions of treaty with the respective Country of Residence.
Please submit the following listed documents along with the mandatory requirements (*).
1) Self-attested valid photo ID proof *
3) PAN card*
4) Original cancelled cheque with your name and account number pre-printed* OR
Self-attested copy of bank statement / pass book copy with bank seal.
List of valid address proofs: Telephone Bill, Bank letter/ Account Statement, Water Bill, Electricity Bill, Valid Passport, Valid Driving License, Ration Card, ESI Card, Domicile Certificate,
Company Lease Agreement/Rental Agreement, Employer's Certificate. Statement/Receipt/Bill should not be more than six months old from the request submission date. Please attach
self-attested identity proof bearing photo (e.g. Pan card, Voters ID, Passport, Driving License, Aadhar Card)
DECLARATION
I take full responsibility for the genuineness and correctness of the details filled herein.
Signature / Thumb Impression of the Policy Owner / Assignee*:
Date
D D M M
Witness
Signature*:
Y Y Y Y
ACKNOWLEDGMENT
SLIP
FOR OFFICE
USE ONLY
*(Should be someone other than the advisor/employee of the company and who has also explained the contents of this form if signature is in vernacular or a thumb impression.)
Date:
Branch
Code:
D D M M Y
Y Y Y
Signature:
Employee No.:
Documents received:
Valid Address Proof
Date:
D D M M Y
Y Y Y
Policy No.
Identity Proof
PAN card
Sign:
Branch
Seal
Others______________________________________________________________________________
Email : customer.service@exidelife.in
Visit : exidelife.in
Registered Office: Exide Life Insurance Company Limited, 3rd Floor, JP Techno Park, No.3/1, Millers Road, Bengaluru - 560 001.
(Formerly ING Vysya Life Insurance Company Limited)
CIN: U66010KA2000PLC028273
POS/SBP/Version 1.0