sDP 50.000-12/12

eTrlrs?T i5fteq sqrLIFE INSURANCE CORPORATION

ctrt ri,/Form No. 5074/351 0

frrrqOF INDIA

ffi qusa/Delhi Division -lll

eicqdq/wrqd loq d meiil qt

Apptication for Surrender /Discounted Value

qRG6 €Irail gr*I?F

The 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 qr€Hr 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 me

the 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 I

Note : 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

g€rE arrl qndrq Gftfi 61 ftrs C €lr$-ffi qTRFff d qtn Tfl r{trd(sr<t d Ea roq qRn)

-''....'...-.'.---....:....-...-...-...-...'H.#;.q.;-.*'ffiit,zgqri am rr<rers Qri 'ri t

surrender/Discounted value (inclusive of case Value of Bonus)

D.A.B. Refund

TOTAT Rs.

frtiT vrft mre aft rr$lless-1P1/Loan

qrq/Loan lnterest

tq frKZPremium Due

q.S. g.?. q qqrril/Apl Debit

er;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 grerqr

scslw 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-frFd'e ffnilRupee One Revenue Stamp

to be alfixed if GrossSurrenderValue is Rs.500

lgl ilt{/Full

(fiqrq! d Wsrqn/Signature of Life assured)

Son of/Wife of

NEFT MANDATE FORM

a

(t

I

O

AccountType: Savings/ CurrenU Cash CrediVNRl

Account No.

(Bank account number should be written from left to right)

MICR No.

IPS Code:

Mobile Number:

+ l9 1

r Emailid :

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 <trl fr{ilvr S............ ...........rrr rrrfl frqr.Rn t sin s€ii firfiq qi .rS qiR qrrs di d qrEt} srqi E-ffiqfi fut d/orq.+r ei.pr .ryqm t I

The content of this discharge form have been explained to .....,......

..'...and he/she/they hasihave signed the same after understanding the same.

SEAL OF OFFICE

IF ANY

rneft qil Hrt ;rFI/Name of Witness............rndfr S frcren/Signature of Witness

orqnrq oI 3fl ,/Seal Off ice

vRgs gr-fl-qqiqr\E ri 3IE-6qfu{fi ieeren ffi€ fu-€g.r-drigrq * fu,ff\'dFqfuol ffriqridE:€'r +aaff'T{ i iit ft-q qfu o} ror *l 61 3Tfqqrn i:cr E} s0 dg o-{ €rq rr$ qfrilqj *1fld Rqr i[fi-o.n q-, qGil*e ql qfussilo'*q qr t|dqBf, srffi sI rso.s f6Ts srlffi-fff ql TI[6R am riqrfuc errffq va h.gr6rq S cElr|rqrd/strFFarq-fiqI {Sq-E-d i{$ S \rf€ IIt Rqq 6sw aM 31punq*ft{qdffici oqt oq frq s{ fsr{-d i|-6 g6r d sf{rytcr.conion a 1r+n * erf { luia-cr e-ge e}d i{rrs fl s*rd efffi o€ qftcr atr $l g.16rq T,

"**i-"f ueqfu d srflqr frn+ srq tqfu 6) frqr qrflr t ql ss qfl { frrq qfuon cr d rff srrqy{--fl dfi r

lmportant

lf the within written receipt is signed by more than one person and payment is desired to bs made to only ono of them thsn thefollowing note ofauthority must be completed and signed byallofthem before a magistrate orto aJustice of peaceorGazettedofficer or a Block Development Otficer or a Principal/Headmasts of Local High School or Higher Secondary school run by theGovernment orAgenl of a Nationalised Bankora class-lofficer of the Corporation ora Deveiopmenr ofiiceiortne corporationwith at least live year's service provided he/she is tully satisfied about the identity of the executants The letter of Authoriv willalso be required if paymentisto be madetoany person otherthan the signalorios or the recerpt.

f,/sq gff{ rmr qrrfrq ftrq qq11}rr:n qll sTForr fur Ven t fr sq$-ffi

;; ;;; ;;;;; ;;; ;; ;n",n""I"fl;;;; ;; ;;;;;,; ;;;;;; ;;;; ;T*"ffi"il;lRs

Address

5 arfrn ?Tr aTMl i f{-{.frlcrqRerft il fwrerq friq r

Witness: (See introduction below)

T{r qrq/Fuil Name-

T€rlOccupation

trcn/Address----------:----------

(cd}$'rt srcil frf gq arftf, sT =Trq)

EnKilqN//Signature

g3r 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 r

I 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 Witness

tl F<flefi/Full Name.....................

Instructions:qr; oi-ion q-* { qftGz qt qfus q frs cr qlqcfud i{Ao.rQ qr go-e frors srFmr{r qr F{irrq aRr {qrfuc safrflraq qI sqin qrtqR-6 G-qffiq d a {|${€-d +6 d \rf€ qI ftqq d nan a}off idffi qt ftqqdfi-rrs3dffi, doq$dqciqs{rtcrdr6gorE} sftrsgrffio'frrql*cltq gutilqldg€didsqfuffi{ FFre-rftioriqGcrThis fetter ot authority must be signsd before a Magistrate or aJuslice of peace ora Gazetted Otficer or a PrincipayHsadmasterot Local High Schoolor Higher Secondary School run by the Govornmentoran Agentof a Nationalised Bank ora Class I Otficerof the Corporation or a Development Ofricer of the Corporation with at least live years service provided hs/she is tully satisfiedabout the identity ot the executants.qRqffiq{ qri qrd qFR erRrl*c€orefi Gdd erdnrfrr qrcrlm$ t d gei6i mrqoqRqffiqt\ilRrssitq +s ql rs!-s ft-6'rs offfi qr rroqBc olffi q1s** em dqrfuc erftq sq frqraq qt vq crqfud frqFTq SctfFTtqrd/cqr{ft4lq-fi qr yT*rrE-d to d \'+€ st Rqq d eqq 4bn qffi S oq $ oq vta q14 *arrc r-e gor t'l amlrro-t rrnen d-fl qGc I

This endorsement is required to be completed and signed by the attesting Magistrate or Justice of the peace or BlockDevelopment Officer or Gazetted Otticer or a Principal/Headmaster ol Local High Schoo/Higher Secondary School run by theGovernment or Officer of Nationalised BankorClass I Officerofthe Corporation ora Development Otficer of the Corporation withat least tive yeafs servicewhen the note ofAuthority is executed byan illitrate orvernacular knowing person (s)