SURRENDER/PARTIAL WITHDRAWAL REQUEST FORM

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Mandatory documents of policyholder- Self attested Photo ID & Address Proof, PAN, Customised cancelled cheque/Pass-book,Policy document/Indemnity bond /m1i66nJCTUllllO(ll)Ao nu121i61!:ilG1<fflQli Qlll)&Jdbcil, • G1nJotllnu1C1n00ci1,woA6>S nupo CTUOdh!ll.)6l�SAtum1(11) <m1<ll1�o1(11)a,i G1m&1, G1121ai6nl1eiO<TU G1m&J, nJocil,, GinJ<li" !IIID�s1�1a!ii. db.)ocil,nuai6 6>.4.l<J,11 6l.4.ldKi"/nJoq;\j-6!lJ,ldKi", QlnJO!i!1nu1 G1WOcN>A6llll�/1!1ci1,6lwai'm1A1 G16!lJ:>6Tli

• Kindly recons ider your dec is ion of surrender ing your Insurance pol icy, as it is worth your F inancial Secur ity!! • Your Insurance product del ivers best value in the long term • Please opt for a Partial Withdrawal to meet your emergency requ irements

IRDA REGN. NO. 142

• (3(ll)G.JOCD51 (!n.JOgimll (Tl)06m!© 6l.!l.J(fill<mas5lm.i� <l!l0!9,§l6lS asliCll.jlllOmo nJ.jffi:�<6](!(1l)OuJl.&6l.jd3o. d3o0Cll6Tllo, (lfCl)(l5) (l!)000,�6)S (Tl)OmJwrnSld3o r.lLC3<l!l6l(ll) (!(30�d:l,ClllllOm51 6llJOuJl.&6l.jo!!• �&neid3ooeJ cm!lsicru.oomwrnll<do <l!lom,�6ls §'Q®�ocroml' <!n.Jogimll <l!lom,cilice6l' ruellw (n.J<!WOl!!!mo 6l.!l.J<fillo.• <l!lOW,�6ls cm!lsiwmrllro (Tl)OmJwrnSld3o CUWG.J(ll)j6lll3cili cu.1&rorolid3orol.&6l6cmas51oi' Bwruom51 r.ioulld3o nJlcioruell.&6l� mscm>6d3o.

D Polley Surrender D Rider Surrender D Partial Withdrawal (please mention the amount) Rs. _______ ./-

G1nJo§lcru1 nuo&llil/6 6l6low/6 QlnJO!i!1nu1 110001db n.J1okuei1cN>mi ( S(ll)OJO(ll)1 <mJdb C11Cll&16l�SJtumJdb) <llA· ------�

Policy No./ <!n.JO�m51 mm.Jm: DDDDDDDDDD PAN (Mandatory) I n.J:>cio (mlili6Y1jrrwo): DDDDDDDDDD �������

1:;t��e!:Um: DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD Address/ nJleJ:JCTllo: DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD

DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD Phone No./ (!nJJ:J6n11m.: DDDDDDDDDDDD �lll<;�i���-�.:DDDDDDDDDDDDDDDDDD Email ID/ [Q6lCDm5i<do 6l<l(j)cull: DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD :�:��!>������Cll6TTlo:DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD

Bank Account Details (Mandatory) / 6Tl..l:>llb «mlc86)'116Tli ru1rum611BCRl ( m1il>6J11m.uo)

!;��:�����o�:s"��m: DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD ==� DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD =���DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD :������m.: DDDDDDDDDDDDDDDD �!��!�m5l<!dh:J(U):DDDDDDDDDDDD ��:;�c:;madhO(U): DDDDDDDDDDDD :t���2:��.:DDDDDDDDDDDDDDDD ::��:l����:m.:DDDDDDDDDDDDDD DD

(*mandatory for payment of Assigned policy) (*cm!l6l6lci;\l® <!n.Jogimllw66ls <!n.J6laic@oi' CTil&6Tllm..uo)

(**mandatory for payment to Union Bank of India NRE or Union Bank of India Assigned policy) (**wJGTT51Wm> 6llJ:Jllh 63:Jnfl �Cllllj amm>cuw&�, WJGTT51Wm> 6llJ:Jllh 63:Jnfl �Cllllj Cl!Tl)6)6lci;\l®cul' C:n.J:igimll C:n.J6llllCWd3ocili.&6l.j mlil>6Tllm..uo)

Note: Account has to be Active and at least 6 months to 1 year old / eSll1cN>Jdb: (IR)cN)'lJW �,C'l.J!O dbJ0611'TO)ari' 6 lllOCTllo �cmai6 1 ruil>n!lo OJ6)(l) nJ'f'cNl�RllAO C119(11)1Cll1cNlfil'T>o.

SURRENDER /PARTIAL WITHDRAWAL DETAILS- For Branch use only/ cruo6Tlilro/so(l)1.e, n.J1cil>ruei1c86)af6 ru1rum611BCJD - l6Tl..l:>6T2ll16)tfl �n.Jcsa»:>(l)cum1mJ aiolano

Surrender effective date: f"olf"olf'ii1'M1fylfylfylfyl(Tl)06m!il> (n.J06llleJjwrn1leJOd3o,l<Tn asliwa,51: ����L'..JL'..JL'..JL'..J

Gross Surrender value: Rs. _____ �/-!1!©!6ld3o (Tl)06m!il> lllJeljo: roA. -----�/-

-g:.c:-------------------------------------------------------------------------------------------------------------:>c(;--ACKNOWLEDGEMENT SLIP - SURRENDER/PARTIAL WITHDRAWAL REQUEST FORM *4�cocru1ari' - CTU06ffil«>/tiOCJ>1db nJ1m>OJeJ1c86>e.i1m� Rffl)<l!nJdb!tO <l!nOOOo

Pol icy No./ c:n.Jogimll m. DDDDDDDDDD IRDA REGN. NO. 142

��������ce��se!:Um: DDDDDDDDDDDDDDDDDDDDDD Branch Date/Time Stamp

(Affix stamp in this box only) Thank you for choosing Star Union Dai-ichi Life Insurance. Your request will be processed in 1 O days subject to documents being complete p (l)J.16Tlil(l)Jm> CUJoall'-!)2..g.jl ooeinrl' !J2�0m>ml' .e,mmil ellmlflcuJl6lm ©llro6l6Tm)S6mm©llm6 m<rll. aro6lJ.e,6l�Oo c.\l�m;Jn/1, <lllO!Bo!l,l6lS �oJ<B"1 oJromoruull 10 [oJru,)moll BirumJ6ffl3<md!6ldbo 6l[oJOCTUC);ll 6l.!l.J'¥l!ITTl<1!l061Tl.

l6llJ06T!!ll asllwroll/(Tl)lll(ll) �lB (g;Q'"O d3o�ri� lllO(<l!lo �lB n.Jas51.&6l.jd3o)

SURRENDER/PARTIAL WITHDRAWAL REQUEST FORM CYU06Yliro / 800016 n.J1<mOJeJ1c86>eJ1m6� Rm>�n.Jdb!:tO �n!lOOo PAGE I 2 I cxn.Jsli' I 2 IRDA REGN. NO. 142

ADVANCE DISCHARGE RECEIPT/ am,cw.J:>cmcru cw1cru.!2..l:>if>N mcru1an

Received from SUD Life sum of Rs. ____________ in full settlement of all claims, as per the policy number mentioned above, in

consideration of which the said policy is hereby discharged, surrendered.

O(j)mi'w6cu51 6l6leJrullm'li mlcm6o mJ. fl\ldb�m'li 6ldbos6{l!Tll)]c6ld!€J6cm <lin.JO�mll mffiJc6lm6 db,\91� �o �w5lfDJdb�6lSW6o "-llill6l;IJillOW 6lcru8'm'li6lm�owfl 6l6ldb\l:IRl,dbW6o <lim�o= <lin.Jo�mll �cnllmom'li cu51mi'-'l..loillM 6l-'l..l�dbw6o cruo6TTilro 6l-'l..l�dbw6o 6l-'l..lC\IJ!c6id!€l6cm6.

Note: As per the new IRDA guidelines, the cut off timings for NAV applicable currently is 3:00pm. This implies that if the application for surrender is

received up to 3:00pm on a working day (Mon-Fri), the same day's NAV will be applicable. If the application is received after 3:00pm on a working day

(Mon-Fri), then the next working day's NAV will be applicable. If the applicable day is not a valuation day, NAVof the next immediate valuation day would

be considered. Charges as applicable will be deducted from the Gross Surrender value.

�1c8'>lce,: 6l"(j)rn@lilicu5inffi rrll6JlJ<TWmdbcil> Clm)m6mx61.qJ nffim>nffinll 6JlJOWdblllOd!€J6cmcnllm6� rrlleinll� crumw n.Jc6iu51 �-'l,ldb\916Tml 3:00 m61Tllwo6Tll. rowcnll6l� Clm)roanoo 63m6 tn.JQ\l{l!Tll)] BiruCTU(l!Tll)]am ( cnlll!bcil> - 6lru�) �-'l,ldb\916Tml 3:00 m61Tll ru6lm eirelid!€J6cm cruo6Tlsro Clm)Cln.Jdh'lldbcil>dMl Clm)CICl!l Blrucru6l= nffi®nffinll 6JlJOWdblllodb66lmcmo6Tll. 63m6 tn.JQ\l{l!Tll)] BiruCTU(l!Tll)]am (cnlli!bcil> - 6lru�) �-'l,ldb\916Tml 3:00 m61Tlld!€J6 <li�o eir.lld!€J6cm Clm)<Jin.Jdh'lldbcil>dMl rows6= (n.J(l\\(l!Tll)] Birucru(l!Til)]6lei nffim>nffinll 6JlJOWdblllO<flllcmCl!lo6Tll. 6JlJOWdblllO<flllcm BiruCTUo nJOeJ.,ll<JOJ�m> BiOJCTUlll6l�llblm'I,, Clm)cnl]m.i 6)Cl!l0§S.!rnTlll (lJOeJ.,ll<JOJ�m> Blrucru6lrnTl!l nffi®nffinll n.Jc61Ul61Tlld!€J.!(TnCl!l06Tll. 6JlJO(l)d3,lllOd3,6(Tn -'l..lOffil!!J€l\ldbcil> rn@)6)d3, CTU06TTilro lllJelJ(l!Til)]m'li rrllcm30 d3,\9]d!€)6ffi)Cl!)06TT).

Name of Policyholder: <Bn.J:Jt!1m>1<Bnnocil>cwol6lS <Bn.JCD:

Name of Witness: m>Odldl1ll»l6lS <Bn.JCD:

Please affix Re 1 /· revenue stamp & sign across

the stamp

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Signature of Policyholder: <Bn.Jot1cru1<Bnnocil>cwol6lS sll::f:

Signature of Witness: cruo-1a»l6lS �:

Policyholder has affixed thumb impression OR Policyholder has signed in vernacular OR Policyholder has not filled the Application an.J�mllannocil>cwill 6ln.Jm6nllmeiswo�o n.Jcnll.!ld3 Clm)6l�llhlm'I, an.Jo�mllannocil>cwill tn.JOC1BCJ6idb eso�wflm'I, 63\l:16 nJ-'ld3 Clm)6)�1!b1m'li an.J�mllannocil>cwill Clm)<lin.Jdh'llO <Jio.nooo n..\lc6lll::!1-'1fl�

I Mr./Ms./Dr. /

6Cl!lOCID, a!l./a!lq;\j'/<liC\DO.

Address / oJleiocruo

having known the policyholder for a period of DD (month/years); do declare that I have explained the contents of this form to the policyholder in

his/her language and have truthfully recorded the answers provided by him/her. I further declare that the policyholder has affixed his signature/thumb

impression in my presence.

<lin.Jo�mll<linnocil>cw6lo db\916TOTID DD (mocruo/ruro�o) dboeimowfl n.Jc6i-'l..lWfDJ6TTi!. 6TIDO® �'ll Clm)<Jin.Jdh'llo <Jio.noo(l!Tll)]6l� ��sd!€Jo <lin.Jo�mll<linnodlicw� Clm)WOg?,!6lS/ Clm)OJm66lsCTUJm!)o eso�wflm'I, nllruc6l.!ld3 mm'li<fllldbW6o Clm)Wodli/rowruro mm'lidb1w �=m=dli CTUCl!lJCTU<TWmowfl <lim6ll6lll:IS6rnTl!l6dbw6o 6l-'l..l<w.\ O(j)cm 6TIDO® �cnllmom'li CTU:>dh'l:1J6lll:IS6rnTl!l6cm6. dbJS06lCl!l, an.Jo�mllannodlicwro nffi6l� cruofTTliB.llJ(l!Tll)]cefli 63\l:13 OJ.!ld3/6ln.Jm6nllmeiswo�o n.Jcnll-'ld3 nfficm6o 61IDO® �cnllmocdli cruodh'llJ6l\l:ls6=6cm.1-

Signature of Declarant: mJ0d3,<!jJ6J\l:IS6cirrm6cmW0™6JS 63\l:1°:

Star Union Dai-ichi Life Insurance Company Limited Registered Office: 11th Floor, Vishwaroop I.T. Park, Plot No. 34, 35 & 38, Sector 30A of IIP, Vashi, Navi Mumbai - 400 703.

'ii': 18002668833 (Toll free)/ 022-39546300 (landline) - 8:00 am to 8:00 pm (Mon - Sat). Email: customercare@sudlife.in I Website: www.sudlife.in I IRDA Regn. No. 142 I C.I.No. U66010MH2007PLC174472

�o/6 a»J61Tl1a»df> ru.>oa»-�..!_?,11 6>6leJnd' �m>n!!,!ool><TU .e,m.Jm1 ei1m1ACU> (1)1111<BCX!lCD<Ui" 6Mlno"l<TU: 11-oo rrllei, nJl(Jl)J(l)Jn..J 6lnffi§I n.JOrodMl, <JgdO§ m. 34, 35 & 38, 6lnffi6lnffin..ll 6lcru�ro 30nffi, ruo�, mnll Q)Jo6l6l6JlJ - 400 703.

'ii': 18002668833 (asodli tcul'I) / 022-39546300 (eiom>ru56l6leim>) - roonJl6lei 8.00 fl\\Cl!lcdli 6l6lru<ibl§'8.00 ru6lm (cnlli!b�0-/-'2..1 - (Jl)rrl]<ll):J-/-'2..1). �6Jmwl�: customercare@sudlife.in I 6lru6TlJ6l6lCTUfl: www.sudlife.in I 6lnffirn@liliru.5lnffi m�. m: 142 I C.I.No. U66010MH2007PLC174472

SUD/Sept2015/ PSRF-Ver4/Mal Trademark used under licence from respective owners/ •tsrul'moill.oo '""'""""" �mCTUDc6i<ll> mim,6� 6l6leJ<l"lXID01llCf'6 ..,,,'91"" �nJo<DJoull..!JJ!c61...,,CTf'6.

SURRENDER/PARTIAL WITHDRAWAL REQUEST FORM CYU06Yliro / 800016 n.J1<mOJeJ1c86>eJ1m6� Rm>�n.Jdb!:tO �n!lOOo PAGE I 3 / csn.Jsi I 3 IRDA REGN. NO. 142

FOR OFFICE USE ONLY (Affix stamp in the box) / �on.01cru �n..Jcsco,:>oo(IMl)1m6 m:>l®o ( cfbi(IMl)1m6�ai IDJ.lG n..Jan1.oo6db)

Signature verified: 6lll::J n.Jc6J<l1Cll>OuJl-9,ll:

DYES / �<11' ONO/�

Bank/Branch staff signature/GT1Joi!b/lGT1Jo� �aa,iomCTU06l(Vl 6lll::J: _____________ _

Branch Checklist / t6llJ0611ll' n.J<b1C3CJ&ow1C3Mln dl>O<b,1'813�:

Policy Document / Indemnity Bond / C!n.Joglmll C!CUJ0'66ll,6llllc-@" / gQ®6lcwlli'mlR1 C!6TlJ06m:

Cancelled Cheque in original / Pass Book Copy (self attested) / cS,JOITTlm>ctrn 6l..!lJCQl 63ol2l!Jmarn 6l..!lJcOO / n.JO<);ll 6TlJl,c&6516lCVJ C!cS,Oll::!l ( m>JCllJo m>O.-J6lll::JS1,®miCllJ@"'):

Photo ID proof (self attested) / C!n.OOC!§O 6l<,mcu51 <llm6lJ ( m>JCllJo m>o.-J6lll::JS1,®m1CllJcm"'):

Address proof (self attested)/ C!lllctrnnJleiom> C1m6lJ (C1UJCllJo m,o.-J6lll::JS1,®miCllJcm"'):

Customer Signature Verified / g2n.JC!@ocemonJ16lCVJ 631l::f 6lruc616l6ln.O 6l..!lJ�:

Star Union Dai-ichi Life Insurance Company Limited

Branch Date/Time Stamp (Affix stamp in this box only)

[6T1JO� rn\'ICllJcmi / CT1Jf1lCllJ fl\l[B (gQ'O <Ebfil<mlJctrn lllO[ClSlo fl\llB n.Jcmi'86ll,<Eb)

D Yes/g29J D No/�

D Yes/g2<1l' D No/�

D Yes/g2<1l' D No/�

D Yes/�<11' D No/�

D Yes/g2<1l' D No/�

Registered Office: 11th Floor, Vishwaroop I.T. Park, Plot No. 34, 35 & 38, Sector 30A of IIP, Vashi, Navi Mumbai - 400 703. 'ii': 18002668833 (Toll free)/ 022-39546300 (landline) - 8:00 am to 8:00 pm (Mon - Sat).

Email: customercare@sudlife.in I Website: www.sudlife.in I IRDA Regn. No. 142 I C.I.No. U66010MH2007PLC174472

�o/6 a»J61Tl1a»df> ru.>oa»-�..!_?,11 6l6leJnd' �m>n!!,!ool><TU .e,m.Jm1 ei1m1ACU> <blll1CICX!lCD<Ui" 6Mlno"l<TU: 11-oo mlei, nJlCll>J(l)Jn..J 6l"{j)§I n.JOio<B6l, CIIJdO§ m. 34, 35 & 38, 6l"{j)6l"{j)n.Jl 6lCT1J�io 30"{j), ruo�, mnll f2\lo6l6l6T1J - 400 703.

'ii': 18002668833 (asocilJ lcul'I) / 022-39546300 (eioc:ioru56l6leJc:io) - roonJ16leJ 8.00 fl\lC!Slmi 6l6lru<ibl§'8.00 ClJ6)(l) (cml!ll>filO'i..!l.l - Cll>miCllJO'i..!l.l). &Q6llllwictrn: customercare@sudlife.in I 6lru6TlJ6l6llJUfl: www.sudlife.in I 6l"{j)csmiioru.5l"{j) m�. m: 142 I C.I.No. U66010MH2007PLC174472

SUD/Sept2015/PSRF-Ver4/Mal Trademark used under licence from respective owners / •tsrul'moill.oo '""'""""" �mCTUDc6i<ll> mim,6� 6l6leJ<l"lXID01llCf'6 ..,,,'91"" �nJo<DJoull..!JJ!c61...,,CTOl·