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Application For General Changes: (Kindly Fill in Block Letter and Use Black Ink)

This document is an application form for general changes to a life insurance policy. It requests updates to the policyholder's identification details like PAN and Aadhar numbers, address, contact details, premium payment mode and source. The policyholder declares that the information provided is correct and consents to linking of Aadhar and PAN details for authentication. Original identity documents must be verified by the insurance branch. The form requires signatures of the policyholder and branch official processing the request.

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Nithin K Reethan
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Download as PDF, TXT or read online on Scribd
32 views

Application For General Changes: (Kindly Fill in Block Letter and Use Black Ink)

This document is an application form for general changes to a life insurance policy. It requests updates to the policyholder's identification details like PAN and Aadhar numbers, address, contact details, premium payment mode and source. The policyholder declares that the information provided is correct and consents to linking of Aadhar and PAN details for authentication. Original identity documents must be verified by the insurance branch. The form requires signatures of the policyholder and branch official processing the request.

Uploaded by

Nithin K Reethan
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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APPLICATION FOR GENERAL CHANGES

(Kindly fill in Block Letter and Use Black Ink)

POLICY INFORMATION
POLICY NO DATE D D M M Y Y Y Y
POLICY OWNER NAME F I R S T N A M E M I D D L E N A M E L A S T N A M E
UPDATION OF POLICY HOLDER IDENTIFICATION DETAILS
PAN No*
AADHAR No*
CKYC No
EIA No
*Self Attested Copy of PAN Card and Aadhar Card is Mandatory for processing any request
CHANGE OF ADDRESS Mailing Address Permanent Address Both
ADDRESS

CITY
STATE PIN
Valid Documents Aadhar Card Copy Passport Copy Voter Id Copy Driving License Copy Job Card Issued by NREGA
(Any One) Letter issued by National Population Register

CHANGE OF CONTACT DETAILS


MOBILE NO
EMAIL ID
LANDLINE NO
CHANGE OF PREMIUM PAYMENT MODE & SOURCE OF PAYMENT
MODE ANNUAL SEMI-ANNUAL QUARTERLY MONTHLY*
SOURCE DIRECT NACH (NATIONAL AUTOMATED CLEARING HOUSE)
BANK A/C NO
BANK NAME
BANK BRANCH
IFSC CODE
1. Cancelled cheque (Preprinted name of account holder) or bank statement/Pass book copy duly attested by bank.
2. If ‘NEW ACCOUNT’ is mentioned on the cheque then we require self attested bank statement / passbook copy.
3. *For Monthly Payment mode NACH Form is mandatory along with two months advance premium.

Acknowledgment Slip

Received a request for General Change against policy no on D D M M Y Y Y Y

Seal /Stamp of the


Branch with Signature

IFLI/PS/General Changes Form/V1.0/0116 Page 1


DECLARATION BY POLICY HOLDER
I / We hereby request that this policy be changed in accordance with the above particulars with the understanding and agreement that a copy of this request shall be attached to
and forms a part of the said policy. I / We understand that IDBI Federal Life Insurance may be unable to process this application if I/We fail to provide any further information
requested by IDBI Federal Life Insurance Co Ltd. in this regard.

I/We hereby submit my Aadhaar Number and PAN as issued by Unique Identification Authority of India (UIDAI) and Income Tax Dept, Govt. of India and voluntarily give my/our
consent to link my/our Aadhaar number and PAN to all my/our IDBI Federal Policies. I/We give my consent to obtain and use my Aadhaar Number, Name, fingerprint/Iris and my
Aadhaar details to authenticate me/us with UIDAI System as per Aadhaar Act, 2016 , and all other applicable laws. I/We also give consent for verification of my PAN with
Income Tax Department. IDBI Federal has informed me/us that my Aadhaar details and Identity information would only be used for demographic authentication, validation,
e-KYC purpose and for all service aspects related to IDBI Federal. I/We will not hold IDBI Federal or any of its officials responsible in case of any incorrect information provided
by me/us.

I/we also authorize IDBI Federal to use my mobile number/email id as mentioned above for sending alerts.

PLACE
Signature of the Policy
Holder/ Assignee
DATE D D M M Y Y Y Y
DECLARATION (By Person filing the form on behalf of the policy holder for forms signed in Vernacular languages or Thumb Impression)

I _______________________________________________________________, having known the policy holder for a period of _____________years do


declare that I have explained the nature of questions contained in this form to the policy holder. I have also explained that the answers to the questions
form the basis for accepting this request.

Signature of the Person PLACE


filling the form on behalf of
the policy holder DATE D D M M Y Y Y Y
FOR OFFICE USE

Date D D M M Y Y Y Y TIME (Tick) BEFORE 3pm AFTER 3pm

Place __________________________ Stamp of the Branch: Signature of the Official:______________________________

Note: Original documents have to be duly verified by the authorised branch staff.

GENERAL INSTRUCTION
1. Address on the KYC proof should match with the change in address requested on the form.
2. For Permanent address change KYC documents are mandatory
3. Policy holder should carry original KYC address/ID proof for verification at branch.
4. All documents have to be attested by the policy holder & branch personnel post verification of Originals.
5. For Mode change request, Branch should check availability of requested mode before accepting the request.
6. Request must be received from Life Assured upon auto vesting.
7. In case policy is assigned, request needs to be signed by Assignee.

IFLI/PS/General Changes Form/V1.0/0116 Page 2

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