Policy Number:

FOR OFFICE USE ONLY

Received Date:

Assignment Form

Policyholder (i.e. Assignor) Contact Details

Landline No. (Residence): 0 *Mobile No.: 0

(Mandatory)
Landline No. (Office): 0 Email ID:
STD Phone

Are you a US Citizen or US tax resident Yes No) If Yes, Please provide TIN:

All communications will be on the e-mail id mentioned above (if available). The mode of communication from and to the company would include electronic mode

like sms, email etc.

Please tick 'Physical copy' if you want to receive communication in electronic form as well as physical Copy

Physical Copy:

Declaration
(Please read the Instructions/Notices mentioned overleaf before filling up this form)
I/We
(Name of the Assignor) First Name Middle Name Last Name

have read and understood the Instructions/Notices mentioned overleaf and I/We hereby give you notice that I/We have assigned the above Policy to:
Name of the Assignee:
First Name Middle Name Last Name

Status of the Assignee: Bank/Financial Institution Relative of the Assignor10 Others11

Relationship with the Assignor:
Address of Assignee:

City State Pin Code

Landline No. (Residence): 0 *Mobile No.: 0

(Mandatory)
Landline No. (Office): 0 Email ID:
STD Phone

Occupation:
Date of Birth: D D M M Y Y Y Y

Signature of the Assignor  Signature of the Assignee8 

Endorsement

I/We
(Name of the Assignor) First Name Middle Name Last Name

as the beneficial owner/s of Policy No. - issued by Bharti AXA Life Insurance Company Limited for the

Sum Assured of ` have assigned the said Policy to the Assignee mentioned hereinbelow:

Name of the Assignee: (Please tick whichever is applicable)

Individual:
First Name Middle Name Last Name

Financial Institution/Bank:
Financial Institution/Bank Name

Type of Assignment:
(Please tick whichever is applicable)

I/We have absolutely assigned the Policy to the Assignee mentioned hereinabove.
OR
I/We have conditionally assigned the Policy to the Assignee mentioned hereinabove, on the condition that the Policy shall

revert to me/us in the event of:

Assignment Form Front: 201 x 350mm

Consideration:
(Please tick whichever is applicable)

I/We have received ` as consideration from the Assignee in respect of the aforesaid assignment.
OR
I/We have assigned the Policy out of natural love and affection and I/We have not received any consideration from the Assignee.

Dated at , this day of

Signature of the Assignor  Signature of the Assignee8 

Name of the Witness12:

First Name Middle Name Last Name
Address of Witness:

City State Pin Code

Signature of the Witness12:

Date: D D M M Y Y Y Y Place:

Vernacular Declaration
DECLARATION* IN CASE THIS ASSIGNMENT FORM IS FILLED BY A PERSON OTHER THAN THE POLICYHOLDER OR SIGNED IN VERNACULAR LANGUAGE:
Declaration by Policyholder:
I hereby declare that the contents in this form have been fully explained to me and I declare that whatever is stated hereinabove has been recorded as per
the information provided by me.

Thumb Impression/Signature of the Policyholder 

Declaration by person filling the form:

I have explained the contents of this form to the Policyholder in language and I have correctly recorded the answer provided
to me. I further declare that the Policyholder has signed/affixed his/her thumb impression in my presence.
Declarant’s Name:
First Name Middle Name Last Name

Declarant’s Address:

City State Pin Code

Date of Birth: D D M M Y Y Y Y

Declarant’s Signature:

Date: D D M M Y Y Y Y Place:
*"The person giving this declaration can be any person other than Introducing Advisor or MOA or MOM."

I/we agree that the Company may provide/transfer/retain any information available with the Company related to me/us, obtained in connection with
processing of my proposal or the policy and servicing thereof to any reinsurers, insurance association, medical registrar, statutory authorities/bodies or
services providers engaged by the Company for policy servicing related activities without any further reference to me/us.
I/we agree that the Company may share my/our information with other insurers for the underwriting and claims settlement purposes.
I/we understand that i/we have an option to review and correct the information already provided or not to provide the data or information sought, also, at any
time while availing the services or otherwise, i/we have an option to withdraw my/our consent for sharing of data given earlier, such withdrawal of the consent
should be sent in writing to the Company. In the case i/we do not provide or later on withdraw my/our consent, the Company shall have the option not to provide
me/us the services.

Date: Signature of the 

D D M M Y Y Y Y Policyholder
Place:
INSTRUCTIONS / NOTICES:
1. All the information is to be filled in BLOCK LETTERS.
2. All fields are mandatory.
3. The term Assignor stands for the current Policyholder, who intends to assign the Policy, whereas the term Assignee stands for the person in whose favour
the Policy is to be assigned.
4. The assignment of a Policy shall automatically cancel any nomination made in the Policy, except for assignment in favour of Bharti AXA Life Insurance
Company Limited (‘the Company’) in which case the rights of the nominee would get affected to the extent of the Company’s interest in the Policy.
5. The Company expresses no opinion as to the legality or validity of the assignment.
6. Partial assignment of a Policy is not allowed.
7. This assignment shall not be effectual against the Company unless this Assignment Form is duly completed and delivered, accompanied by the original
Policy Bond to the Company.
8. In case of assignment in favour of a financial institution/bank, the financial institution/bank should affix its stamp and should be countersigned by its
authorised signatory.
9. In case where the assignee is a minor, the legal/natural guardian of the minor shall sign on behalf of the minor.
10. Relative shall mean and include only the father, mother, spouse and child/children of the Assignor. In case of assignment in favour of a relative,
documentary proof (preferably ration card) mentioning the relation therein should be produced along with this form.
11. In case of assignment to third party/(ies), other than relatives/banks/financial institutions, the Assignor should submit identification proof, residential
proof and income proof of such third party.
12. The witness should be a person competent to contract.

Bharti AXA Life Insurance Company Ltd.

Regd. Office: Unit No. 1904, 19th Floor, Parinee Crescenzo, 'G' Block, Bandra Kurla Complex, BKC Road, Behind MCA Ground, Bandra East,
Mumbai -400051, Maharashtra Regn. No.: 130. CIN no: U66010MH2005PLC157108. Comp-Oct-2010-1116AA
Service address: Bharti AXA Life Insurance Company Ltd., Spectrum Tower, 3rd Floor, Malad Link Road, Malad (West), Mumbai - 400064.

1800-102-4444 SMS SERVICE to 56677 We will be in touch within 24 hours to address your query www.bharti-axalife.com

Assignment Form Back: 201 x 350mm