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Request Form For Correction/change in Policy Holders' Name or Correction in Nominees'/Appointees' Name

This document is a request form for correcting or changing the name of a policy holder or correcting the names of nominees/appointees in an insurance policy. It requests the current and proposed names, address, policy details, reason for change, and lists required supporting documents. The policyholder must sign to take responsibility for the requested changes, which are subject to policy terms and conditions. A CPC branch representative certifies reviewing and verifying the documents.

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Manoj Kumar
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54 views

Request Form For Correction/change in Policy Holders' Name or Correction in Nominees'/Appointees' Name

This document is a request form for correcting or changing the name of a policy holder or correcting the names of nominees/appointees in an insurance policy. It requests the current and proposed names, address, policy details, reason for change, and lists required supporting documents. The policyholder must sign to take responsibility for the requested changes, which are subject to policy terms and conditions. A CPC branch representative certifies reviewing and verifying the documents.

Uploaded by

Manoj Kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Request form for correction/change in Policy holders’ Name or

correction in Nominees’/Appointees’ Name


Full Name as per exiting policy ( Mr. Mrs. Ms.)

First Name Middle Name Last Name

Address

Village/ Taluka/
City District
Post
Office State
Country Pincode

Mobile No E-mail ID (If any)

Policy No

Sum Assured

Change /Correction in Name Policy Holder OR * Nominee OR * Appointee


(Please tick as applicable )

(*Only correction is allowed in case of Nominee(s)/Appointee(s) name. For change in nomination separate
form is prescribed)

Old Name ( Mr. Mrs.)

First Name Middle Name Last Name

New Name ( Mr. Mrs.)

First Name Middle Name Last Name

Reason for Change

__________________________________________________________________________________________________
Documents Attached

Documents Enclosed: Yes/No/ NA(Not


Applicable)

1. Original Policy Bond


2. Self Attested copy of ID proof of the Insurant
3. Self Attested copy of address proof of the Insurant
4. Relevant Documents of Policyholder for change of name of Policy Holder on applicable grounds as per
SOP.
5. Relevant Documents of Nominee/Appointee for correction of their name as per SOP.
6. Self-Attested Copy of ID proof of Messenger (if messenger appointed by Insurant for submission of
name change request)
7. Self-Attested Copy of Address proof of Messenger (if messenger appointed by Insurant for submission
of name change form)
8. Self-Attested medical certificate of insurant from Govt. Hospital/Govt.accredited hospital
Or
Self-attested copy of passport clearly showing visa details and date of departure from India
9. Any other document(s), pls specify ____________________________

Date : ______________

I have understood the meaning and scope of the name change request and take complete responsibility of
the changes submitted by me/us. Any changes in the Policy/Personal details are subject to the policy terms
and conditions and on acceptance of relevant documents submitted.

Thumb Impression/Signature of Policyholder

(If policyholder is illiterate or is signing in a language other than the language of this form, his/her thumb
impression/signature must be attested by any Postmaster/ Gram Pradhan, Notary, his/her PLI/RPLI Agent
with his/her official seal after explaining the content of this form)

Name: __________________________________

Address: ________________________________

Signature of the person making the declaration

(For Office Use Only. To be filled in by receiving CPC PLI Branch)

Certified that I have checked all the documents enclosed and compared with the original documents
produced by the Insurant/messenger and verified the averments made in the name change form based on
these documents and found no discrepancies.

Date:- Signature of CPC in-Charge


Name :
Designation:
Office Stamp:

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