Please read all instructions before filling the form

Kindly fill all details in BLOCK LETTERS only

For unit-linked products, if the request is received and accepted at the Company's office before 3 p.m., unit price declared on the same date will be
applicable, and if the request is submitted and accepted at the Company's office after 3 p.m., the next working day's unit price declared will be applicable
If the policy has been assigned, the request would be accepted on receipt of letter from the assignee of the policy
All communication will be sent to the address recorded with us
Please do collect the acknowledgement number from the customer service executive as this will be your reference number for all future communications
on this request
The application for any withdrawal needs to be submitted along with requisite documents as mentioned in the form

Policy Details
Kindly fill in BLOCK LETTERS only
Policy Number

Name of Policyholder:
First Name Middle Name Last Name
Are you a US Citizen or US tax resident Yes No If Yes, Please provide TIN:

Policyholder Contact Details

Mobile Number (mandatory): Alternate Contact Number:

Email ID :

Pre-Issuance Cancellation

Amount (₹) or Maximum eligibility

Name of fund(s) to be withdrawn Percentage/Amount

Note: 1) Request will be processed if withdrawal requested is greater than or equal to minimum amount mentioned in the policy document. Partial withdrawal is not
allowed in case of pension products. If the fund names are not mentioned above, the partial withdrawal amount will be deducted in the current fund ratio. Please note
that in case "Maximum eligibility" is selected, the policy fund value will reach to minimum account value that needs to be kept in the policy, which will result in
surrender of policy & payout will be processed, as per policy feature. Please refer policy bonds for details. 2) As per Finance Act 2019, life insurance companies need
to deduct tax at source (TDS) 5% on the gains from the payments made on or after 1st September 2019 under any life insurance policy if such payouts are not exempt
from tax. Further provided that if PAN is not submitted by the payee then TDS will be 20%

Surrender
Documents Submitted: Welcome Kit Pan Card
Please Note:
1) Amount payable on surrender of the units is as per the product terms & conditions. The surrender of the units results in termination of the contract and all the
rights/title and interest under the policy shall stand cancelled. If the policy is surrendered before the completion of the lock-in period then the surrender value
calculated as on the date the request of such surrender is received from the policyholder, shall be frozen and shall become payable after the completion of the lock
in period. For lock-in period details please refer your policy bond. 2) As per Finance Act 2019, life insurance companies need to deduct tax at source (TDS) 5% on
the gains from the payments made on or after 1st September 2019 under any life insurance policy if such payouts are not exempt from tax. Further provided that if
PAN is not submitted by the payee then TDS will be 20%

Payout Options (mandatory)

Mode selected would be used by the company to make payout(s) to the Policyholder.
Payout would be in accordance and subject to the terms and conditions of the policy.
Full Name of the Policyholder/ Bank Account Holder:

First Name Middle Name Last Name

Payment Mode: NEFT Cheque

MICR Code: IFSC Code*:

Bank Name:
Bank Account Number:

Bank Account Type: Saving Account NRO NRE#

#Please note that payout can only be made in the NRE account to the extent of premiums received from NRE account (repatriable rupees), and any payout amount over and above will be credited to alternate
NRO or savings bank account. (hence, we recommend you to provide your NRO bank account details as well)

Documents required, if NRE account is chosen: 1. Passport 2. NRE Bank Account statement reflecting premium payment details

Bank Branch Name:

Address:
City State Pin Code

Additional Bank Account Details

Additional Bank Account Details are required in case the primary bank account is a NRE bank account.

Full Name of the Policyholder/

Bank Account Holder: First Name Middle Name Last Name

Payment Mode: NEFT Cheque

MICR Code: IFSC Code*:

Bank Name:

Bank Account Number:

Bank Account Type: Saving Account NRO

Bank Branch Name:

Address:
City State Pin Code
*Please submit a cancelled cheque/ Bank Statement / Bank pass book copy bearing pre-printed account number, policyholder name, and IFSC code.
Kindly carry original documents for verification at branch.

DECLARATION* IN CASE THIS PAYOUT 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 the 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:
Declarant’s Signature:

Date: Place:
*

The person giving this declaration can be any person other than Introducing Advisor or Manager of Agency (MOA) or Manager of Manager (MOM).

I hereby take the sole responsibility for the correctness of my bank account number and other details of this form. I undertake that I will not hold the company
responsible in any manner for any transactions affected by the company due to incorrect bank account number or these details stated by me.
I understand and agree that the company reserves the right to use any alternative payout option including a demand draft payable at par or cheque, in spite of my
opting for the electronic payout method.

` `1

Signature of assignee
Signature of proposer
(required in case of absolute assignment of policy)

Bharti AXA Life Insurance Company Ltd. IRDAI Regd. No. 130 dated 14/07/2006 [Life Insurance Business] Unit No. 1902, 19th Floor, Parinee Crescenzo, ‘G’ Block, Bandra Kurla Complex, BKC Road, Behind MCA Ground, Bandra East, Mumbai - 400051, Maharashtra.
CIN No.: U66010MH2005PLC157108 | Toll free No.: 1800-102-4444 | Website: www.bhartiaxa.com | Comp-Mar-2021-3212

BEWARE OF SPURIOUS/FRAUD PHONE CALLS and FICTITIOUS/FRAUDULENT OFFERS!

IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving such phone calls arerequested to lodge a
police complaint.

Trade Logos and used in the document belong to the Bharti Enterprises (Holdings) Private Ltd. and AXA SA respectively and are used by Bharti AXA Life under license.

We will be in touch within 24 hours to address your query

1 800-102-4 4 4 4 SMS SERVICE to 56677 WhatsApp Number – 022-48815768 www.bhartiaxa.com