POLICY Number

YES NO
Amend Combo Policies
If No, Policies will change to Single

POLICY AMENDMENT REQUEST FORM

SECTION A
(PLEASE FILL THE FORM IN CAPITAL LETTERS)

1. Change in Address / Personal Update

Current Address Permanent Address Work Address

Address:

Landmark:
City: PIN Code:
State: PAN:
Mobile No.: Tel. No.:
E-mail ID:
(Kindly share a valid E-mail ID to receive progress update and closure confirmation on your request)

Please indicate your preference for preferred mailing address: Current Permanent Work
Note: Any of the Officially Valid Proof (Aadhaar, Voter ID, Driving License, Passport or NAREGA Job Card) having
preferred mailing address to be attached irrespective of annualized premium.

Aadhaar card / letter issued by UIDAI or National Passport

Population Register (NPR) containing details of name, Voters ID card issued by Election
address and Aadhaar number Commission of India
Job card issued by NREGA duly signed by an officer of the
Driving License
State Government

2. Change in Name

Policyholder Life Insured Company Name Assignee

Title
First Name
Middle Name
Last Name
Request to submit the following additional documents along with a duly signed Policy Amendment Form

For Individual Name Change:

Affidavit on stamp paper (according to the state value) attested by First Class Magistrate / Notary and copy of
marriage Certificate / marriage card (for name change after marriage) Affidavit on stamp paper (according to the
state value) attested by First Class Magistrate / Notary and proof for name change.

For Company Name Change:

Certified true copy of Memorandum and Articles of association of the Company along with a certified true copy of
certificate of incorporation issued by Registrar of Companies.
 SECTION A
I fully understand the meaning and scope of the Policy Amendment Request form and the questions / amendment
requests contained above and submitting the completed Policy Amendment Request form of my own volition.
I hereby authorise Max Life to process my payouts to my Aadhaar linked Bank Account and to use the same to
validate / update my KYC details. I accept to receive all future communication from Max Life Insurance through E-mail
ID only (strike if you want to continue with hard copy).
“In case the Policyholder provides incomplete or incorrect information in this form, the company will not be held
liable for any delay arising due to such incorrect / incomplete information.” Also, the relevant processing will be
applicable from the date of complete requirements / documents received by Max Life Insurance.
“I / we understand that, I / we have disclosed my / our personal information (which may include Aadhaar related
information) with Max Life for the purpose of providing insurance and related services and I / we hereby consent and
authorise Max Life to use, for the purposes of underwriting assessment, claim investigation / settlement, KYC and
policy servicing purposes, as per applicable law.”

Signature of Policyholder / Assignee: (should match with policy records)

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

Note: In case, policy is issued under Married Women Property Act (MWPA, Section 5), please share the consent from
Wife / Trustee / Legal heir.
Vernacular Declaration: In case policyholder’s signatures is in the form of a thumb impression (left thumb) or in a
vernacular language, I hereby declare that I have fully explained the contents of this form to the policyholder and
that left thumb impression / signature of the policyholder has been appended after fully understanding the contents
of this form.

Name & Address of Declarant:

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

GO Stamp
Signature:
Signature Verified

POLICYHOLDER ACKNOWLEDGEMENT SLIP

Policy Number: Type of request:

Received by: Date: D D M M Y Y Y Y

Time of Receipt: Employee Code:

GO Stamp
Signature:
Signature Verified
 SECTION B
Policy Number: Mobile No.:
E-mail ID:
Name of Policy Holder/Assignee:
Name of Life Insured:
(Kindly share a valid E-mail ID to receive progress update and closure confirmation on your request)

Amend Combo Policies YES NO

If no, then policies will change to

Is new nominee a Politically Exposed Person* (Yes / No) Please tick

* Politically Exposed Persons (PEP) are individuals who are or have been entrusted with prominent public functions, for example Heads / Ministers
of Central / State Government, Senior Politicians, Senior Government / Judicial / Military Officers, Senior executive of State-Owned Corporations,
Important political party officials & immediate family member of above persons (Spouse, Children, Parents, Siblings, In-laws).

Date of Birth DD/

From To Relationship % Share
MM/YY

Note: If nominee is a minor; below the age of 18 years please name a person (Appointee) to receive policy proceeds in the event of death of Life
Insured, while the nominee is still a minor. Please provide following information for “Appointee.”

Name of Appointee:
Relationship to Nominee:
Address:

Appointee DOB: Appointee’s Signature:

4. Change in Premium Mode (Tick the preferred Mode)

Monthly Quarterly Semi-annual Annual
Terms & Conditions
• For Other than Annual Mode, Electronic Payment Mode is Mandatory i.e the method of payment should be
through ECS or Credit Card Standing Instruction only.
• Change of Mode is subject to the Terms and Conditions of the Policy Contract or determined by the Company
from time to time.

5. Change in Premium Payment Method (Tick to indicate Method required)

Cash / cheque Direct Debit (Completely filled ECS mandate required)
*Remittances of premium by cash should not exceed ` 50,000
Note: In case Policyholder wants to change from auto debit to direct bill, then the bank statement of last three months is required to validate if
the ECS account is also the NEFT account of the policyholder. In case the account is not active, the bank statement of the last three months and
a cancelled cheque are required from another account of the policyholder to enable the update of NEFT details.
 SECTION B
6. Change in Bonus Option (Tick to indicate the Bonus option required)
Cash / cheque Premium offset Paid-up addition (PUA)
7. Change in Non-Forfeiture option (Tick to indicate the NFO required)
Reduced Paid-up Extended Term Insurance
I fully understand the meaning and scope of the Policy Amendment Request form and the questions / amendment
requests contained above and submitting the completed Policy Amendment Request form of my own volition.
I hereby authorise Max Life to process my payouts to my Aadhaar linked Bank Account and to use the same to
validate / update my KYC details. I accept to receive all future communication from Max Life Insurance through E-mail
ID only (strike if you want to continue with hard copy).
“In case the Policyholder provides incomplete or incorrect information in this form, the company will not be held
liable for any delay arising due to such incorrect / incomplete information.” Also, the relevant processing will be
applicable from the date of complete requirements / documents received by Max Life Insurance.
“I / we understand that, I / we have disclosed my / our personal information (which may include Aadhaar related
information) with Max Life for the purpose of providing insurance and related services and I / we hereby consent and
authorise Max Life to use, for the purposes of underwriting assessment, claim investigation / settlement, KYC and
policy servicing purposes, as per applicable law.”
Signature of Policyholder / Assignee: (should match with policy records)
Date: D D M M Y Y Y Y Place:

Note: In case, policy is issued under Married Women Property Act (MWPA, Section 5), please share the consent from Wife / Trustee / Legal heir.
Vernacular Declaration: In case policyholder’s signatures is in the form of a thumb impression (left thumb) or in a vernacular language, I hereby
declare that I have fully explained the contents of this form to the policyholder and that left thumb impression / signature of the policyholder has
been appended after fully understanding the contents of this form.

Name & Address of Declarant:

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

GO Stamp
Signature:
Signature Verified

POLICYHOLDER ACKNOWLEDGEMENT SLIP

Policy Number: Type of request:

Received by: Date: D D M M Y Y Y Y

Time of Receipt: Employee Code:

GO Stamp
Signature:
Signature Verified
 SECTION C
Policy Number: Mobile No.:
E-mail ID:
Name of Policy Holder/Assignee:
Name of Life Insured:
(Kindly share a valid E-mail ID to receive progress update and closure confirmation on your request)

1. Addition / Change of Rider A – Addition C - Change D - Deletion

Coverage Effective Date

A C D Rider (Tick to Indicate) Term Current Occupation
Amount (DD/MM/YY)

Policyholder Request
Premium Amount (without Service Tax and Education Cess) Date (DD/MM/YY)

Service Tax and Education Cess

Total Premium Payable (with Service Tax and Education Cess)

Note:
• Health Declaration form is required for any addition of rider. Life Insured may be required to undergo medical
tests.
• Completely filled pay or questionnaire and duly attested date of birth proof is required for Addition of payor rider.
• Any addition of rider / option is subject to company underwriting the risk or realization of premium whichever is
later and the company shall not be liable until such time it has underwritten the risk and issued the rider / option
contract to the policyholder.

I understand and agree that the change request by me will be accepted by the Company subject to the terms and
conditions of the policy contract.
I fully understand the meaning and scope of the Policy Amendment Request form and the questions / amendment
requests contained above and submitting the completed Policy Amendment Request form of my own volition.
I hereby authorise Max Life to process my pay-outs to my Aadhaar linked Bank Account and to use the same to
validate / update my KYC details. I accept to receive all future communication from Max Life Insurance through E-mail
ID only (strike if you want to continue with hard copy).
“In case the Policyholder provides incomplete or incorrect information in this form, the company will not be held
liable for any delay arising due to such incorrect / incomplete information.” Also, the relevant processing will be
applicable from the date of complete requirements / documents received by Max Life Insurance.
 SECTION C

“I / we understand that, I / we have disclosed my / our personal information (which may include Aadhaar related
information) with Max Life for the purpose of providing insurance and related services and I / we hereby consent and
authorise Max Life to use for the purposes of underwriting assessment, claim investigation / settlement, KYC and
policy servicing purposes, as per applicable law.”

Signature of Policyholder / Assignee: (should match with policy records)

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

Note: In case, policy is issued under Married Women Property Act (MWPA, Section 5), please share the consent from Wife / Trustee / Legal heir.

Vernacular Declaration: In case policyholder’s signatures is in the form of a thumb impression (left thumb) or in a vernacular language, I hereby
declare that I have fully explained the contents of this form to the policyholder and that left thumb impression / signature of the policyholder has
been appended after fully understanding the contents of this form.

Name & Address of Declarant:

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

GO Stamp
Signature:
Signature Verified

POLICYHOLDER ACKNOWLEDGEMENT SLIP

Policy Number: Type of request:

Received by: Date: D D M M Y Y Y Y

Time of Receipt: Employee Code:

GO Stamp
Signature:
Signature Verified
 SECTION D
Policy Number: Mobile No.:
E-mail ID:
Name of Policy Holder/Assignee:
Name of Life Insured:
(Kindly share a valid E-mail ID to receive progress update and closure confirmation on your request)

9. Switching of funds 10. Redirection of Funds

I authorise Max Life I authorise Max Life
insurance to invest all Insurance to invest
existing premium in all future premium in
proportion as mentioned proportion as mentioned
below below
Name of Fund (depends From (% To (% or Name of Fund (depends From (% To (% or The
upon availability of funds or Amount) upon availability of funds or Amount) request for
in Plan) Amount) in Plan) Amount) redirection
Secure Fund Secure Fund or
Growth Fund Growth Fund switching
of funds
Growth Super Fund Growth Super Fund
will be
Balance Fund Balance Fund
accepted
Conservative Fund Conservative Fund subject to
Dynamic Opportunity Fund Dynamic Opportunity Fund Terms and
Secure Plus Fund Secure Plus Fund Conditions
Others (if specify) Others (if specify) of Policy
Contract
Total of Fund investment percentage should be 100%

I fully understand the meaning and scope of the Policy Amendment Request form and the questions / amendment
requests contained above and submitting the completed Policy Amendment Request form of my own volition.
I hereby authorise Max Life to process my payouts to my Aadhaar linked Bank Account and to use the same to
validate / update my KYC details. I accept to receive all future communication from Max Life Insurance through
E-mail ID only (strike if you want to continue with hard copy).
“In case the Policyholder provides incomplete or incorrect information in this form the company will not be held
liable for any delay arising due to such incorrect / incomplete information.”
Also, the relevant processing will be applicable from the date of complete requirements / documents received by
Max Life Insurance.
“I / we understand that, I / we have disclosed my / our personal information (which may include Aadhaar related
information) with Max Life for the purpose of providing insurance and related services and I / we hereby consent
and authorise Max Life to use for the purposes of underwriting assessment, claim investigation / settlement, KYC
and policy servicing purposes, as per applicable law.”
 SECTION D
Signature of Policyholder / Assignee: (should match with policy records)
Date: D D M M Y Y Y Y Place:

Note: In case, policy is issued under Married Women Property Act (MWPA, Section 5), please share the consent from Wife / Trustee / Legal heir.

Vernacular Declaration: In case policyholder’s signatures is in the form of a thumb impression (left thumb) or in a vernacular language, I hereby
declare that I have fully explained the contents of this form to the policyholder and that left thumb impression / signature of the policyholder has
been appended after fully understanding the contents of this form.

Name & Address of Declarant:

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

GO Stamp
Signature:
Signature Verified

POLICYHOLDER ACKNOWLEDGEMENT SLIP

Policy Number: Type of request:

Received by: Date: D D M M Y Y Y Y

Time of Receipt: Employee Code:

GO Stamp
Signature:
Signature Verified
 SECTION D
11. (i) Surrender of Paid Up Addition (PUA) (ii) Bank Details of the Policyholder - Mandatory
Refund the amount accumulated as
MICR Code
PUA of `
Type of Bank Account: Savings Current NRO NRE
Adjust accumulated PUA amount
of ` Bank Name

Towards Renewal premium for Policy Bank Account No.

No.
Note: Policy should be active at the time of submitting the IFS Code
PUA Surrender request. In case policy is inactive, please
get the policy reinstated before submission of PUA request. Bank Address

PAN
Note: Kindly attach a cancelled cheque bearing account number and Policyholder
name or copy of Bank Passbook
Disclaimer: TDS will be applicable in accordance to Section 194DA of Income Tax Act prevailing at the time of payment. If you are an NRI,
please fill up the NRI declaration, available at the end of this form and TDS will be governed in accordance to Section 195.

12. Deactivation of STP / DFA

*STP (Systematic Transfer Plan) / DFA (Dynamic Fund Allocation)
Deactivation of STP Deactivation of DFA (Note: Both are allowed on policy anniversary only)

13. Partial Surrender/Smart Withdrawal Option

Note: - The Company will accept the request for partial surrender/Smart Withdrawal Option subject to the terms and conditions of the Policy
Contract.

Amount to be
Name of the fund II. Bank Details of the Policyholder - Mandatory
withdrawn/Percentage

MICR Code
Type of Bank Account: Savings Current NRO NRE
Bank Name
Bank Account No.
Smart Withdrawal Option

Smart Withdrawal Payout Date: DD MM YYYY IFS Code

(please specify policy year here) Bank Address
Frequency of Smart Withdrawal Payouts:
Annual/Semi Annual/Quarterly/Monthly PAN
% of fund value that would be required in a year Note: Kindly attach a cancelled cheque bearing account number and Policyholder
% name or copy of Bank Passbook
Disclaimer: TDS will be applicable in accordance to Section 194DA of Income Tax Act prevailing at the time of payment. If you are an NRI,
please fill up the NRI declaration, available at the end of this form and TDS will be governed in accordance to Section 195.
 SECTION E
Policy Number: Mobile No.:
E-mail ID:
Name of Policy Holder/Assignee:
Name of Life Insured:
(Kindly share a valid E-mail ID to receive progress update and closure confirmation on your request)

No Objection Certificate from Life Insured (applicable only if Life Insured has turned major)
I ; hereby confirm the valid discharge of the requested
payouts towards the above Policy and will not hold Max Life Insurance liable for any further claim in future.

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

I fully understand the meaning and scope of the Policy Amendment Request form and the questions / amendment
requests contained above and submitting the completed Policy Amendment Request form of my own volition.
I hereby authorise Max Life to process my payouts to my Aadhaar linked Bank Account and to use the same to
validate / update my KYC details. I accept to receive all future communication from Max Life Insurance through E-mail
ID only (strike if you want to continue with hard copy).
“In case the Policyholder provides incomplete or incorrect information in this form, the company will not be held
liable for any delay arising due to such incorrect / incomplete information.” Also, the relevant processing will be
applicable from the date of complete requirements / documents received by Max Life Insurance.
“I / we understand that, I / we have disclosed my / our personal information (which may include Aadhaar related
information) with Max Life for the purpose of providing insurance and related services and I / we hereby consent and
authorise Max Life to use, for the purposes of underwriting assessment, claim investigation / settlement, KYC and
policy servicing purposes, as per applicable law.”

Signature of Policyholder / Assignee: (should match with policy records)

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

Note: In case, policy is issued under Married Women Property Act (MWPA, Section 5), please share the consent from Wife / Trustee / Legal heir.
Vernacular Declaration: In case policyholder’s signatures is in the form of a thumb impression (left thumb) or in a vernacular language, I hereby
declare that I have fully explained the contents of this form to the policyholder and that left thumb impression / signature of the policyholder has
been appended after fully understanding the contents of this form.

Name & Address of Declarant:

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

GO Stamp
Signature:
Signature Verified

POLICYHOLDER ACKNOWLEDGEMENT SLIP

Policy Number: Type of request:

Received by: Date: D D M M Y Y Y Y

Time of Receipt: Employee Code:

GO Stamp
Signature:
Signature Verified
 SECTION F
Policy Number: Mobile No.:
E-mail ID:
Name of Policy Holder/Assignee:
Name of Life Insured:
(Kindly share a valid E-mail ID to receive progress update and closure confirmation on your request)

15. Change in Signature

I , hereby declare that below mentioned specimen signature
provided on day of 20 and the same witnessed hereunder duly attested
by Bank authority. I further state that henceforth, the signature as appended below should be considered for all
future requests.
Old Signature New Signature with Bank Attestation Bank Seal (Bank Attestation)

Note: Please attach acceptable self-attested Photo Identity Proof, specimen signature form and affidavit on ` 100/- stamp paper stating,
“Change of Signature.”

16. Change in Plan / Policy Term

Plan Change Change in Policy Term

Existing / Old Plan details New Plan details

Plan Name Plan Name

Policy Term Year Premium Paying Term Year Policy Term Year Premium Paying Term Year

Base Sum Assured Base Sum Assured

Rider Sum Assured Rider Sum Assured

Rider Term (No. of years) Rider Term (No. of years)

Rider Term Rider Term

Change in Premium Frequency (Annual, Semi-Annual, Change in Premium Frequency (Annual, Semi-Annual,
Quarterly, Monthly) Quarterly, Monthly)
Note: New proposal form and Illustration is mandatory (duly signed by Policyholder) in case Plan is getting changed from Traditional to ULIP,
one ULIP to another ULIP or vice-versa.
 SECTION F
17. Change in Sum Assured
Increase in Sum Assured Decrease in Sum Assured Revised Sum assured
Increase in Sum assured Life Stage Benefit option-
Volunteer Top Sum Assured
under Volunteer Top Up Increase Sum Assured
I hereby deposit ` against Premium in lieu of Increase in Sum Assured.
Note: Change in Sum assured / Death benefit can be made subject to Policy Terms and Conditions.

18. NEFT Update II. Bank Details of the Policyholder - Mandatory

I Mr. / Ms. ,
MICR Code
hereby request you to update my bank a/c
Type of Bank Account: Savings Current NRO NRE
details as per the details given here with
against Policy No. for Bank Name
disbursement and transfer of Contractual pay- Bank Account No.
outs through NEFT.
IFS Code
Bank Address

PAN
Note: Kindly attach a cancelled cheque bearing account number and Policyholder
name or copy of Bank Passbook
Disclaimer: TDS will be applicable in accordance to Section 194DA of Income Tax Act prevailing at the time of payment. If you are an NRI,
please fill up the NRI declaration, available at the end of this form and TDS will be governed in accordance to Section 195.

I fully understand the meaning and scope of the Policy Amendment Request form and the questions / amendment
requests contained above and submitting the completed Policy Amendment Request form of my own volition.
I hereby authorise Max Life to process my payouts to my Aadhaar linked Bank Account and to use the same to
validate / update my KYC details. I accept to receive all future communication from Max Life Insurance through E-mail
ID only (strike if you want to continue with hard copy).
“In case the Policyholder provides incomplete or incorrect information in this form, the company will not be held
liable for any delay arising due to such incorrect / incomplete information.” Also, the relevant processing will be
applicable from the date of complete requirements / documents received by Max Life Insurance.
“I / we understand that, I / we have disclosed my / our personal information (which may include Aadhaar related
information) with Max Life for the purpose of providing insurance and related services and I / we hereby consent and
authorise Max Life to use, for the purposes of underwriting assessment, claim investigation / settlement, KYC and
policy servicing purposes, as per applicable law.”

Signature of Policyholder / Assignee: (should match with policy records)

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

Note: In case, policy is issued under Married Women Property Act (MWPA, Section 5), please share the consent from Wife / Trustee / Legal heir.
 SECTION F
Vernacular Declaration: In case policyholder’s signatures is in the form of a thumb impression (left thumb) or in a vernacular language, I hereby
declare that I have fully explained the contents of this form to the policyholder and that left thumb impression / signature of the policyholder has
been appended after fully understanding the contents of this form.

Name & Address of Declarant:

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

GO Stamp
Signature:
Signature Verified

POLICYHOLDER ACKNOWLEDGEMENT SLIP

Policy Number: Type of request:

Received by: Date: D D M M Y Y Y Y

Time of Receipt: Employee Code:

GO Stamp
Signature:
Signature Verified
 SECTION G
Policy Number: Mobile No.:
E-mail ID:
Name of Policy Holder/Assignee:
Name of Life Insured:
(Kindly share a valid E-mail ID to receive progress update and closure confirmation on your request)

19. (i) Surrender of OPPB (ii) Bank Details of the Policyholder - Mandatory
Refund the amount accumulated against
MICR Code
OPPB of `
Type of Bank Account: Savings Current NRO NRE
Adjust accumulated OPPB amount of
` Bank Name

Towards Renewal premium for Policy no. Bank Account No.

Note: Policy should be active at the time of submitting the IFS Code
PUA Surrender request. In case policy is inactive, please
get the policy reinstated before submission of PUA request. Bank Address

PAN
Note: Kindly attach a cancelled cheque bearing account number and Policyholder
name or copy of Bank Passbook
Disclaimer: TDS will be applicable in accordance to Section 194DA of Income Tax Act prevailing at the time of payment. If you are an NRI,
please fill up the NRI declaration, available at the end of this form and TDS will be governed in accordance to Section 195.

No Objection Certificate from Life Insured (applicable only if Life Insured has turned major)
I ; hereby confirm the valid discharge of the requested payouts
towards the above Policy and will not hold Max Life Insurance liable for any further claim in future.
Date: D D M M Y Y Y Y Place: Signature:

20. Policy Reconsideration

Please tick the appropriate option:

Change in family details Change in occupation Disclosure of disease Photo update

Change in height and weight Disclosure of smoking status Change of work country
Disclosure of other insurance details Change of income details Disclosure of drinking habits
Others
Details / revised update for option selected
Note:- Policy should be active for reconsideration and any amendment or modifications are subject to underwriting decision as per Policy
term & conditions. Please attach all relevant and supporting documents.
 SECTION G
I fully understand the meaning and scope of the Policy Amendment Request form and the questions / amendment
requests contained above and submitting the completed Policy Amendment Request form of my own volition.
I hereby authorise Max Life to process my payouts to my Aadhaar linked Bank Account and to use the same to
validate / update my KYC details. I accept to receive all future communication from Max Life Insurance through E-mail
ID only (strike if you want to continue with hard copy).
“In case the Policyholder provides incomplete or incorrect information in this form, the company will not be held
liable for any delay arising due to such incorrect / incomplete information.” Also, the relevant processing will be
applicable from the date of complete requirements / documents received by Max Life Insurance.
“I / we understand that, I / we have disclosed my / our personal information (which may include Aadhaar related
information) with Max Life for the purpose of providing insurance and related services and I / we hereby consent and
authorise Max Life to use, for the purposes of underwriting assessment, claim investigation / settlement, KYC and
policy servicing purposes, as per applicable law.”
Signature of Policyholder / Assignee: (should match with policy records)
Date: D D M M Y Y Y Y Place:

Note: In case, policy is issued under Married Women Property Act (MWPA, Section 5), please share the consent from Wife / Trustee / Legal heir.
Vernacular Declaration: In case policyholder’s signatures is in the form of a thumb impression (left thumb) or in a vernacular language, I hereby
declare that I have fully explained the contents of this form to the policyholder and that left thumb impression / signature of the policyholder has
been appended after fully understanding the contents of this form.

Name & Address of Declarant:

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

GO Stamp
Signature:
Signature Verified

POLICYHOLDER ACKNOWLEDGEMENT SLIP

Policy Number: Type of request:

Received by: Date: D D M M Y Y Y Y

Time of Receipt: Employee Code:

GO Stamp
Signature:
Signature Verified
 SECTION G
Please fill below table for residency declaration:

SETTLEMENT
Settlement payout mode

Monthly Quarterly Semi-Annual Annual

Settlement Term (in years)

1 2 3 4

Note:
1) TDS would be applicable as per prevailing rate basis country of residence, submission of above details and
compliance under provision of Section 10(l0D) / Section 10(10A) of the Income Tax Act, 1961.
2) In case of non-availability of PAN, no TDS certificate will be issued.
“I / we understand that, I / we have disclosed my / our personal information (which may include Aadhaar related
information) with Max Life for the purpose of providing insurance and related services and I / we hereby consent and
authorise Max Life to use, for the purposes of underwriting assessment, claim investigation / settlement, KYC and
policy servicing purposes, as per applicable law.”
Signature of Policyholder:

Date: D D M M Y Y Y Y Place:
Note: In case, policy is issued under Married Women Property Act (MWPA, Section 5), please share the consent from Wife / Trustee / Legal heir.
 SECTION H
Yes / No
a. If Non-Resident (NR) as per Indian Income Tax Act, 1961
b. If Yes
(i) Country of Residence
(ii) Do you have PAN Card (If Yes, please provide)
(iii) If Tax Residency Certificate (Certificate issued by Govt. of respective)
(iv) Signed form 10F (format attached)
(v) Permanent Establishment declaration (format attached)

Note:
1) Payment method through electronic payment mode (NEFT) only. (Cancel cheque required)
2) Minimum term for the Settlement option is 1 year & maximum is 5 years.
3) First payout will start from the policy maturity date as per the opted payout and settlement term.
“I / we understand that, I / we have disclosed my / our personal information (which may include Aadhaar related
information) with Max Life for the purpose of providing insurance and related services and I / we hereby consent and
authorise Max Life to use, for the purposes of underwriting assessment, claim investigation / settlement, KYC and
policy servicing purposes, as per applicable law.”
Signature of Policyholder:

Date: D D M M Y Y Y Y Place:
Note: In case, policy is issued under Married Women Property Act (MWPA, Section 5), please share the consent from Wife / Trustee / Legal heir.

YOU ARE THE DIFFERENCE

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Important: DO NOT believe in calls, SMS, E-mail offering discounts. For NEFT Payments, please transfer only to “HSBC Bank A/C No. 1165<Followed by 9 digit Policy No.> IFS Code: HSBC0110002”. Max Life does not collect
Premium in any other account. Max Life Insurance Co. Ltd.: Plot No. 90C, Sector 18, Udyog Vihar, Gurugram, Haryana - 122015. Regd. Office: 419, Bhai Mohan Singh Nagar, Railmajra, Tehsil Balachaur, District Nawanshahr,
Punjab - 144 533. Fax: 0124-4159397, CIN: U74899PB2000PLC045626 | CUSTOMER HELPLINE NUMBER: 1860 120 5577 IRDAI Regn. No. 104

BEWARE OF SPURIOUS / FRAUD PHONE CALLS!

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