10M ASSIGNMENT FORM - BANK/FINANCIAL INSTITUTION SIL

Important instructions for you to proceed:

• All fields are mandatory
• Assignor is the policyholder intending to assign the policy. Assignee is any Bank/Financial Institution in
whose favour the policy is assigned.
• Assignment is subject to terms and conditions of the assignment agreed by the assignor and the Barcode
Bank/financial institution.
• If more than one policy is to be assigned separate forms are to be filled up in respect of each of them.
• A nomination gets cancelled in the case of assignment until reassigned.
• Post assignment of the policy, the Assignee will be entitled to all the payouts/ benefits subject to the terms and conditions of the transfer/assignment.

POLICY DETAILS
Policy Number Date D D M M Y Y Y Y

Name of Proposer
Mr./Mrs./M/S.

Address

Landmark Pin Code

Contact Nos.
STD Residence STD Office Ext. ISD Mobile
E-Mail ID

CKYC Number (if available) : ___________________________

Purpose of Assignment* Loan Over draft

Amount- ` _______________________________________

DETAILS OF THE ASSIGNEE

Name of the Bank/
Financial Institution
Official Address

Landmark Pin Code Branch/Office Code

Contact Nos.
STD Office STD Office/Fax Ext. Mobile

Comp/doc/Sept/2015/521
E-Mail ID Pan No.

Regulated by IRDA RBI SEBI Industry Type Bank Financial Institution Capital Market Intermediary

CKYC Number (if available) : ___________________________

I/we agree that the PAN details and other information provided by me/us in this form maybe used by the Company to download/verify/ register/ update my/our KYC documents
on/from the CERSAI* CKYC portal for processing this request, any future applications, or any other requests. I/We understand that only the acceptable officially valid documents
would be relied upon for processing any requests/applications.(*Central Registry of Securitisation and Asset Reconstruction and security Interest of India.)
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case
any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that ICICI Prudential reserves the right to take appropriate action.

Terms & Conditions

• All future premiums shall be paid by the Assignor of the Insurance policy.
• The assignor shall not exercise or hold any rights pertaining to services of the insurance policy including partial withdrawal/surrender without specific consent of the
______Bank/financial institution.
• The Assignor with suitable concurrence from the Assignee shall intimate the Company about its loan closure for suitable reassignment of the insurance policy to the
Assignor.

ACKNOWLEDGEMENT SLIP

This is to acknowledge the receipt of application for Assignment.

Policy Number Date D D M M Y Y Y Y

STAMP
Documents Submitted Policy Certificate Address proof Photo Id Proof &
TIME
Received By
Declaration
With reference to the indicated terms and conditions of this assignment, the Company shall, from the date of receipt of this notice, recognize the assignee Bank/Financial
Institution as the only person entitled to the benefit under the policy.
• I/We understand that the assignment shall not be considered valid by the Company, until a notice in writing of this assignment and either the said endorsement or the
instrument itself or a copy thereof certified to be correct by both the assignor and the assignee or their duly authorised agent have been delivered to the specified
office of the Company
• I/We hereby declare that receipt of benefits arising under the policy by the Assignee, shall be valid for sufficient discharge of the said loan
• Policy servicing requests, as applied to the Policy prior to this Assignment, would continue unless specific instructions are provided to the Company by both the
Assignor and the Assignee
• If the Application for assignment is rejected by the insurer, the customer may approach IRDAI within 30 days of receipt of notice of rejection
• Assignment will be as per Section 38 of the Insurance Act, 1938
• I/We do hereby declare that I/we have read and understood the Terms & Conditions mentioned herein above and agree to abide by the same

Notice of Assignment
Notice is hereby given that I, _____________________ the holder of the Insurance policy, have read and understood the above instructions, and
subject to the above instructions, assign the rights and benefits of the above policy to the _______________________________Bank/Financial
Institution, whose registered office is at _____________________________________________________________.

Consent for information sharing with third party

I request ICICI Prudential to share my registered KYC documents and policy details with ___________________________________as required for
processing my loan formalities.

Signed by me on this ___________ day of ____ 20____.

_______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________
Place __________________ Signature of Assignor Signature of Assignee with stamp

Details of the person signing as Witness (Please note that the witness should be major and competent to contract)
The assignor has duly executed the endorsement on the policy, and the signature/thumb impression is of the assignor affixed on the date and at the Place herein above stated.

Name of
the Witness Mr./Mrs./M/S.
Address

Landmark Pin Code Mobile No.

Occupation

Declaration
Applicable when the Proposer is illiterate or suffering from disability due to which writing is restricted or the proposer has signed in vernacular language. Note: Must be
witnessed by someone other than the advisor/agent/employee of the Company.

I (Full name of Witness) ____________________________________________________________________________________________________________________ (Relation with

Proposer) ____________________________________________________________________________________________________________________________________ adult and

inhabitant of (Address) _________________________________________________________________________________________________________________________________

do hereby declare that I have read and explained the contents of this form to the Proposer and he/she/they have understood the same.

_______________________________________________________________________________________________________________________________________
(Signature of Witness)

FOR OFFICE USE ONLY:

ER Requestsubmitted by C S CR CS

Date D D M M Y Y Y Y
STAMP
Spaarc Call ID
&
Scanning Cabinet Received By TIME

Remarks

Kindly call our Customer Service Number 1800 2660 (toll-free)

Call Center timings: 10.00 A.M. to 7.00 P.M. Monday to Saturday (except national holidays)

Communication Address
ICICI Prudential Life Insurance Co. Ltd., Unit No. 1A & 2A, Raheja Tipco Plaza, Rani Sati Marg, Malad (east), Mumbai 400097.