Part Withdrawal or Surrender Form

PARTIAL WITHDRAWAL/SURRENDER FORM
INSTRUCTIONS FOR FILLING UP THE FORM: 1. The policyholder must sign any cancellation/alteration. 2 Surrender or withdrawal will be done by liquidating the required number of units
of the Fund at the prevailing Unit Price. 3.If this application form is received by 3.00 p.m. on a working day units shall be redeemed at the unit price declared on the same day. If the application is
received after 3.00 p.m.,units will be redeemed at the next working day's unit price. 4. This application will not be effective until it is officially accepted by Kotak Mahindra Old Mutual Life
Insurance Ltd. 5. Please refer to the policy contract for terms & conditions regarding Partial Withdrawal/Surrender.
1. PARTICULARS OF THE POLICYHOLDER
a) Policy Number
b) Full Name : Title Surname First Name Middle Name
c) Contact No : S T D Mobile
d) Address:
City: State : Pin : M A N D A T O R Y
2. DETAILS REGARDING PARTIAL WITHDRAWAL/ SURRENDER
Name of the Plan
Partial Withdrawal Yes No Full Surrender of Policy Yes No

Withdrawal Amount (in case of partial withdrawal) Rs._________________________ or in % of holding ____ %.
For Kotak Safe Investment Plan II Kotak Flexi Plan Kotak Platinum Advantage Plan-Shield Account
Kotak Guaranteed Growth Kotak Guaranteed Balanced Kotak Guaranteed Bond
Kotak Guaranteed Floating Rate Kotak Guaranteed Gilt Kotak Guaranteed Money Market
For Kotak Retirement Plans (Unit-linked)

Kotak Pension Balanced Kotak Pension Bond Kotak Pension Floating Rate
Kotak Pension Gilt Kotak Pension Money Market
For Kotak Easy Growth Plan Kotak Platinum Advantage Plan-Dynamic Account Kotak Headstart Plans
1
Kotak Smart Advantage Kotak Long Life Plan Top-up Premium
Opportunities Fund Kotak Dynamic Aggressive Growth Kotak Dynamic Growth
2
Kotak Dynamic Balanced Kotak Dynamic Floor Kotak Dynamic Bond
Kotak Dynamic Gilt Kotak Dynamic Floating Rate Kotak Dynamic Money Market
For Kotak Privileged Assurance Plan

Kotak Advantage MultiplierII Kotak Advantage Plus II
1
Kotak Smart Advantage has only 3 fund options available – Dynamic Bond Fund, Dynamic Floor Fund and Opportunities Fund.
2
Not available with Kotak Easy Growth Plans
Please note that for full surrender of policy, the policy document/certificate of life insurance cover must be returned together with the application.
3. SETTLEMENT OPTIONS (Tick the relevant option)
A. Pay directly to my bank account mentioned here (please attach a blank cancelled cheque)
* Account No:
* Bank Name
& Address * IFSC Code
* Account Type * MICR Code
B Transfer of fund Rs.____________________________to Policy no._____________________________towards first/Renewal Premium
4. DECLARATION BY THE POLICYHOLDER

I wish to withdraw the amount indicated above from units credited to my policy. I understand and agree to all information and terms and conditions given above and in my policy contract.
Place Signature of the Policy holder or Guardian (if life insured is minor)
Date D D M M Y Y Y Y or Assignee (if policy is Assigned)
5. DECLARATION BY THE PERSON FILLING IN THE FORM

(For form filled in by a scribe or for forms signed in vernacular languages)
I________________________________________, having known the proposer for a period of ________________ do declare that I have explained the nature of the questions contained
in this form to the proposer. I have also explained that the answers to the questions form the basis for accepting this request for Partial Withdrawal/Surrender.
Place
Signature of the Life Advisor Signature of Scribe
Date D D M M Y Y Y Y
Address of the Scribe
FOR OFFICE USE ONLY
Branch Name Mode of receipt
Date of receipt D D M M Y Y Y Y Time of receipt H H M M
Name of branch co-ordinator Signature of branch co-ordinator
Kotak Mahindra Old Mutual Life Insurance Ltd. Regn. No. : 107, Regd. Office: 9th floor, Godrej Coliseum, Behind Everard Nagar, Sion (E), Mumbai - 400 022.
Insurance is the subject matter of the solicitation. 1.7/052008
ACKNOWLEDGEMENT
We acknowledge the receipt of request for partial surrender/full surrender for Policy no.: ________.
Branch Name
Date D D M M Y Y Y Y Time H H M M
Name of branch co-ordinator Signature of branch co-ordinator
Kotak Mahindra Old Mutual Life Insurance Ltd. Regn. No. : 107, Regd. Office: 9th floor, Godrej Coliseum, Behind Everard Nagar, Sion (E), Mumbai - 400 022.
Insurance is the subject matter of the solicitation. 1.7/052008

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PARTIAL WITHDRAWAL/SURRENDER FORM

1. PARTICULARS OF THE POLICYHOLDER

City: State : Pin : M A N D A T O R Y

2. DETAILS REGARDING PARTIAL WITHDRAWAL/ SURRENDER

Name of the Plan

Partial Withdrawal Yes No Full Surrender of Policy Yes No

For Kotak Retirement Plans (Unit-linked)

For Kotak Privileged Assurance Plan

* Account Type * MICR Code

B Transfer of fund Rs.to Policy no._towards first/Renewal Premium

4. DECLARATION BY THE POLICYHOLDER

5. DECLARATION BY THE PERSON FILLING IN THE FORM

Address of the Scribe

FOR OFFICE USE ONLY

Branch Name Mode of receipt

Date of receipt D D M M Y Y Y Y Time of receipt H H M M

Name of branch co-ordinator Signature of branch co-ordinator

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