Payout Form1
Payout Form1
Payout Form1
Dear Sir,
With reference to the above policy please process ___________________ (Tick the appropriate, below)
+91-9673473900
Mobile No: _______________________ Land Line:_________________________
k_s_harish@yahoo.com
Email ID: ______________________________________________________
Signature proof attached
Surrender charges informed to the customer from LA (For surrender of ULIP policy)
* This is an indicative surrender value depends on the effective NAV rates, please refer point no. 2 of T&C section on page 2.
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Signature of Policy holder Date
Remit payment through cheque (Cheque will be sent to the communication address as per company records).
1Further the cheque should bear the name of the policyholder/account holder's name and IFSC / RTGS / NEFT Code. In the event the details are not
appearing on the cheque leaf, the applicant needs to submit a recent statement from the bank issuing the cheque where all such details are available.
The bank a/c number should be clear & visible (please do not cross on a/c no.). In case, such details are not available, the payment would be released by
cheque. Policy holder’s signature to be taken on cancelled cheque.
Branch Name:_________________________________________________________
Please verify that account number matches with the cancelled cheque/bank statement attached and counter sign.
1. Incase of Surrender/Partial Withdrawal Certain charges will be deducted as mentioned in the terms & condition in the policy document.
2.2 After 3.00 p.m, NAV of the next working day shall be applicable
3. The contract shall conclude upon payment of the surrender money and the same shall be treated as valid discharge for company (RLIC)
4. RLIC shall not pay any money against surrender, partial withdrawal, refund of excess money or loan amount in the form of Cash.
5. If the electronic credit is not effected, delayed or credited to a wrong account on account of incorrect or incomplete information provided, RLIC shall not
be held liable now or in future for such losses.
6. In the event the credit is not effected by your Banker for any reason, RLIC reserves the right to make the payment through cheque/DD.
7. All the above requisitions shall be processed as per the terms and conditions as laid in the policy contract and will be binding.
I understand and agree to all the above terms and conditions as referred above.
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Signature of Policyholder with Date
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Customer Acknowledgement (Tear here)