Policy/Application Number

For Office Use Only

Received By ______________________________________________________________

(Please mention above Employee Bank Staff Name & Designation)

Date & Time of Receipt/ ______________________________________________________________

Date & Time of Dispatch of Request _______________________________________

Please update your latest Bank Account details with us.

Change in Contact Details (Mandatory valid self attested address proof to be submitted)1

(Please tick as applicable) Update applicable for Policyholder Life Assured Nominee

Office Appointee Assignee

Current Address

Permanent
City State

Update new address as **Country Pin Code

communication address?
* Mobile
Yes No
Residence Ph.

Please tick this box, if you want us to contact you on the above mentioned contact number for
future communication purpose.
*Email

CKYC No.

Details are mandatory to be filled.

**If Country is other than India then please submit FATCA/CRS Questionnaire available on our website.

Rectification/Modification of Personal Details (Mandatory valid self attested identity proof to be submitted)
Are you making the request while you are in US. Yes No

(Please tick as applicable) Title Mr. Mrs. Miss. Ms. Dr. Other (Specify)____________

Life Assured Name First Name

Policyholder Name Middle Name
Life Assured DOB Last Name

Policyholder DOB New Date of Birth Gender Male Female

Addition/Change of Nominee Details

New Nominee Name

Date of Birth Relationship with the policyholder
If nominee is a minor (below 18 years) please provide appointee details. The appointee will receive the proceeds under the policy on behalf of
nominee till the nominee remains a minor.
New Nominee Name
Date of Birth Relationship with Nominee

Address

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Issuance of Duplicate Policy document

I request you to provide a duplicate Policy document and confirm that the necessary documents (as applicable) are being submitted along with
this request. Reason for Issuance of Duplicate Policy document ____________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Change in Premium Payment Method

Are you making the request while you are in US. Yes No

I would like to Change the premium payment method to (Please tick as applicable)

Direct Debit/ECS/NACH Cheque Credit Card

For Direct Debit, ECS, NACH and Credit Card method of payment, duly filled mandate form along with supporting documents need to be submitted
at least 30 days before the next premium due date. In case premiums are due please make a payment by Cheque/DD/PO/Credit card. Request for
cancellation of Direct Debit/ECS/NACH facility should be submitted at least 15 days before next premium due date.

Change in Premium Payment Frequency

Are you making the request while you are in US. Yes No

I would like to change the premium payment frequency to (Please tick as applicable)
Monthly Quarterly Semi Annual Annual

Request for changing premium paying mode should be submitted at least 60 days before the next anniversary date. Changes would be effective from next
premium due date only. If the request is received after the billing notice issuance, no separate billing notice will be issued for the payment as per the new mode.

Updation of Bank Account Details

I hereby request you to update my bank account as per the details furnished below

Bank Account Holder Name:

Bank Name:

Bank Branch Address:

Bank Account Type: Savings Current

(Is the selected account NRE : Yes No In case of NRE account, kindly submit supporting documents to show that all the premium
payment towards the policy was made from NRE account and submit FATCA/CRS Questionnaire available on our website.)

Bank Account Number:

(9 digit number available on your cheque book. Correct code to be provided if the 9 digit number
MICR Code: available on the copy of cancelled cheque starts with '000)

(11 digit number available on your cheque book; attestation by the Bank in case
IFSC Code: if this is not printed on the cancelled cheque)

PAN Card Number:

List of supporting documents submitted along with this form (tick √ as applicable) /

A copy of 'Cancelled' cheque Self attested copy of passbook

(Account number and account holder name should be 'printed') (Account number and account holder name should be 'printed' on the passbook)

OR
Self-attested copy of Bank Statement
(Mandatory in case of NRE payment; statement reflecting transactions of the premium paid from NRE account)

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• I hereby declare that the Bank account particulars furnished are true, correct and complete in all aspects.
• I understand and agree that the submission of this form does not mean that the request will be acceded.
• If the transaction is delayed or not effected at all for any reasons due to incomplete or incorrect information, I shall not hold the Company
responsible in any manner whatsoever.
• I understand and agree that, under the circumstances where in the electronic payment is not possible, the Company reserves the right to use any
alternative payout option as per applicable laws.
• I/ We authorize the Company to seek/ store or/and to share my KYC details from/ with (i) Governmental and/ or Regulatory Authority,
(ii) Insurance Repositories (iii) CERSAI/ UIDAI (iv) reinsurers/group companies/ hospital or diagnostic centers/ other insurance companies or third
parties for underwriting assessment, claim investigation/ settlement, KYC authentication, policy servicing purpose and such like purposes.

Signature of Policyholder/Assignee:

Signature/Thumb Impression of Signature/Thumb Impression of Assignee

Policy holder (Required in case of Absolute Assignment of Policy)

Name of Policy holder/ Assignee: ____________________________________________________________________

I understand that to proceed with the request there may be a requirement of additional documentation. I agree to submit additional documents as
applicable.
I fully understand the meaning and scope of this Policy Servicing request and I am submitting the completed form of my own volition.

Declaration, if this form is signed in Vernacular/Thumb Impression:

I hereby declare that I have explained the contents of this form to the Policyholder Mr/Mrs/Ms __________________________in___________________
language and that the Policyholder has affixed the thumb impression(s)/ signed in language other than English in my presence after fully understanding
the contents thereof.

Name of Declarant_____________________________Signature _________________Date_______________ Place ___________________________

Instruction & Disclaimer:

• Product specific requests/ funds will be allowed, only if it is applicable under the respective terms & conditions of the Policy. Please refer to the
terms and conditions of the Policy for details. The formats for additional documentation can be downloaded from our website.
• Processing of the requests will be initiated on receipt of this form at any of our Company's Offices. In case of Unit Linked Policies, for the requests
impacting the funds of the Policy, if application is received before 3:00 pm on a business day, NAV of same day will be applicable. If received after
3:00 pm, next business day NAV will be applicable.
• Register now on our website to avail the benefits of various options for on-line servicing of your Policy.
• All the supporting proof/s & document/s submitted along with the request have to be self-attested along with attestation by below designated
authority – A Gazetted officer as specified by Government of India/Authorized personnel of our company (including our Corporate Agents)/ Branch
Manager of a Nationalized Bank.
• The original form will be submitted back to the customer incase request is taken through Distributor App.
• Kindly fill the form in English.
• In the event of any disagreement in interpreting the language, English version will prevail.
• There are restrictions on requests of Top-ups, Increase or Decrease in Sum Assured, Changes in Funds (including Fund Switch and Redirection),
Revival of Policies, any request that results in change of premium or policy feature while the customer is in the US. We reserve the right to restrict
any other policy servicing request basis the applicable US Laws. Please contact our call center for further information.

Canara HSBC Life Insurance Company Limited

(formerly known as Canara HSBC Oriental Bank of Commerce Life Insurance Company Limited) IRDAI Regn. No. 136
Corporate Office Address: 139 P, Sector 44, Gurugram – 122003, Haryana, India
Registered Office Address: Unit No. 208, 2nd Floor, Kanchenjunga Building, 18 Barakhamba Road, New Delhi - 110001
Corporate Identity No: U66010DL2007PLC248825

Call us at 1800-103-0003/1800-180-0003/1800-891-0003 SMS at 09779030003

E-mail us at [email protected] Visit our website at www.canarahsbclife.com

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