pnb MetLife

Policy Service Payout Request Form

For hassle free & Swift payouts, get your
BANK DETAILS
mportantnlormation.EMandatoy.documents
Processing ortne o r m at any of our CompanystoCh points
*At the me of
reueu oo the Polcholder to be
mandatorily presarted and o
. /Bank ats book co t sh be self-ttested by the Poleholdr
name and IFSC oode. Kindly carry original documents for verification at branch
*
tpe t e d tor Cases where duplicate policy document/ indermnity given or there i s dhange

certificate/Clearance certificatee Tro taaan sure

ofIndemnity/DPO, please provide d
In the event hank
onamum avmert d

o MetLufe oR original 1D proof same s provided at the me of Proposal Login of the polieyholder
mandatonilyto process your request faster

iral
h e h e of frequest submission

* application f o r Unit Linked Product s received up to 15:00 hs 5T an a business/ workine day, the same day s

unt value wibe applicabe while procesing the request. However, if the applcation is recelved ater 1500 hrs
PNB Metufe can call for additional documentation if requlred
Please submit a self-attested PAN Cad copy for updation of PAN No. Form 60 needs to be in PNB Metife format

Forthird party submissions (anyone other than Polioyholder). the following docume nts duly zet-attested by the
) Authorization letter from the Policyholder PMLUformat, SelfAtested iD proefof the Policyholder (Mandatory

Copyof Bonk Statement occount

heing
Copy of Boank Stote ment refiecting premlum poid to PNS Netufe
number some as proides ot the me of roposei egin g

0 onginafio proe som t provaed a ne oopo h e some

Aadhoor cord is submitted, first 8 digits of Aadhoar no. needs to be masked
# request is submtted through Third Party along with Indemnty Bond or Duplicate Polley bocument, either ef
, o r Ds mandatory
K i n d l y J the r e q u e s t form in Block ietters

Policy.Detail
Polily Number :21318O5 8 1418I Applation (Mera umber Medidalm Plan
Dae 2 ol6 2lo2
*Name of the
Policyholde Caimant:APUYAL IMUINS H
* Mobile Nurmber:.

**"Aadhaar Card No: B

HL
4 1 E 6 H | 0 C E Country of Binth: 19LH Nationaity (aoplicable for Non-indan ctae:N 9IAN
mAKV6
India? Yes DNo Ye, piease fil up FATCW C8 questionnaire)
Are you Tax
resident of any other country other than Name:
s this policy assigned: Ys Yes,
No Aasgnee
subimit separate request for address change along with valid proof
s there a Change in Address: s UNo y e , please

Alfelds ere mondatory

Plan
updastnd for Mero
Medkckaim
Applicotion number to be

No. t o De m e n t o n e d
Oniy a t 4 d i g i s of Aadhaar
Think again before you surrender your Policy.
will lose its benefits too!!
By surrendering this policy, you
fill up the form.
Ask yourself a few questions, before you
or make a Partial Withdrawal?
to opt for Surrender/Free Look Cancellation
Why do you wish
M Funds Requlreme nt P o l k y did not meet expectatons t h e r s e a speriy

Yurrendez/iKcontinuance.und Movementss Please tick as applicable: (V Auto-Ferediosure Payou

Diacotinuance Fund Movement D Surrender (Fund Transfer and Part Payout
Surrender and Payout
DAuto-Foreclosure Payout (Fumd Transter to new applcatian/Poley ne.)
Surender (Fund Transfer ta new applcationyolicy no.
pe traharredi
nber where runds w l
umerolsY Ta n cae of poly
opplcebie Prpoc to
paon ond other
samriddh
Easy Super a n d Met Dhan
d, Met

inuation before
tinuation before comple tion of
comple tion o
5 yeora, the total und v pot o or rofter, the customer would be paid the fund velue
comnencement of Gth polcy yror. oniyfundmonopermen haroes
enorg e050%
po p.a wou
lchever higher) s
a v o l a b i l e i n d i s c o n t i n u a biom J u n d o r j u n o e co

mion2 20
 please tick as applcabie:
ganahdewal andana
va Partial withdrawal and aout Partial withdirwa,(und ranster
Dartial
withdrwwal (fund Transfer to new
applicationy elcy
no h o k u n d r . i 3 1 . 6 s s e bliow

mber whiare ftnde w l e Pttwoth

Applicatien S2, 2501-mt ption
wEhdrawal

Fund Option w
Perserver
ultiplier l
Protector/ Protecto
Moderator
in Jurtde
w
Balancar Balancer withdniwn
in cae porti
h d r o w o r e s t i

the o i m u m
omount that cun be
e

r
onae
mit, the policy would be terminateo

ceD0Aenteltion Please tick as applicable: Wj:

look Cancellation and Payout
Free
T r a n e r tn naw a p p l a t a n
ree lok
Cancelatien (und

Applicatlon Number/cy
wm1/o5/202
Date of Recept
eron ENETES NED EUND
D1eAL EMER in Ter

C h a n g e in
ode DChang
in 7emium
dhange
Opd foriange
Prouuct
DSum
Au ured
Free lek.chnees; opton the ebsence of which mey reee
tranterm
tvloble policy would be
C hats1 For Free Look canceliotlo, a velid reuonocp cha in the current

t h e eout would be credited to the oan orco h l be deducted from the premium amouni

Ppicotiona weoC

MatuntyEttlemonulBeneitapDe
prouED Pase tiek as pplicabie
t Amount
Totel Fund Value per POY0uE
lstallment Option Percentogeaf
-(Msimum up to 3
No. ofYears for Settlernent
Annua
Ha yearty
Qarerly Ment
Frequeney et Payout:
A Lurmp su
No of Yean r o
d '
Ccombinan uareny Monthly

Frequency ot fe
Anmual OHalf Yearty or c unicotn by me. l onderstand het maturn vellie
wil be errived et unit pror
honreeptor inturet
not be sbie or any 55 OrAng jrom
ef the day of policy maturity,

Refundollceszn Rs
e a e re

ODeyielhue ollndin2axouH Peasetick

as applicable: (V
etund Chequ ning ayout
1Se ParFund transfer to anothe
Applcation Number/ l c y m a n e n
e i n
Cheque validity over ethers, please specity
Reason
for Step Payment: Non receipt
of ahegue
unds detal
p
Renewal Prermium
r a n s t e r of Cheque Amount:.
r Che
Cheque No:
share the detaile:
n a s a refund cheque has been retumed, please

elundefUnclaimedAniountiPlease tick as applicable: (VJ:

Advance Renewal Premum
Death ian E a
e r a y , ett
D New Busines M
untfs) lying in my Applatidn/
y nank a t c o detai s t e d alonE w t n tha Tom O a tranater the s a

na.
other Pelicy/Application
=

Uncaimed n cdocuments in original et nearestNa Metuye Bronch post which efund to be trip0ered from uncikalmeed und to customer

Mate PoleyH h e m u n t due ond as declared unclolmed en the wwbsite of t u e w r e t e o3 per the c tdoo

u sotifoction under this polcy

ails
aymen daimant name as per PAPA UNSH
UN1ON - ANK
Branch Name: 1O10o0 60
rsc Code: 2
MICA Code: 00o 26193
NROD
Bank Account 7yper SavingM Current NAE"
 os Be t -eameton euet& Senk Cefte ofal prenima being peid thveugh NSE ocount for Repet

c t o n is deied ar net e f d et al er eny recsons due napietror hol not hei PNB Mecie reuonbie in ay
nernc thot N Met ahol not be held reponable for any nonreoeipt of pyment on eeount of wrong/ incorect/ incompiet
yteetve peyout m e t h e d n e t e re
or direct creditia net rerel H
est a ejcted by the

arnising out oftha reoutindr

undentand that a Metute wa be communicating through telephane als, SMS, or emals for providing detalls of transactions payment reminden, e

han India, we undentand the PNMie n e w e m e set tota tres

mersMe
Nonties who may shere such information wth the rwievant overseas comoetent authoy

natureyiat Hand Thumb

Snature/let Hand Thumb tureen Hand Thumb Impressien of
impeion o oint Uife (Second Lte)
PolieholderjClaimartt
ete: For conditionely asigned poloRequest s h u be signed beth by teAngnee &Agnow

Date: DD-MMm 21o6/2021 Pace OLKATA

ethe heome Tav Act 186 frum1 September 2018, tvour poliayia net eempt under Sertion 10a00) ef te neume Ta Act
GovemmentPrecury. ATDS cef we e
p e r the income t x reguiesion and theretore we request yeu to zubmit a copy of your PAN in cese of it net being submited earfer. TDS rats are as per

men mde te rom time to time.

emacul daetkon Te be hled Incase polcyhaider'i sgnatures ls in the furm of a thumb lmpresalon (left thumb) er in a vernacua

hi ee
ater c avundetani
o raenaierate applcant who a penonaly inown to me and he has ed up the contents and aftand
u e a n t h e a p p c a n t has a a d h a e h a n d t h u m b gat n dc

Strike out whichever b not appliable.

a e or D e c a r a w n e

Dute: DD-MM-YYYY

oBrendhUn Only Te be fled by Branch Services - Mandatory

Hegunztreceleed.fremi astomer a t o m e r Representatve bank Courier

Hequest Recelved date at Branch: 00-MM-YmY Mequest recelved Time at 5ranak: HHEMM

branch Stanmp

, 7th Floor, West W e -540001, Kamataka, IRDA of India

legietraten hurn
GN, UE010KA2001PLCO2883, call us Toli roe at 2-800-45 6969, Webste www.pmbmetif.com, Emalt ndiaservice@pnbmetile.co.n er wrilte to u at 1stoe
Technlex 1, Techalplex Comples, Ofl veer Sawvarkar Fhyover, Goregen (West, Mumbal-40002 hone: * 2 A 1 0 0 , ax31-24170203

ACANOWLIOGtMINT.RP
-pietlcy No
-entaining Poliey No
aI/pm
mplo yee N a
Heselved y Employee Cods ianch 3tamp
Date and time Stamp /Seal et Branc

erslen 2.2/ey
 Andhra India undertaiing)
Bankk
(A Gan. of
UNLON FANK OF NDIA

ASBA
ROAD
1ST FLOOA. 378. R43Dle(A nAIN
K9KAA
ADUALENTTu ARaNgAiH HATCHETES.
FHE e33-244) 7577
a1E 21-94-2921
T0:
S PAPI YA MUNSHI
339,P MAJuNtER ROAD, Pj- HALTU
CIRCUS AVENUE KOLKATA
KOLKATA-708878
CuST 1D 30421762
aEST BENGAL, INDIA

Nomi nee Nane LUVNA RUNSHI SAVINGS Be D3 GEN Pur (5

19-86-2621 SUG-A/C NO: 167516198011962
STATEMENT 0F ACCOUNT FUR THE PERI0D FROM 01-85-2921
to

- - - - - - - - - -

DEPGSITS BALANCE
CHO NO. wTHDANALS
DATE PARTICULARS ------

57,581.64 59,581.640
nUNBAI, ATH CELL, NUNBAI
e2-85-2021 IHPSAR/112225718174/ANDE9801673/9838979991
1,800.08 61,381.640
RUNBAI, ATH CELL, MUNBAI
11-85-2021 UPIAR/113183557325/DR/ RAGINI N/PYTR/9831768015ép ay 1,890.46 59,581.64
999.90 58,591.64Cr
14-95-2021 APY-SI-66420-14/05/2021
DELHI,GOVERNENT BUSINESS BRANCH
14-85-2921 APY-SI-66420-14/65/2021 996.00 57,641.640
DELHI, GOVERNNENT BUSINESS BRANCH
26-65-2021 UPTAR/114856833871/DR/PNËMETLI/HDFC/onbeet lhfe.bi i 52,256.06 5,351.64r
999.99 4,361.640r
95-6-2021 APY-SI-66420-05/06/2021
DELHI.GOVERNMLNT RUSINESS BRANCH
17.79 4,343.94
15-@6-2821 Srs Charges Tor June, 2021 Buarrer
- - -

- - - -

Cunulatave Totals: 37.937.79 6381.64 4,343.940r

---------------- ------ -----
The hin. Bal. Requrenent in (Metra Br.) For SB Account 1s Rs 592/- (w1thout Cheque bopx) ang Rs 1963/-(N2th neque oca
Unless constituent natifies the bank 1mmedi ately or any ciscrepa nty Toun
by hin in his statenent of Account, 1t w2 il be taxen that he nas Tound zne account correc

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