POLICY SURRENDER FORM

Before you surrender this policy, ask yourself .

Am I taking the right decision?
THINK Do I want to withdraw the financial security of my family?

AGAIN! By surrendering this policy, you will lose long term benefits like
Life insurance cover Opportunity to earn good returns

Policy Number Date

Name of Proposer
Mr./Ms./Mrs First Name Last Name

Contact Nos.
STD Residence STD Office Ext. ISD Mobile

Email Id

Is this Policy Assigned? Yes No

Assignee Name
Mr./Ms./Mrs First Name Last Name

ENTITY DETAILS
Entity Type: Individual Non Individual Residential Status: NRI RI

Entity Regulations Non Profit Organization Regulated by RBI / SEBI / IRDA Others Not Applicable

Have you availed any tax benefits under 80C/ 80CCC for this policy? (For NRI customers only) Yes No

IMPORTANT GUIDELINES:
1. The Policyholder is required to personally visit the branch for submitting this request.
2. If the request under the Unit Linked Product is received up to 3:00 pm IST on a weekday (Mon-Fri), the same day’s NAV will be applicable. However, if the application is received after 3:00 pm IST, then the next declared NAV will be
applicable.
3. Where the policy is assigned, this request would be processed only on receiving consent / no objection from the Assignee of the policy.
4. All communications will be sent to the mailing address registered with us. The Company will not be liable for any loss arising from non-receipt of communication.
5. If the application for re-instatement/renewal premium and surrender is received on the same day, first the policy will be re-instated/Premium allocation will be done and then the surrender will be processed on the next working day and
the NAV of the date of processing will be applicable.
6. Amount payable on surrender/ partial withdrawal of the units shall be net of all applicable taxes, and will be charged as per prevailing tax laws.
7. TDS (Tax deducted at Source) provisions are applicable on all taxable payouts under section 194DA (Resident Indians) and 195 (Non-residents) subject to conditions under section 10(10D) for life insurance policies,10(10A) for
commutation and other provisions of Income Tax Act, 1961. TDS credit will not be available to you if valid PAN is not submitted with us. TDS rate u/s 194DA is 1% if valid PAN is available with us else 20% on total payout under all your
taxable policies aggregating ` 1,00,000 or more in a financial year. TDS rate u/s 195 is 30.9% +12% surcharge (if applicable) on tax, applicable on income arising to a non-resident policyholder.
8. Amount payable on Surrender/ Full Withdrawal of the units shall be as per the policy terms & conditions. The Surrender / Full Withdrawal of the units will result in termination of the policy and all rights / title and interest under the
policy shall stand extinguished.

FULL SURRENDER
Documents Submitted: Welcome Kit / Policy document Self-Attested photo id Signed Cancelled Cheque
Reason for Full Surrender

PARTIAL WITHDRAWAL
Documents Submitted (mandatory): Original & photo copy of Welcome Kit / Policy document Self-Attested photo id Signed Cancelled Cheque
Reason for Partial Withdrawal

Name of the Fund(s) Percentage Amount (Rs.)

Note: Request will be processed if withdrawal requested is greater than or equal to minimum withdrawal amount mentioned in the policy document. Partial withdrawal is allowed as per your policy terms and
conditions. On Partial withdrawal, sum assured reduction will be as per your policy terms and conditions.
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ACKNOWLEDGEMENT SLIP
This is to acknowledge the receipt of application for: Partial Withdrawal (Amount ` ____________________) Surrender/Full Withdrawal

Policy Number Form Generation Date

Surrender Request Date STAMP

Reference ID
&
TIME
Documents Submitted Welcome Kit / Policy document Self Attested Photo ID Signed Cancelled Cheque
Received By
PAYMENT DETAILS:
Name of Proposer as in the Bank Account *
* Where the policy is absolutely assigned the payout will be processed in favor of the Assignee

Bank Name

Bank Account Number

Bank Account Type Savings Current NRE NRO Aadhaar linked account**
DATE ........................

Aadhaar Number PAY .........................................................................................................................................................

..................................................................................................................................................... OR BEARER
**Alternate bank account details to be mentioned for the event if payout cannot be credited to the Aadhaar linked account. RUPEES ...........................................................................................................
......................................................................................................................... `
Branch Name SBGEN A/c No. ANWB
001010101000
XYZ Bank
MICR Code (You can get this code from your cheque book) XYZ Bank Limited
Address 1
Address 2
Address 3 RTGS / NEFT IFSC Code : AAAA0000000

|| 111111|| 222222222|: 000000|| 00

IFSC Code (You can get this code from your bank)
Note:
 Please take due care and caution to ensure that the bank related information is filled correctly.
 Payout will be made in Savings Account only.
 Bank account number provided in this form should match with the account number appearing on the cheque. The account number must be pre-printed
 This electronic mandate request will apply to all policies held by you with ICICI Prudential where no mandate is currently attached
 Any payout under the policy shall be made after realization of the last renewal premium payment.
 If the transaction is delayed or not effected at all or is effected in some other account for any reasons due to incomplete or incorrect information, I shall not hold the company responsible in any manner.
 I/We further confirm that the account details provided herein are not pertaining to NRE account and NRE payouts will be processed by cheque only
 I/We understand and agree to inform ICICI Prudential with an advance notice of 6 weeks; in case I/we desire to change my bank details or withdraw the current mode of payment due to any reason, however, ICICI Prudential shall retain
the right to accept/reject this in case the revised bank details are not enabled under this NEFT Framework. In case details are not submitted 6 weeks in advance, then the interim payments will be processed by way of cheque & will be
sent at your registered communication address. This mandate shall be used for future payments, if any.
 I hereby declare that the particulars given in this form are true, correct and complete in all aspects. I take full responsibility of accuracy and correctness of the details filled herein.
 Further, I undertake that I shall not hold the Company responsible for non-receipt of payment due to wrong/ incorrect/ incomplete information given by me in this form. I also understand and agree that the Company reserves the right to
use any alternative payout option.
 I am aware of the FATCA/CRS rules released by Central Board of Direct Taxes incorporated under Section 285BA of The Income Tax Act, 1961 read with rules 114F to 114H.
 I am aware that Tax at source, if applicable, will be deducted by the company from the payout amount and I will not hold the company responsible for the same.
 I hereby indemnify the company against any adverse consequences under FATCA/CRS or any other tax regulation.

_____________________ _____________________
Signature of Proposer Signature of Assignee

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 Mobile Number of Witness

FOR OFFICE USE ONLY: Form Spaarc Call ID Surrender Spaarc Call ID

Form Generation Date Surrender Request Date

Received by _________________________________________________________________________________
STAMP
MANDATORY DECLARATION BY BRANCH OPERATIONS & SALES EMPLOYEE: &
TIME
I hereby confirm that I have explained the benefits of policy continuance & the implications of surrender of the
aforementioned policy to the policy holder.
BRANCH OPERATIONS EMPLOYEE DETAILS:
Ops Employee Name and ID

_______________________________
(Signature of specified person)
SALES EMPLOYEE DETAILS:
Sales Employee Name and ID

_______________________________
REASON FOR NON-AVAILABILITY OF SALES PERSONNEL: (Signature of specified person)

Not present in branch Attending other customer(s) Others (please specify)

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Kindly call our Customer Service Number 1860-266-7766 (local charges apply). Call Center timings: 10.00 A.M. to 7.00 P.M. Monday to Saturday (except national holidays)

Communication Address: ICICI Prudential Life Insurance Company Limited, Unit No. 1A & 2A, Raheja Tipco Plaza, Rani Sati Marg, Malad (East), Mumbai 400097.
ICICI Prudential Life Insurance Company Limited. Registered Address: ICICI PruLife Towers, 1089 Appasaheb Marathe Marg, Prabhadevi, Mumbai-400025. IRDAI Regn No. 105. CIN:L66010MH2000PLC127837 Call us on
1860-266-7766 (10am-7pm, Monday to Saturday, except national holidays and valid only for calls made from India). Trade Logo displayed above belongs to ICICI Bank Ltd & Prudential IP services Ltd and used by ICICI
Prudential Life Insurance Company Ltd under license. Comp/doc/June/2017/0215.