Freelook Cancellation Form

FREE LOOK CANCELLATION FORM
Policy Number:
Name:
Contact Number*: PAN NO.
Email ID:
Reasons for Cancellation:
1. Stated policy benefits and returns, as per the policy contract, vary from those understood by me at the time
of purchase
a. I thought that I need to pay premiums for lesser years / only 1 year,
b. I thought I will get higher returns,
c. The maturity period is different from what I understood,
d. Other reasons:
2. I cannot afford to pay the premium for this policy
3. I was sold this policy in exchange for a loan and/or a locker
4. The agent advisor/ bank staff/ seller who sold this policy is asking me
to cancel it within the free-look period
5. I did not receive my policy pack
6. My policy took too long to get issued
Customers who have registered under the National Do Not Call Registry, will be considered to have consented to
us communicating with him/ her on the contact details provided herein.
Declaration:
 I am the Policyholder of the Insurance Policy number mentioned above and have requested Max Life Insurance
Co. Ltd (“Company”) to process the cancellation of the Policy under the freelook option, after deducting the
proportionate risk premium for the period of cover, charges of stamp duty paid and the expenses incurred on
medical examination of the Life Insured, if any, in accordance with the Policy contract
 I am aware that the cancellation of the Policy results in termination of the Insurance Contract and all rights/ titles
and interest under the Policy shall stand terminated
 I am aware that the payment of the premium refund amount by Max Life Insurance in accordance with the terms
hereof, shall constitute a full and final discharge of the obligations of Max Life Insurance under the Policy and I shall
not claim/ demand anything thereafter
 I further declare that the details provided in this Form are correct and accurate to the best of my knowledge and
records, and I will hold the Company harmless and indemnified against any and/ or all losses, claims, liabilities, legal
proceedings (including attorney fees), expenses or damages suffered by or taken against the Company arising on
account of any error or misrepresentation in the information furnished in this Form by me or any wrongful refund
obtained by me
“I/we understand that, I/we have disclosed my/our personal information (which may include Aadhaar related
information) with Max Life for the purpose of providing insurance and related services and I/We hereby consent and
authorize Max Life to use, store and/or share the same with government/ regulatory/ statutory bodies, insurance
repositories, reinsurers / hospitals or diagnostic centers/ other insurance companies for the purposes of underwriting
assessment, claim investigation / settlement, KYC and policy servicing purposes, as per applicable law.”
Signature of the Policyholder Place: Date:
DISCLAIMER:
 The Company shall not be held responsible in case the premium refund is not credited to your bank account or if
the transaction is delayed or not effected at all for reasons of incomplete/ incorrect information provided by you
in the proposal Form at the time of issuance of this Policy
 Credit will be affected based solely on the Policyholder account number information provided by the Policyholder
and the Policyholder name particulars will not be used thereof. The Company may also pay you via any mode like
demand draft/ cheque etc.
 The relevant NAV and processing of the Policy will be applicable post receipt of all the requirements/ documents
received by the Company
Vernacular Declaration (To be filled if the Customer has signed in language other than English/ Affixed Thumb
Impression) “I hereby declare that I have explained the contents of the cancellation Form/ request letter to the
Policyholder Mr./ Mrs./ Ms.in their language and that the Policyholder has affixed the thumb impression/ signed in a
language other than English in my presence after fully understanding the contents thereof. I further declare that I am
not related to the Company in any manner, whatsoever.”
(Name and Signature of the Declarant)
Ver2.3, Aug’19

Freelook Cancellation Form

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Freelook Cancellation Form

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FREE LOOK CANCELLATION FORM

Contact Number*: PAN NO.

Reasons for Cancellation:

Signature of the Policyholder Place: Date:

(Name and Signature of the Declarant)

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