Payout Form

Policy No.: __10286007______________ Date: __________________

Dear Sir,
With reference to the above policy please process ___________________ (Tick the appropriate, below)

1) ULIP-Surrender / Traditional Surrender (Tick Appropriate)

2) Partial Withdrawal – Amount Rs.___________________________
3) Refund - Excess money paid
4) Loan – Maximum loan available / Amount – Rs.________________
5) Re-Issue / Revalidate the cheque (Enclose stop payment indemnity / stale cheque)
* For ULIP products NAV, please refer point no. 2 of terms and conditions section on page 2.
Harish Kulkarni
Name of the Policy Holder: _________________________________________________________

H. No. 410, Yamagarni Tal. Chikkodi, Dist. Belgaum Pin - 591241

Address: _______________________________________________________________________
Yamagarni
City: ______________________ Karnataka
State: _____________________

+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)

Request received time stamp to be affixed

In case of ULIP surrender

Current Fund value (Indicative) ----------

Surrender charges ----------

* Surrender value (Indicative) ----------

* This is an indicative surrender value depends on the effective NAV rates, please refer point no. 2 of T&C section on page 2.

-------------------------------- ------------
Signature of Policy holder Date

Selection of Payment option (Tick Appropriate)

Direct Transfer to my bank account. (Cancelled cheque is mandatory) 1.

Remit payment through cheque (Cheque will be sent to the communication address as per company records).

Attach Cancelled Cheque Here

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.

Reliance Life Insurance Company Limited. (Reg. No. 121)

Registered Office:-H Block, 1st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai, Maharashtra 400710, India
Corporate Office- 1st Floor, Midas, Sahar Plaza, Andheri Kurla Road, Andheri (East) Mumbai 400059, India
Phone No- 1800 300 08181/30338181 Email: rlife.customerservice@relianceada.com Website: www.reliancelife.com

Payout Form Ver 1.4 Apr 10

Policy holder’s name as per bank records: ________________________ __________

Bank Name: __________________________________________________________

Branch Name:_________________________________________________________

Bank Account Number: _________________________________________________

IFSC Code: _______________________

Please verify that account number matches with the cancelled cheque/bank statement attached and counter sign.

Name & Sign of CE Branch Stamp & Date

Terms & Conditions (T&C):

1. Incase of Surrender/Partial Withdrawal Certain charges will be deducted as mentioned in the terms & condition in the policy document.

2. For ULIP Products, if the request is received:

2.1 Before 3.00 p.m, NAV of date of application shall be applicable.

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.

_________________________________________
Signature of Policyholder with Date
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Customer Acknowledgement (Tear here)

Policy No.: __________ Date: __________

Service Request No: __________

In case of ULIP surrender

Current Fund value (Indicative): __________

Surrender charges: __________

Surrender value (Indicative): __________

Name & Sign of CE Branch Stamp & Date

Reliance Life Insurance Company Limited. (Reg. No. 121)

Registered Office:-H Block, 1st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai, Maharashtra 400710, India
Corporate Office- 1st Floor, Midas, Sahar Plaza, Andheri Kurla Road, Andheri (East) Mumbai 400059, India

Payout Form Ver 1.4 Apr 10