Birla Sun Life Insurance Company Limited

Registered Office: 6th Floor, Vaman Centre, Makhwana Road, Near Marol Naka, Andheri (E), Mumbai - 400 059.
Call Centre: 1-600-22-7000 E-mail: clientservices@birlasunlife.com www.birlasunlife.com

POLICY SERVICE REQUEST FORM Registration No. 109

[IMPORTANT : All the information is to be filled in BLOCK LETTERS only]

POLICY No. Complete relevant sections of the form for

the changes / transactions you require.
CLIENT ID (Owner) Strike out sections not required.

PERSONAL DETAILS

Name
(Title) (Surname) (First Name) (Middle Name)

1. Change of Address / Contact details Yes No

A. New Mailing Address

City State Pin

B. New Contact Details

Tel. Home Office Mobile E-mail

2. Change of Name Owner Insured

From
(Title) (Surname) (First Name) (Middle Name)
To

(Title) (Surname) (First Name) (Middle Name)

Reason : Records Incorrect Others (Specify)

(A certified true copy of the supporting document should be enclosed).

3. Change of Premium Mode to Annual Semi Annual Quarterly ECS (Monthly) ECS
(Mode)
l Change of mode is allowed only after the completion of the first policy year.
l Electronic Clearing Service (ECS) is available across all modes including monthly.
l For processing an ECS request, an ECS mandate form and a cancelled cheque will be required.
l Contact 1-600-22-7000 for details regarding the ECS service.

4. Switch in Investment Fund Option (For Flexi-Save Plus, Flexi Cash Flow & Flexi Life Line only).

l Switching between investment funds is allowed only after completion of one Policy Year. One free switch is allowed in a Policy Year.
l For any additional switch in the investment fund option, in a policy year, a service charge of Rs.100/- will be levied.
(The charges are as per current administrative rules and are subject to change).
l The effective date of the change will be the month anniversary date coinciding with, or immediately following the date of request for
change.
NOTE: The Minimum Policy Values of your policy contract are subject to the Investment Fund opted at inception of the Policy not being
changed throughout the lifetime of the policy and other conditions mentioned in the Minimum Policy Value page.
Investment Fund Option - From To

Protector

Builder

Enhancer
5. Withdrawal from Holding Account (For Flexi Save Plus, Flexi Cash Flow & Flexi Life Line Only)

I l The Policy Values reflecting in the Minimum Policy Values page would be reduced subsequent to the withdrawal.

l Withdrawals can be made only after completion of 2/3 Policy Years (Conditions Apply).

l The minimum amount per withdrawal should be at least Rs.2000/-

l Whilst 2 withdrawals are free in a Policy Year, for any withdrawals thereafter a service charge of Rs.100/- will be levied
(The charges are as per current administrative rules and are subject to change)

II To request a withdrawal please complete this section and section 7

In case your request is for more than the amount available for withdrawal we will process your application only for the amount
available.

Withdraw Rs from the Holding Account.

6. Policy Loan (For Flexi Save Plus, Flexi Cash Flow & Flexi Life Line Only)

I l You can avail of a policy loan after completion of 2 Policy Years.

l The loan is subject to the terms and conditions mentioned in your Policy contract. The maximum loan may not exceed 90% of
the Surrender Value and subject to minimum loan availability of Rs. 3000/-.

l The Policy values reflecting in the Minimum Policy Values page are subject to there being no outstanding loans existing and the
other conditions mentioned therein.

II To request a loan please complete this section and section 7

I request for: (tick the relevant box)

A policy loan of Rs. or The maximum available loan amount.

In case your request is for more than the amount available for loan we will process your application only for the amount available.

III I hereby assign all my rights, title, interest and all benefits attached to the said policy to Birla Sun Life Insurance Company Limited.

7. Receipt for Withdrawal / Loan Amount

I hereby acknowledge receipt of Rs. as a withdrawal / policy loan paid to me by Birla Sun Life Insurance
Company Limited.

Signature of Policy Owner/Assignee/Trustee Dated

Witness’s Signature

Witness’s Name Dated

Witness’s Contact No.