INSURANCE
                                                                Policy Cancellation Form ( Surrender Form )
                                                                                                                                       
                                                                      PLEASE FILL THE FORM IN BLOCK LETTERS
            Do you know by cancelling your policy you are losing on-
             
                    Your Life cover
             
                    Your Rider benefit
             
                    Opportunity of earning Long term return on your systematic planned investments.
            To know more you can call us at 1800 200 5577 or SMS "RET"at 5424243 or get in touch with your Agent Advisor in case you 
            need any assistance in understanding your plan or our services.
            Reason for Surrender
                    Financial reasons (Immediate Fund requirements,Purchase of Asset,etc.)
                    Unsatisfactory returns  
                    Unsatisfactory services  
                    Buying a new plan 
                    Others,please specify
            Did you consult any one before taking the decision to surrender: 
             Agent                        Friend                        Relative                       Others (pls specify)________________________________________
             We regret your decision and hope you have evaluated all the benefits of continuing with your policy prior  to making this application.We 
             thank you for choosing Max Life Insurance as your preferred insurance partner and hope that you will reconsider our products in the near 
             future.
             Please Note:
             “Your request will be processed, provided the request form has been filled in complete and all mandatory documents have been submitted.Ž
             “For Unit Linked Products if application is received up to 15:00 hrs IST on a business / working day, the same days NAV will be applicable. However, if 
                  application is received after 15:00 hrs, then the next day declared NAV will be applicable
             
                  In case of address change or contact details change request, please fill up a separate Policy Service Request Form and submit with valid address  proof.
             
                  Max Life Insurance shall not be held responsible for delay or non- receipt of the cheque in case the postal address is incomplete / incorrect in company's 
                  records.
             Max Life Insurance will not be responsible in case of non credit to your account or if transaction is delayed or not effected at all for reasons of incomplete/ 
                  Incorrect information provided or rejected by your bank. In case requisite information for direct credit is not received or transaction is rejected by bank the 
                  payout will be made vide cheque
              Mandatory Documents for processing payout
                  Original Policy document submitted by the Policy holder for Surrender request.                            
                   Self attested valid copy of Photo ID proof, carry original for verification at Branch. 
                  Original Cancelled Cheque with pre printed name & account number 
                   Pass book copy / Bank statement having pre printed name & account number in case Cancelled cheque does not
                   have pre printed name and account number, carry original for verification at Branch.
                  Latest Contact Details. NRE bank statement reflecting any premiums paid from NRE account.
                            Do you know
                            New insurance is expensive than insurance purchased at a younger age.Don't surrender!
                            You can also opt for partial surrender to meet your immediate fund requirements and continue with your policy.
                                  Low  Charges:  In  Unit  linked  products,  the   charges   come           High Growth Potential: Unit linked products may be linked to 
                                  down significantly after 3rd  year  resulting  in more  of your            stock market and your investments grows at  a fast  pace as 
                                  premium  being allocated towards your funds. ULIP thus help you            compared to many other investments.
                                  achieve long term goals.
                                  Life Cover: Once the policy is surrendered the life cover ceases           Tax Benefit: You can continue to avail tax benefits under the 
                                  and you may not get cover when you actually need it the most.              applicable sections of the Income Tax Act, 1961 subject to any 
                                                                                                             amendment made there to from time to time.
                                                       INSURANCE
                                                                                                                                                           Policy Cancellation Form ( Surrender Form )
                                                                                                                                                                                                                                                                                                                                    
                                                                                                                                                                         PLEASE FILL THE FORM IN BLOCK LETTERS
                           Request Form
                            Policy No.                                                                           Name of the Policy Holder_____________________________________________________
                            Mobile Number                                                                                             Alternate Mobile No.
                            Address 1 ____________________________________________________________________________________________________________________________
                            Address 2 _________________________________________________________________  Email ID__________________________________________________
                            City ______________________________________________ State ________________________________________________ Pin
                            Bank Details for NEFT
                                                                                                                                                                                                                                                  b)      Bank Account No...................................................................................
                            a)              Pan Card                                                                                                
                            c)      IFSC Code.............................................................................................d)      Bank Name............................................................................................
                                                                                                                                                                                                                                                     )      Account Holder Name
                            e)     Bank Address..........................................................................................f                                                                                                                                                                                        ...........................................................................
                            Note - Kindly attach a cancelled cheque bearing account number and policyholder name or copy of Bank Passbook along with this Form.
                            Declaration
                                                                                                                                                                            .                                                                                                                                                                                                                                                                                                  
                            I herebysubmit thatIamtheholderofaninsurancepolicyno                                                                                                                                                                                                                                                    withMaxLifeInsuranceCompanyLimited. I would
                                                                                     .                       
                            like to voluntarily surrender and terminate the a foresaid Policy I request you to please process the surrender request of my policy and pay the applicable
                                                                         (  )                                                                                                                 (  ). /                                                        ____________________________________________________________  / ,  
                                                                                                                                                                                                                                 Miss
                                                                                                                                                                                                                              ..                                                                                                                                                                                                                             s
                            surrendervalue ifany afteradjustingapplicablecharges ifany  I Mr                                                                                                                                                  / Mrs                                                                                                                                                                                                                 o
                                               
                                / ,
                            dowo__________________________________aged___________residentof______________________________________doherebydeclareandaffirmthatthe
                                            /
                                                      .                          ,  
                            details provided in this Form are correct and accurate I do hereby agree to receive the surrender value payable under the policy terms and conditions after
                                                                                                                     .  ,                                                                                                                                            .                                                                                                                                                                                             
                            deductionofapplicablecharges Further I confirmthattheinformationprovidedbymehereinistrueandcorrect I confirmandstandindemnitytowardsMax
                                                .
                            LifeInsuranceforanyincorrectorwrongfulrefundobtainedbyme
                                                                                                                                                                                  .                                                                                                                                                                                                                                                                                         
                            I understand post processing the surrender request for my policy no                                                                                                                                                                                                                                                             mylife cover for___________________
                                                                                                                                                                                               .
                            _________________________________________along with other benefits as mentioned in policy contract will cease to exist
                            ______________________________                                                                                                                                                                                                                                    ______________                                                          ______________
                            Signature of Policy Holder                                                                                                               Date:                               Place:
                            Branch Mandatory checklist
                                      All mandatory documents as listed above are collected. 
                                      All copies to be self attested by Policy Owner.                                                                                                                                                                                                                                                                                                                        GO STAMP
                                      All documents are Original seen and verified by the Max Life Insurance Personnel.
                                      Received Surrender request on                              at _______:______am/pm 
                                      Retention Efforts made- Yes / No_______________ Reason for Surrender________________________
                                      Pay out to the customer : 1) NEFT process                      2) Cheque process
                                      Acknowledgment Slip
                                        We thank you for choosing Max Life Insurance as your preferred insurance partner and hope that you will reconsider  our products in the near future. We regret your decision and hope you have evaluated all the 
                                         benefits of continuing with your policy prior to making this application. Your Request will be processed within 1 0 days of submission at our Branch office. In case you need any clarification or assistance 
                                        regarding your policy, please call 1800 200 5577 Or SMS 'RET' to 5424243.
                                       Max LifeInsurance Co.Ltd.
                                         3rd Floor, Operation Center, 90. A, Udyog Vihar, Sector-18, Gurgaon- 122015,Regd office: Max House 3rd Floor,1 Dr. Jha Marg, Okhla, New Delhi-110020,India Contact Details: Tollfree Customer Helpline:1800.200.55 77
                                         e-mail: service.helpdesk@maxlifeinsurance.com Visit us at: www.maxlifeinsurance.com
                                                                                                                                                 SURRENDER REQUEST CUSTOMER ACKNOWLEDGEMENT SLIP
                                           Policy Number                                                                                                                                                                                                                                                                                                                                                     GO STAMP
                                           Received by __________________________Date & Time of Receipt_________________
                                                                                                                                                                                                                                                                                                                                                                                             Max Life Insurance/SUR/Version 2.2/June’13