Policy Service Request Form

1800-102-4444www.bharti-axalife.comSMS SERVICE to 56677We will be in touch within 24 hoursto address your quer yPolicy Service Request FormPolicy DetailsKindly fill in BLOCK LETTERS onlyPolicy Number:Name of Plan:Name of Policyholder:Name of Life Insured:First Name Middle Name Last NameFirst Name Middle Name Last NamePolicyholder Contact DetailsLandline No. (Residence):Landline No. (Office):STDPhone*Mobile No.:(Mandator y)Email ID:Request For Personal Details Change(Tick the relevant box)Change of mailing address #AddressCity State Pin CodeChange of Name #PolicyholderLife InsuredFromFirst NameMiddle NameLast NameToFirst NameMiddle NameLast NameAlteration in Date ofFromBir th of the Life Insured # D D M M Y Y Y YToD D M M Y Y Y Y( # Please submit suppor ting documents along with the request form.)(Tick the relevant box)Request For Premium Payment Details ChangeChange in Frequency ofpremium payment (Notavailable for Bhar ti AXA LifeBright Stars, Spot GuaranteeBuilder & Merit Plus plans)FromToAnnual (once a year)Annual (once a year)Semi-annual(twice a year)Semi-annual(twice a year)Monthly @(twelve times a year)Monthly @(twelve times a year)Quar terly @(four times a year)Quar terly**(four times a year)Change in method ofpremium paymentFromCash/ChequeECS*Credit Card*ToCash/ChequeECS*Credit Card**Electronic Clearing Ser vice (ECS) & Credit Card facility is available across all frequencies of premium payment. @ ECS or Credit Card facility ismandator y for monthly and quar terly mode of payment. For availing these facilities, an ECS Mandate Form with a cancelled cheque, or a Credit CardAuthorisation Form with photocopies of the front side of the Credit Card will be required. **Not available for Spot Suraksha. You can download theforms from our website www.bhar ti-axalife.com

DeclarationI understand and agree that:• I/We would be required to comply with additional terms on the basis of the aforesaid change/s• The aforesaid change/s would be effective only when notified to be accepted by Bhar ti AXA Life Insurance Company LimitedDate:Place:D D M M Y Y Y YVernacular DeclarationSignature of thePolicyholderDECLARATION* IN CASE THIS POLICY SERVICE REQUEST FORM IS FILLED BY A PERSON OTHER THAN THE POLICYHOLDER OR SIGNED IN VERNACULARLANGUAGE:Declaration by Policyholder:I hereby declare that the contents in the form have been fully explained to me and I declare that whatever is stated hereinabove has been recorded as perthe information provided by me.Thumb Impression/Signature of the PolicyholderDeclaration by person filling the form:I have explained the contents of this form to the Policyholder inlanguage and I have correctly recorded the answer provided to me. Ifurther declare that the Policyholder has signed/affixed his/her thumb impression in my presence.Declarant’s Name:First Name Middle Name Last NameDeclarant’s Address:City State Pin CodeDate of Bir th:D D M M Y Y Y YDeclarant’s Signature:Date:Place:D D M M Y Y Y Y*"The person giving this declaration can be any person other than Introducing Advisor or MOA or MOM."Bharti AXA Life Insurance Company Ltd.Regd. Office: Unit 601 & 602, 6th Floor, Raheja Titanium, Off Western Express Highway, Goregaon (E), Mumbai 400 063. Regn. No.: 130. Comp-Oct-2010-11211800-102-4444 SMS SERVICE to 56677 We will be in touch within 24 hours to address your quer y www.bharti-axalife.com