Form No.

3543

LIFE INSURANCE CORPORATION OF INDIA

Place

Date................... ..

Re: Policy No .....................................

At the request of the Life Assured the following alterations are hereby made in the
Policy:
Sum Assured reduced to Rs.......................................
from the premium due .............. .................................
.....premiums from ........................................... @ Rs..
The sum of Rs .....................has been paid as surrender value* inclusive of cash value
of bonus in respect of the portion of the Sum Assured dropped.
*Bonus already vested till date shall stand reduced proportionately.
(*To be deleted where not applicable)

for LIFE INSURANCE CORPORATION OF INDIA

P. Branch Manager.