Survival Benefit Payout Form

Note: Please complete the form in CAPITAL LETTERS.

All fields with (*) are mandatory

POLICY
DETAILS

I request Exide Life Insurance Company Limited to release my survival benefit amount for the below mentioned policy.

Policy Number*:

Policy Holder’s Name*:

ADDRESS

Address*:

City*:

State*:

PIN*:

Landline*:

Mobile*:

PREMIUM
ADJUSTMENT

E-mail*:
Renewal Premium adjustment*

BANK ACCOUNT
DETAILS
TAX DEDUCTIONS

Yes

No

I hereby agree for the installment premium which is due on the benefit due date (current and future), to be adjusted from the proceeds.

Bank Name*:

Bank Branch*:

Account Number*:

IFSC Code*:

Please tick (ü) any one Bank Account Type*:

Savings

Current Account

Over Draft / Cash Credit

NRO

In case the IFSC code is not provided or if the same is not enabled for NEFT, then the payout will be made by A/c payee special crossed cheque. Direct credit is
not possible for NRE accounts.

1. Do you have a PAN card* Yes

No

If Yes, kindly provide your Permanent Account Number (PAN)*:

along with self-attested photo copy of PAN Card.

As per Finance Act 2014, payments made under Life Insurance policies which are not exempt under the Income Tax Act are subject to tax deduction at source @ 2%
(Under Section 194DA). In case the payee does not furnish valid PAN details, the rate of tax deduction will be 20%.

2. Are you currently a Resident of India* Yes

No

If No, please specify country of Residence________________________________________.

DOCUMENTS REQUIRED

Note: In case you are not a Resident of India, then tax deductions will be applicable as per beneficial provisions of treaty with the respective Country of Residence.

Please submit the following listed documents along with the mandatory requirements (*).
1) Self-attested valid photo ID proof *

2) Self-attested valid address proof

3) PAN card*

4) Original cancelled cheque with your name and account number pre-printed* OR
Self-attested copy of bank statement / pass book copy with bank seal.
List of valid address proofs: Telephone Bill, Bank letter/ Account Statement, Water Bill, Electricity Bill, Valid Passport, Valid Driving License, Ration Card, ESI Card, Domicile Certificate,
Company Lease Agreement/Rental Agreement, Employer's Certificate. Statement/Receipt/Bill should not be more than six months old from the request submission date. Please attach
self-attested identity proof bearing photo (e.g. Pan card, Voter’s ID, Passport, Driving License, Aadhar Card)

DECLARATION

I take full responsibility for the genuineness and correctness of the details filled herein.
Signature / Thumb Impression of the Policy Owner / Assignee*:
Date

D D M M

Witness
Signature*:

Y Y Y Y

Name of the Customer
Service Representative:

ACKNOWLEDGMENT
SLIP

FOR OFFICE
USE ONLY

*(Should be someone other than the advisor/employee of the company and who has also explained the contents of this form if signature is in vernacular or a thumb impression.)

Date:

Branch
Code:

D D M M Y

Y Y Y

Signature:

Employee No.:

This is to acknowledge receipt of application for Survival Benefit payouts

Documents received:
Valid Address Proof

Date:

D D M M Y

Y Y Y

Policy No.
Identity Proof

Bank Account Proof

PAN card

Sign:

Branch
Seal

Others______________________________________________________________________________

Call : 1800 419 8228 (TOLL FREE); +91 80 4134 5444

Email : customer.service@exidelife.in

Visit : exidelife.in

Registered Office: Exide Life Insurance Company Limited, 3rd Floor, JP Techno Park, No.3/1, Millers Road, Bengaluru - 560 001.
(Formerly ING Vysya Life Insurance Company Limited)

IRDAI Registration No. 114

CIN: U66010KA2000PLC028273

POS/SBP/Version 1.0

Name & Address of the Witness*: