§ POLICY BENEFIT cara | ss5.6 yaad, f DISCHARGE FORM io seraankhon par IM | | | | Kil | | Signature/Thumb impression of Policy Holder X —— Date Vernacular Declaration (to be filled If this form is signed in Vernaculariaffixed thumb Impression) Applicable when tre Proposer is ilitrate or suflering trom disabilty ve to which writing is restcted or the proposer has signed in vernacular language. I! this declaration is applicable andi nt flied, we shal be constrained to reject this request frm. Note: Must be declared by someone other than the banks staf or representative ofthe company. | nereby declare that! have explained the contents ofthis form tothe Polcyholder MeMrs/Ms in language and thatthe Poleyholer has affixed the thumb impression(s'signed in language other than English in my presence ser uly understanding the contents thereot Date Place Name of Declarant Signature of Declarant ‘An individual sa resident, ihe satisfies any of the two conclions below:- He is in India inthe relevant nancial year for 182 days or more; OR He isin India for 80 days or more in the relevant financial year AND 385 days or more during four years immediately proceeding relevant financial year Instruction & Disclaimer: + Product specific equestsfunds willbe lowed, only if tis applicable under te respective terms & conditions ofthe Policy. Please refer tothe terms {and conditions of the Poley for deals. The formats for additional documentation can be dowelcaded from our website + understand and agree thatthe submission of this form dovs not mean thatthe request willbe acceded, + Processing ofthe roquests wil be inated on receipt ofthis form a any of our Company's Offices. n case of Uni Linked Policies, forthe requests Impacting the funds ofthe Policy, i application is received before 3:00 pm on a business day, NAV of same day willbe applicable, I receved after 3:00 pm, next business day NAV willbe applicable. + Register now on our webste to avai the benefis of various option fo on-line servicing of your Palicy + The orignal form wil be submited back othe customer incase request taken through Distributor App. + Kindly the form in English + ond ‘event of any dlsagreement in interpreting the language, English version will provall5 POLICY BENEFIT AXCanara HSBC a apke vaade, _brsewamee rome Scan MMMM PSAQOOLOL “The SFIN (Sogragaled Fund indox Number) for: Equity Fund i¢ ULIF00"16!06/08EQUITYFUND'36, Equty Fund i ULIFOOSO7IO1OEQUTYHFND'35, Grows Fung is ULIF002 6108 {08GROWTHFUND'35, Groth Il Fund ie ULIFOQTO7IOIOGROWTIFNDI26, Growth Plus Fund ie ULIFO0913/09"10GROWTPLEND'36, Balanced Fund ¢ ULIFO03"6/06/086LNCEOFUND 136, Balanced I! Fund is ULIFO0807/07/108L NCDIFND36, Salanced Pis Fund ig ULIFOTO13I08/1OBLNCOPLF- [ND#36, Debt Funds ULIF00409107/08INDESTFUND'36, Debt Plus Fund ie ULIFO*T15100ODEBTPLFUND' 36, Liquid Fund is ULIF00514/07708LIQUIDFUND'36, NAY Guarantee Fund serie ti ULIFOY25104/TINAVGFUNOSIT96 PLFUND'36,Liguid Fund is ULIFOD5%4/07/08LIQUIOFUNDI36, NAV Guarantee Fund series ‘is ULIFOT215)04/1 NAVGFUNDSI136, Inia Muli-Cap Equity Fund i ULIFOTS16I08/16IMCAPEQFND36, Pension Growth Fund is ULIFOTA0S/T1/15PENS- GROFNDIS6, Emerging Leaders Equty Fund ULIF02020/"2/17EMLEDEGFNO'S, ‘ane NSBE veal Bank of Crave Lie surance Company Lied (ROA Rego.) Paley Serving eprint nd lor Orch Bones Par econ an Ron ‘uregran-1220, Haryana, aa Regd fe Unt Ne. 28,2 Flot, Kachajunga Suing 8 Bardhanbs Reed New Gi 100%, orporte ety No UEEOOL207PL CEE Conte 06-18-98, 190-169-083 401 12448800 (Fa)! Emal:utomerenenicaerahaelein, Mab wc