LIFE INSURANCE CORPORATION OF INDIA QUESTIONNAIRE TO BE SUBMITTED WITH SURRENDER APPLICATION / DISCHARGE FORM (EXIT INTERVIEW) Nameof Life Assured: Policy No. Date of Surrender: (Kindly, Select only one option for each question) qvesies Question Options {1)_ | Are youaware tna surrender of LIC poliey means losing a | life cover and financial lossto you? 2) NO (2) | Reasonsforsurrender of the LIC policy. 1) Ungentfinanciatneed [1 =tienttnanchlness, = __ = _—— 2) _ Not satisfied withterms and conditions of the plan 3) Not satisfied with service 4) Anyotherreason fa) _| Whether surcender amount Is being invested in any|1)_Yes other LIC product? 2) No thereby declare that have understood the surrender value calculation fully and signing the discharge formatter understanding the same. Signature of Life Assured Name of Life Assured: Mobile /Contact Number: ‘OHANRAJ PRINTERS 100 Pages 1 1000 Pads - 100,000 Forms 06/2017