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Exide life insurance policy bo... Maturity Payout Form Note Please complete the form in CAPITAL LETTERS. All fields with are mandatory I request Exide Life Insurance Company Limited to process my maturity proceeds and refund the eligible maturity value after deducting all dues under this policy. Maturity Date D D Policy Number M M Y Y Y Y POLICY DETAILS Policy Holder s Name To enable us to get in touch with you and facilitate quick processing kindly update your latest contact information In case of change in communication address a valid address proof of the new address is mandatory - Refer below for list of valid address proof Current Address Pin Code Landline Mobile Email ID SETTLEMENT OPTIONS Fund Transfer Yes No New PDA / Policy No* Settlement Options 3 5 installments option is applicable for products eligible as per Terms Conditions Full Settlement BANK DETAILS Payment Method Direct credit NEFT/RTGS A/c Payee Special Crossing Cheque Bank Name Bank Branch Account Number IFSC Code Please tick any one Bank Account Type Savings Current Account Over Draft / Cash Credit NRO TAX DEDUCTIONS Note In case IFSC code is not provided the payout will be made by A/c payee special crossing cheque. Direct Credit is not possible for NRE account 1. Do you have a PAN card If Yes kindly provide your Permanent Account Number PAN Attach a self-attested photocopy 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 If No please specify country of Residence. 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. I take full responsibility for the genuineness and correctness of the details filled herein* Date D D M M Witness Signature Name Address of the Witness ACKNOWLEDGMENT SLIP FOR OFFICE USE ONLY Should be someone other than the advisor/agent/employee of the company and who has also explained the contents of this form if signature is in vernacular or a thumb impression* Name of the Customer Service Representative Branch Code D Y Y Signature Employee No* This is to acknowledge the receipt of application for Maturity Payout. D D M M Y POS/MPA/Version 2. 1 DECLARATION Signature / Thumb Impression of the Policy Owner / Assignee Policy No* Sign Documents received Original Policy Document Valid Address Proof Identity Proof Bank account proof Seal Others Turn over leaf for more details. 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 TERMS CONDITIONS DOCUMENTS REQUIRED Please submit any one of the following listed documents along with the mandatory requirements.

Portable equipment insurance p... THE NEW INDIA ASSURANCE COMPANY LIMITED Registered & Head Office 87, M. G. Road, Fort, Mumbai400001. PROPOSAL FORM FOR PORTABLE EQUIPMENTS SPECIAL CONTINGENCY INSURANCE POLICY 1. (a) Name of proposer

I am your life insurance polic... I am your life insurance policy. You and I have similar purposes in this world. It is your job to provide food, clothing, shelter, schooling, medicine, and other things for your loved ones. You do

Sample homeowners insurance po... (06 97). QUIT CK REFERENCE'SEE AL FORM. HOMEOWNERS SPEC AL FORM. MARYLAND SPEC ILL FIVE S I Wins. ADJUSTED BUI LYING COST ...

Icici prudential life insuranc... ICICI Prudential Life Insurance Policy Surrender Form Select Download Format:Download ICICI Prudential Life Insurance Policy Surrender Form decisions PDF. Download ICICI Prudential Life Insurance Policy Surrender Form doc.

Agreement to furnish insurance... Q TO REORDER CALL JB GRAPHICS (818) 90207672748911AGREEMENT TO FURNISH INSURANCE POLICY (TO BE USED WITH SECURITY AGREEMENT ON SALE OF VEHICLE)Date Seller undersigned Purchaser(s) agree(s) to furnish

Insurance policy form POLICY CHANGE REQUEST FORM Please mail completed form to Policy Processing P. O. Box 9026 Melville NY 11747 or Fax to 1 866 344-1295 AutoOne Insurance Company Effective Date of Change Policy Number Insured Name / Producer Name Street Address Insured Phone Producer Phone SS or Tax ID City/State/Zip NAME/ADDRESS CHANGE Name Correction Change New Name Address Mailing Garage Location ADD/REPLACE/DELETE VEHICLE Vehicle Deleted or Replaced Year Added Use Pleasure Farm Business Commute Anti-Theft Device Model Make Make Model VIN Miles to Work/School/Transportation Cost New Passive Active Name of Owner/Lessor if not named Principal Operator State of Registration Territory Rate Class Symbol Address on registration if other Was a Temporary ID Card issued Yes COVERAGES No Same Limits of Liability Apply to All Vehicles on Policy Add Bodily Injury Liability Delete Property Damage Applies to Personal Injury Protection Coverages Mandatory Full Limits/ Deductible Additional Guest Medical Payments Uninsured Motorists Statutory Supplementary UM SUM Comp. Other than Collision OBEL Annual Premium Authorization for Inspection Form must be attached. ADDITIONAL INSUREDS/LESSORS/LOSS PAYEES Additional Insured Loss Payee T31 500 03/03 DRIVER INFORMATION Add Driver Delete Driver REASON for deletion Relationship to Insured DOB Sex Marital Status Driver s License and State Licensed of use Veh. 1 Veh. 2 ACCIDENTS Additional driver s involved in any motor vehicle accident during the preceding 40 months Accident Date Accident Location PIP Claim Yes Bodily Injury or Death Property Damage Amount including your own Chargeable Please provide reasons if accident is not chargeable in Additional Comments section* CONVICTIONS Date of Type of Violation Conviction Place of Conviction ATTACHMENTS Check all that apply Certificate of Completion of Defensive Driver Course Certificate for Driver Training Credit Proof for Deleted Driver POLICY CANCELLATION Request to Cancel Entire Policy If FS-6 submitted to the company within 30 days of surrender of plates the effective date will be the day after the date of surrender of the plates. Otherwise effective date will be the company s date of receipt of the FS-6. ADDITIONAL COMMENTS Any person who knowingly makes or knowingly assists abets solicits or conspires with another to make a false report of the theft destruction damage or conversion of any motor vehicle to a law enforcement agency the department of motor vehicles or an insurance company commits a fraudulent insurance act which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation* Authorized Representative s Signature Insured s Signature if applicable. 1 Veh. 2 ACCIDENTS Additional driver s involved in any motor vehicle accident during the preceding 40 months Accident Date Accident Location PIP Claim Yes Bodily Injury or Death Property Damage Amount including your own Chargeable Please provide reasons if accident is not chargeable in Additional Comments section* CONVICTIONS Date of Type of Violation Conviction Place of Conviction ATTACHMENTS Check all that apply Certificate of Completion of Defensive Driver Course Certificate for Driver Training Credit Proof for Deleted Driver POLICY CANCELLATION Request to Cancel Entire Policy If FS-6 submitted to the company within 30 days of surrender of plates the effective date will be the day after the date of surrender of the plates. Otherwise effective date will be the company s date of receipt of the FS-6. ADDITIONAL COMMENTS Any person who knowingly makes or knowingly assists abets solicits or conspires with another to make a false report of the theft destruction damage or conversion of any motor vehicle to a law enforcement agency the department of motor vehicles or an insurance company commits a fraudulent insurance act which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation* Authorized Representative s Signature Insured s Signature if applicable.

Insurance policy record templa... Name Year Service Provided Date of Service Provider Medicare/Medical Insurance Record Tracking Form Medicare Private Insurance Patient Responsibility Assign Applied Amount Amount Amount Amount Amount Date -ed To Paid Patient Paid Billed Approved Sent Y or N Deductible Provider Patient Provider Patient Paid Check.

Collateral assignment of life... Collateral Assignment of Life Insurance Policy A. FOR VALUE RECEIVED, I (we) assign, transfer and set over to the Assignee, Name: Address: Date of Birth TIN No. Telephone Number of its successors

Adamjee insurance policy downl... ADAMJEE INSURANCE COMPANY LIMITED HEALTH INSURANCE DEPARTMENT 2nd Floor Adamjee Insurance Building Opp National Bank of Pakistan I. I. Chundrigar Road. Karachi-74000 Telephone 021 32414028 32420740 Fax 021 32470111 health adamjeeinsurance. com Health Questionnaire Form HQF Note This questionnaire is to be filled by the employee only. Any alteration must be signed by the employee. ADAMJEE INSURANCE COMPANY LIMITED HEALTH INSURANCE DEPARTMENT 2nd Floor Adamjee Insurance Building Opp National Bank of Pakistan I. I. Chundrigar Road* Karachi-74000 Telephone 021 32414028 32420740 Fax 021 32470111 health adamjeeinsurance. com Health Questionnaire Form HQF Note This questionnaire is to be filled by the employee only. Any alteration must be signed by the employee. Name of Employee In Block Letters Employer s Name Employee s NIC No Employee Code No if any Designation Joining Date Residential Address Phone No* FAMILY MEMBERS TO BE COVERED Please use additional sheet if necessary. S/ No* Name Relationship Date of Birth Height Feet Weight Ibs SELF Please read the following questions carefully and answer each question by ticking the appropriate boxes. If the answer to any of the question s is YES than please give full details disclosing the exact diagnosis attach copies of reports / investigations. If you are in any doubt than refer to your physician for the details. Non disclosure of any fact may invalidate a future claim* Before applying for insurance have you or any of your family members spouse/children/parents a* b. c* d. e. Aware/suffered from any medical condition/disease/illness/injury If yes details Received any diagnosis from a Doctor / Hakeem or Homeopath even if no treatment is provided Have any of the members listed above is suffering / suffered from any physical deformity Yes No Do you or any member of your family smoke or consume alcohol If yes than how much Are you or your spouse pregnant If yes how many months Are you and all members of your family listed above in good health PLEASE GIVE DETAIL S OF THE QUESTION S 1 a to 1 e TICKED YES. Name of the person whose answer has been ticked Yes Nature of Illness Medicines Taken Name of the Hospital Attended Physician Present Status DECLARATION AUTHORIZATOIN I hereby declare that what has been stated above is true and complete and to the best of my Please mention the plan / category for this employee. knowledge and belief* I have not withheld any material information and that it is understood and agreed that this declaration the application of my employer to the Adamjee Insurance Company Limited are the basis for the Group Hospitalization Insurance cover applied for and that any non-disclosure or misrepresentation of facts will make my/our insurance cover void since inception* I hereby authorize any hospital physician or surgeon who has or may attended to me or my family to furnish to the Adamjee Insurance Company Limited with any information they may require concerning my/our medical history or examinations.

Insurance policy card form Insurance Policy Card Homeowners Insurance Provider: Phone #: Policy #: Agent: Deductible: Policy Notes:Auto Insurance Provider: Phone #: Policy #: Agent: Deductible: Policy Notes:Life Insurance Provider: Phone

Electronic equipment insurance... The New India Assurance Company Limited Registered & Head Office : New India Assurance, 87, M.G. Road, Fort, Mumbai 400 001. QUESTIONNAIRE AND PROPOSAL FOR ELECTRONIC EQUIPMENT INSURANCE POLICY Downloaded

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