PSRF283621062416 | Comp/Oct/Int/4070

For Office Use Only Current Day NAV

Branch: Next Day NAV
Unit Linkd Partial Receipt Date & Time: Existing KYC
Withdrawal Form Receivec by: Fresh KYC
Employee Code: ___________________
Interaction ID:
Signature: ___________________________

Do you really need to withdraw funds from your life

insurance policy?

We would like you to take a well-informed decision with regard to the partial withdrawal from your life insurance policy. Help us by sharing the
reason for partial withdrawal. Please select from any options given below:
Policy sourced by: HDFC Life Financial Consultant Bank Employee/Broker HDFC Life Employee
Name: ____________________________________________ & Contact No. ______________________ of the above mentioned person, if available.

Reason for Partial Withdrawal:

Child’s education Wedding/family function Buy another product from HDFC Life Buy gold/silver Buy a vehical

Invest in real estate Re-invest in other financial instruments Others(Please specify): ____________________________________________________

Please ask yourself the following question before filling up the from.

Are you ready to reduce your cover Are you compromising on your long term goals
on Life or old age pension? or your family’s financial security?

As per a survey, life expectancy of an average Indian Higher education, wedding, contingency planning are some events
is 68 years*. that need you to stay insured for a longer period. You will be able to
This means that there is a need to have sufficient funds meet your long term expenses better only if you remain insured till
at the time of retirement to ensure a self-dependent the end of the policy term and allow your corpus to keep growing.
future.
If you have partially withdraw from your funds or Remember, wealth accumulation happens only through saving more,
reduced the premium, you are requested to stay i saving regularly and allowing optimum growth of your funds.
nsured by paying your policy premium. In case you fail
to do so, your policy status will change and it may
result in your policy getting paid up/cancelled and all
benifits/risk cover may accordingly cease to exist.
please refer to your policy documents for details.
*Source: World Bank
https://data.worldbank.org/indicator/SP.DYN.LEOO.IN

The above information is generic in nature and is circulated in the general interest of the policyholders. Please refer the policy
document for the applicable terms and conditions before taking any decision.

Name of the Policyholder: __________________________________________________________________________________________________________________________________________

Policy No.: E-Insurance Account No.:
PAN (Permanent Account Number): (In case of UL Young Star and Children's plans, if the beneficiary is a
major, then provide the beneficiary details as TDS will be accordingly deducted for the beneficiary).
Email ID*________________________________________________________________________________________________________________________________________________________________
Contact * No .: (Off)_____________________________ /(Res)_______________________________ /(Mob)_______________________________(Mobile number is preferable)
*We will use the contact details provided by you here for all future communications and treat this as consent to communicate with you on the same.

** Amount to be withdrawn from the policy: INR___________________________

** Partial Withdrawal charges and taxes & levies (if relevant on this charge) are applicable as per policy provision. TDS shall be deducted as applicable.

This Partial Withdrawal request received for Surrender Reversal is within 30 days from the surrender date Yes No#
KYC documents will be mandatory if the option 'No' is selected. This question will be filled by the Customer Relations official only.
#

Self-Attested Photo ID and Address Proof of the Beneficiary or Appointee##submitted: Yes No NA

Customer Acknowledgement Copy (UL Partial Withdrawal Form)

Policy No .: ______________________ Interaction ID No .: ______________________________________ Policyholder name:______________________________________________________________

Documents accepted (specify): __________________________________________
Customer Relations Officer: Date: Time:
Note : If you have partially withdrawn from your funds or reduced the premium, please stay insured by paying your premiums regularly, failing which, the policy can
be paid-up/cancelled. A policy can be cancelled if the fund value falls below its minimum threshold limit. Please refer to your policy document for details.
For queries or more information, call us on 022-68446530 (Call charges apply). Available Mon-Sat from 10 am to 7 pm. DO NOT prefix any country code c.g. +91 or 00. |
Email - service @hdfclife.com | [email protected] (For NRI customers only) Visit - www.hdfclife.com
PSRF283621062416 | Comp/Oct/Int/4070
As per IRDAI guidelines, cut-off tirnings for NAV application and redemption of units stands revised to 3 PM IST with effect from June 1, 2007. This implies
that if the application for partial withdrawal along with all required documents are received by 3 PM IST on a working weekday (Mon-Fri) by HDFC Life,
the same day's unit value will be applicable. However, if the application for partial withdrawal along with all the required documents are received post
3 PM IST on a working weekday (Mon-Fri) by HDFC Life, then the next working day's value will be applicable. When the applicable day is not a valuation
day, NAV of the next immediate valuation day will be considered. Any fluctuations in NAV as a result of Partial Withdrawal will be borne by policyholder.
The same is subject to changes as and when amended by IRDAI. In case a prior unit allocation is pending, your current request will be processed on the
successive working day.
As per section 194DA of the Income-tax Act###, 1961, tax will be deducted at source from the payments made to residents of any sum under a life insurance
policy including the sum allocated by way of bonus, other than the amount exempt u/s 10(10D) of the Income-tax Act###, 1961, at the rate as applicable
subject to the conditions and limits specified therein. It is important to note that, as per Income-tax Act###, 1961, the rate of deduction of tax at source of 1%
is applicable only in instances, where valid PAN has been communicated to the deductor before the payment is made under a life insurance policy. In
those instances where valid PAN has not been communicated to the deductor before the payment is made under a life insurance policy, the rate of tax
deductible is 20%.
###
Tax laws are subject to change.

I/We confirm having read and understood all the policy provisions before making this application and its consequences.
Policyholder/ Assignee Name: ____________________________________________________________________________
SIGN HERE SIGN HERE

Date: __________________________________
Place: __________________________________
Signature of Policyholder/Assignee Signature of Joint Life Assured
(In case of Joint Life Assured)

In case of Unit Linked Young Star or Children's plans, if beneficiary is major, then please provide beneficiary's account details.

Bank Account No .:
IFSC(11 Characters)

Account Holder Name: ___________________________________________________________

Bank Name & Branch: ___________________________________________________________
Account Holder’s Name

Account Type : Savings Current NRO NRE

*All premium(s) paid from NRE Account: ** Proportionate premium(s) paid from NRE Account:

IFSC^ :

^
11 character code appearing on your cheque leaf
*Refund to NRE account (full or proportionate) will be subject to ratio of premium(s) paid through NRE account. Please submit a bank
statement or bank confirmation letter as an evidence for premium(s) paid through NRE account.
** In case of proportionate payout, please provide two NEFT mandates l.e. for NRE account and non-NRE account.

Tax declaration

1. Are you a tax resident of any country other than India as per the Income-tax Act, 1961?
Yes^ No^^
^
To be tickedif youare atax resident inIndia under the Income-tax Act, 1961.
^^
If you are a non-resident in India as per the Income-tax Act, 1961, you are mandatorily required to submit Tax Residency Certificate (TRC) with Form 10F to avail
treaty benefits, otherwise tax will be deducted at source at a higher rate from policy payouts. As per section 195 of the Income-tax Act, 1961, tax will be deducted at
source from any payout to a non-resident at the rate applicable therein and subject to the conditions specified therein. Tax laws are subject to change.

2. Does your total taxable income for the relevant financial year (April 1 to March 31) exceed INR 1 crore?
Yes No
3. Self-attested documents submitted: TRC FORM10F

Note:

A cancelled personalised cheque with account no. and IFSC should be submitted along with this NEFT Mandate. In case
the cheque is not personalised, a latest bank statement or copy of passbook where account number and IFSC are
mentioned needs to be submitted with the mandate.
This mandate, upon processing, will override any of the previously tagged NEFT mandates for all policies, held by the
client with HDFC Life.
In case of NEFT failure or any further requirements pending on the mandate, payout will be kept on hold till a fresh NEFT
mandate is received. We will inform you about the same.

Customer Acknowledgement Copy (UL Partial Withdrawal Form)

For queries or more information, call us on 022-68446530 (Call Visit https://twitter.com/hdfclife_cares?lang=en and
charges apply). Available Mon-Sat from 10 am to 7 pm. DO NOT drop us a direct message or #AskNeo @HDFCLife_Cares
prefix any country code e.g. +91 or 00.
Email – [email protected] | [email protected] Visit https://simplychat.hdfclife.com/simplychat/
(For NRI customers only) Visit – www.hdfclife.com to Simply Chat
PSRF283621062416 | Comp/Oct/Int/4070

Declaration:
1. I/We hereby declare that the particulars given above are correct. If the transaction is delayed or not effected at all for reason of
incomplete or incorrect information provided by me/us above, I/we would not hold HDFC Life Insurance Company Limited or any of its
associates/employees/agents responsible. Further, I/we agree to indemnify or keep indemnifying HDFC Life against any loss, claim,
damage or expenses arising out of any incomplete or incorrect information provided by me/ us above.
2. I/We further undertake to refund any excess amount whether demanded by HDFC Life or not, which has been credited in excess to my/
our account at any time due to any reason.

Consent for usage of Aadhaar information

I voluntarily consent for Aadhaar based KYC, Aadhaar authentication or offline verification to be done through HDFC Life either now or
anytime in future. I am aware that my Aadhaar number, Virtual ID, e-Aadhaar, XML, Masked Aadhaar, face authentication details and/or
biometric information, Aadhaar demographic data including my name, address, gender, date of birth and photograph shall be shared by
UIDAI with HDFC Life for KYC purposes/ due diligence. I confirm that I was provided an option for submitting other acceptable KYC Documents
besides Aadhaar. I confirm that this consent is valid for KYC purposes/ due diligence done for issuance/ servicing of insurance policy/poli-
cies, claim related purposes or for any other regulatory/ statutory related requirements.

SIGN HERE SIGN HERE

Date: _________________________
Date: ________________________
Place: _________________________
Place: ________________________
Signature of Account Holder Signature of Policyholder
(If policyholder is different from Life Assured)

Declaration to be made by a third person where:

The life assured has affixed his/her thumb impression / has signed in vernacular / has not filled the application. I hereby declare
that I have explained the contents of this application form to the life to be assured in _________________________________ language and
have truthfully recorded the answers provided to me. I further declare that the life assured has signed/affixed his/her thumb
impression in my presence.
Declarant Name: _______________________________________________________________ SIGN HERE

Address: _________________________________________________________________________
Date: _________________________ Place: ________________________
Signature of Third Person

Name Declaration (To be filled only under instances of abbreviation of a full name / expanded form of abbreviated initials)

I hereby declare, represent and warrant that ___________________________________________________________________________________

and _____________________________________________________________________________________ are names of one and the same
person. I hereby agree that I shall indemnify and hold harmless HDFC Life and its agents, representatives, employees or directors against any claims,
damages, penalties, charges or levies whatsoever caused in connection with my breach of this declaration/representation stated herein.
Note: For any major name mismatch (addition / change of surname or middle name, correction of name leading to different
pronunciation), please fill and submit change in name form.

Declaration for Specimen Signature (To be filled only if there is a signature variation with records available in the system)

<Name of the Policyholder>

I, _________________________________________________________ hereby declare that my specimen signatures in short, full, vernacular
language and in all different styles are as mentioned below. I shall indemnify and hold harmless HDFC Life and its agents, representatives,
employees or directors against any claims, damages, penalties, charges or levies whatsoever suffered by HDFC Life, for relying on the details
/specimen provided below.

SIGN HERE SIGN HERE SIGN HERE

DD/MM/YYYY
Date:______________________
Place:_____________________
Specimen 1 Specimen 2 Specimen 3
Note: Not applicable for non walkin request

HDFC Life Insurance Company Limited (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, Call 022-68446530 (Call charges apply). DO NOT prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm |
Email – [email protected] | [email protected] (For NRI customers only) Visit – www.hdfclife.com

For queries or more information, call us on 022-68446530 Visit https://twitter.com/hdfclife_cares?lang=en and

(Call charges apply). Available Mon-Sat from 10 am to 7 drop us a direct message or #AskNeo @HDFCLife_Cares
pm. DO NOT prefix any country code e.g. +91 or 00.
Email – [email protected] | [email protected]
(For NRI customers only) Visit – www.hdfclife.com