Service Request Form

Important Note: FOR OFFICE USE ONLY

1. Kindly fill details in BLOCK LETTERS only.
2. This form should be filled up by the policy holder or the assignee. Received Date:

Policy number:

Name of the policy holder:

1. Update Personal details

Policy Holder Name:

Correct Date of Birth: PAN Card:

Life Insured Name:

Correct Date of Birth: PAN Card:

2. Update Address and Contact details (provide details of policy holder)

Address:

City State Pin Code

Contact Number: Alternate Contact Number:

Email ID:

Contact details provided herein will be updated for all future communications. This will be considered as consent to communicate.

3. Update payment frequency/payment mode

Change of Premium payment frequency

Annual Semi-Annual Quarterly Monthly

New Payment Mode

Cash/Cheque Auto Pay

NACH Debit Card Credit Card E-NACH UPI

Add: What I need to know while updating my payment frequency/payment mode?

Auto-pay facility is available for all premium payment frequencies; however, it is mandatory for the monthly payment mode.
Credit card and Debit card services are available exclusively on the website.
For availing auto-pay facility, NACH Form along with personalised [account holder(s) name pre-printed] cancelled cheque bearing pre-printed account number and Bank IFSC is
required. You can download the form from our website [Link]
Mode change is applicable as per policy terms and conditions. This is applicable only during policy anniversary.
For unit linked product, if the request is received and accepted at the company's office before 3 p.m. NAV declared on same date will be applicable and if request is submitted and
accepted at company’s office after 3 p.m., the next working day’s NAV declared will be applicable.

4. Update Nominee details (to be filled by policy holder)

I, (policyholder) _________________________________, nominate the following person(s) as the nominee(s) of the above-mentioned policy.

Name

Date of Birth

Relationship with the Life Insured

Beneficiary Percentage
(Total percentage should add
to 100%)

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 In case of a minor nominee, please fill the following information:

I hereby appoint Mr./Mrs./Ms.

as the appointee of the policy during the minority of the nominee. Appointee's relationship with the nominee : ______________________

Signature of the Policyholder Signature of Appointee

D D M M Y Y Y Y Place: ______________________

Note:
1. Any nominations shall automatically cancel all previous nominations made in the policy except where the policy is assigned to Bharti AXA Life Insurance Company Limited.
2. In case of transfer/assignment of a policy, whether wholly or in part, in consideration of a loan advanced by the transferee or assignee to the policyholder, shall not cancel the nomination
but shall affect the rights of the nominee only to the extent of the interest of the transferrer or assignor, as the case may be in the policy.

5. Specimen Signatures
Specimen 1 Specimen 2 Specimen 3 Specimen 4

Declarations and Agreement

I hereby agree and confirm that the above details provided by me are true and correct. I request you to update above information in your records.
The aforesaid change(s) would be effective only when notified to be accepted by Bharti AXA Life Insurance Company Limited
I agree that the Company may provide/transfer/retain any information available with the Company related to me, obtained in connection with processing of my proposal or the policy
and servicing thereof to any insurers, reinsurers, Insurance association, medical registrar, statutory authorities/bodies or services providers engaged by the Company for policy servicing
related activities without any further reference to me.

Name of Policyholder/Assignee Signature

Date

Are you a US Citizen or US tax resident? Yes No If yes, please duly fill and submit FATCA/CRS Form along with this form: __________________________________________

Vernacular Declaration (to be filled by the person filling the form)

I have explained the contents of this form to the Policyholder in ________________________ language and I have correctly recorded the answer provided to me. I further
declare that the policyholder has signed/affixed his/her thumb impression in my presence.

City State Pin Code

D D M M Y Y Y Y

Note: The person giving this declaration can be any person other than Introducing Advisor or Manager of Agency (MOA) or Manager of Manager (MOM)

DECLARATION IN CASE THIS POLICY SERVICE REQUEST FORM IS FILLED BY A PERSON OTHER THAN THE POLICYHOLDER OR SIGNED IN VERNACULAR LANGUAGE

Declaration by Policyholder:
I hereby declare that the contents in the form have been fully explained to me and I declare that whatever is stated hereinabove has been recorded as per the information
provided by me.

Bharti AXA Life Insurance Company Ltd. IRDAI Regd. No. 130 dated 14/07/2006 [Life Insurance Business] Unit No. 1902, 19th Floor, Parinee Crescenzo, ‘G’ Block, Bandra Kurla
Complex, BKC Road, Behind MCA Ground, Bandra East, Mumbai - 400051, Maharashtra. CIN No.: U66010MH2005PLC157108 | Toll free No.: 1800-102-4444 |
Comp-Aug-2024-7064 | Website: [Link]

BEWARE OF SPURIOUS/FRAUD PHONE CALLS and FICTITIOUS/FRAUDULENT OFFERS!

IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving such phone calls are requested to lodge a
police complaint.

Trade Logos and used in the document belong to the Bharti Enterprises (Holdings) Private Ltd. and AXA SA respectively and are used by Bharti AXA Life under
license.

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