Page1 - PSRF/Jan_2025/Ver 1.
POLICY SERVICE REQUEST FORM
Change in Name / Change in Permanent or Correspondence Address / Change in Contact / Email ID /
Update PAN / GSTIN Details / Update Bank Account Details / Mandate Cancellation / Addition of Rider /
Top-Up Premium / Change in Premium Payment Method / Billing Frequency / Change in Sum Assured
Edelweiss Life Insurance Company Limited | IRDAI Regn. No. : 147 | CIN: U66010MH2009PLC197336
Registered Office: 6th Floor, Tower 3, Wing ‘B’, Kohinoor City, Kirol Road, Kurla (W), Mumbai 400070
Fill the form in BLOCK LETTERS only.
Policy No.: E Date: D D M M Y Y Y Y
Name of the Policy Holder: ________________________________________________________________ Tel. No.: _______________________
Address: ______________________________________________________________________________________________________________
______________________________________________________________________________________________ Pin Code: ______________
Change in Name
Life Assured Policy Holder
Change in Name From: First Name Middle Name Last Name
Change in Name To: First Name Middle Name Last Name
• Married woman whose name has been changed due to marriage is requested to submit the Marriage certificate along with this form.
• For all others, attested copies of Gazette notification are required to be submitted.
Change in Correspondence Address
New Address:
City / District: State: Pin Code:
(Provide any of the following Address proofs along with this form)
Aadhar Card Passport Driving License Voter’s Card NREGA Job Card NPR (National Population Register) Letter
Offline Verified Aadhar Card Others ___________________________________________
Change in Contact / Email ID / Update PAN / GSTIN Details
New Mobile No.: + Country Code - Mobile Number Landline No.: Area Code - Tel. Number
New Alternate Contact No.: Area Code - Contact Number PAN
New Email ID: __________________________________________________________ GSTIN
Update of Bank Account Details
Bank Name
Account Holder’s Name
Account No. IFSC
• Note all policy payouts will be made to the above account
Account Proof accepted: Personalised Cancelled Cheque / Bank Pass Book / Bank Statement
Mandate Cancellation
1. Request for deactivation needs to be submitted 15 days prior to the debit date.
2. If the request is given within 15 days from the debit date, then the premium will be debited as per the existing mandate on the debit date
and the mandate shall be deactivated from the next due date.
3. Mandate Deactivation request stands confirmed only once the request is complete in all aspects and the same is accepted and processed.
4. Assignee's details, registered stamp (wherever applicable) and signature are mandatory in case of assigned policies.
Reason for deactivation:_________________________________________________________________________________________________
Mandate Cancellation For Assigned Policies
Name of the Assignee ____________________________________________
Date: __________________ Place: _________________________
Assignee's Stamp and Signature
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Addition of Rider
Choice of Rider (Sum Assured in ₹)
Total Premium Accidental Accidental Total
Critical Illness Death Benefit Hospital Payor Waiver Waiver of
and Permanent
(CI) (ADB) Cash Benefit Benefit* Premium
Disability (ATPD)
Y N
* Payor Waiver Benefit Rider: On Death On CI or ATPD On Death, CI or ATPD
(Applicable only when Life Insured and Proposer are different)
Top-Up Premium
A. Fill the fund allocation of your Top-up premium
Name of the Fund Amount (₹)
Equity Large Cap Fund (SFIN:ULIF00118/08/11EQLARGECAP147)
Equity Top 250 Fund (SFIN:ULIF0027/07/11EQTOP250147)
Bond Fund (SFIN:ULIF00317/08/11BONDFUND147)
Money Market Fund (SFIN:ULIF00425/08/11MONEYMARKET147)
PE Based Fund (SFIN:ULIF00526/08/11PEBASED147)
Managed Fund (SFIN:ULIF00618/08/11MANAGED147)
Equity Blue Chip Fund (SFIN: ULIF01226/11/18ETLBLUCHIP147)
GILT Fund (SFIN: ULIF01326/11/18ETLGILTFND147)
Long Term Bond Fund (SFIN: ULIF01426/06/20ETLLNGTERM147)
Small Cap Fund (SFIN: ULIF01523/12/24SMALLCAP147)
TOTAL
B. Top-Up Amount: Minimum Maximum
• Top-Up premium is subject to terms and conditions of the policy.
• It is mandatory to submit duly filled Certificate of Insurability & same will be subject to underwriting norms.
• Income Proof if the Top-Up amount is more than ₹ 100,000/-.
Change in Premium Payment Method / Billing Frequency
Premium payment Method: Direct Bill ECS CC Standing Instruction
(ECS Mandate & Cancelled cheque would be required if opted for ECS) (CCSI Form & Front Copy of Credit Card would be required, if opted for CCSI)
Billing Frequency Required: Annual Semi Annual Quarterly Monthly
Changes in Sum Assured
Increase Decrease
From ₹ : Required ₹ :
Note : Change in sum assured is subject to terms and condition of the policy or evidence of insurability in accordance with company under writing guidelines.
DECLARATION: Upon signing the request above, I, the Policy Holder hereby declare that all the information given above is true and correct and I
agree to all the terms and conditions.
For Branch Office Use Date and Time Stamp
Service Request No.: _____________________________
Branch Name: __________________________________ Signature of the Policy Holder
Staff Name: ____________________________________
Staff Sign: _____________________________________ Date: D D M M Y Y Y Y
Place: ________________________________________
Place:______________________
*KYC document to be collected as per Service Request
Vernacular Declaration (To be filled if the Customer has signed in language other than English / Affixed Thumb Impression)
I hereby declare that I have explained the contents of the payout form to the
Policyholder Mr. / Mrs. / Ms. in their language and that the Policyholder has affixed
the thumb impression / signed in a language other than English in my presence after
fully understanding the contents thereof. I further declare that I am not related to
the Company in any manner, whatsoever. Name and Signature of the Declarant
Acknowledgement Slip
Received a request for _______________________ for policy no.: _______________________ on D D M M Y Y Y Y at ____ a.m./p.m.
Registered Office:
Edelweiss Life Insurance Co. Ltd.
6th Floor, Tower 3, Wing ‘B’, Kohinoor City,
Kirol Road, Kurla (W), Mumbai 400070.
Toll Free : 1800 212 1212 | www.edelweisslife.in
Stamp/ Seal of the Branch
