request for issuance of fresh payment

REQUEST FOR ISSUANCE
OF FRESH PAYMENT
>tå¡> A¡ì¹ "=¢¡ šøƒà> A¡¹à¹ \>¸ ">åì¹à‹
BFG
">åNøÒ A¡ì¹ "àš>à¹
šàÎìšài¡ ÎàÒü\
ó¡ìi¡àNøàó¡ ºàKà>
To
please affix your
passport size
photograph
Aviva Life Insurance Company India Limited
Policy Name / Number:
(FOR OFFICE USE ONLY)
(&A¡³ày "[ó¡ìι ¤¸¤Òàì¹¹ \>¸)
Service Request ID: _____________
______________________________
Îà[®¢¡Î [¹ìA¡àìÚС "àÒü[l¡: _____________
______________________________
Affix date and time stamp
t¡à[¹J &¤} i¡àÒü³ С¸à´š Î}Ø™åv¡û¡ A¡¹ç¡>
š[º[Î >´¬¹ / >à³
Non-receipt of cheque issued under Policy Number .........
....
. against payment towards Freelook Cancellation
/ Partial Withdrawal / Surrender / Early Surrender / Auto Foreclosure / Death / Rider / Annuity Payment / Excess Premium Paid / Declined
by Company / Pre-issuance Cancellation / Maturity.
š[º[Î >´¬¹ ¡ ……………………………. &¹ [óø¡ºåA¡ ¤à[t¡ºA¡¹o / "à}[ÅA¡ šøt¡¸àÒ๠/ l¡ü;Î\¢> / ™=à γìÚ¹ šè줢 l¡ü;Î\¢> / Ѭt– ¤Þê¡A¡ã δš[v¡¹ ƒJºãA¡¹o/ ³õt塸 / عàÒül¡à¹
/ ¤à[È¢A¡ "àÚ šøƒà> / "[t¡[¹v¡û¡ [šø[³Úà³ šøƒà> / ìA¡à´šà[> ‡à¹à šøt¡¸àJ¸à> / šøàAô¡-šøƒà> ¤à[t¡ºA¡¹o / ë³Úàƒ šè[t¢¡¡-¹ \>¸ šøìƒÚ ëW¡A¡ "šøà[œ¡¡ú
Cheque issued under Policy Number .........
....
. against payment towards Freelook Cancellation / Partial Withdrawal
/ Surrender / Early Surrender / Death / Rider / Annuity Payment / Auto Foreclosure / Excess Premium Paid / Declined by Company / Pre-issuance
Cancellation / Maturity for which the cheque has become stale / is lost
š[º[Î >´¬¹ ¡ ……………………………. &¹ [óø¡ºåA¡ ¤à[t¡ºA¡¹o / "à}[ÅA¡ šøt¡¸àÒ๠/ Ѭâ«t¡¸àK / ™=à γìÚ¹ šè줢 Ѭâ«t¡¸àK / Ѭt– ¤Þê¡A¡ã δš[v¡¹ ƒJºãA¡¹o/ ³õt塸 / عàÒül¡à¹ /
¤à[È¢A¡ "àÚ šøƒà> / "[t¡[¹v¡û¡ [šø[³Úà³ šøƒà> / ìA¡à´šà[> ‡à¹à šøt¡¸àJ¸à> / šøàAô¡-šøƒà> ¤à[t¡ºA¡¹o / ë³Úàƒ šè[t¢¡¡-¹ \>¸ šøƒv¡ ëW¡ìA¡¹ ë³Úà샹 t¡à[¹J l¡üv¡ão¢ ÒìÚ ëKìá /ëW¡A¡ Òà[¹ìÚ ëKìá¡ú
.
Confirmation by Customer
NøàÒA¡ ‡à¹à [>[ÆW¡t¡A¡¹o
I would like to inform that I have not yet encashed the refund / payout cheque that has been issued by Aviva Life Insurance Company India
Limited in my name towards Policy No.
.........
....
. as this cheque had been received by me but has now expired / been
lost / not been delivered to me. I would like to confirm that in case I receive the same post signing on this consent form, the said cheque will
not be utilised / encashed by me. Basis this, please issue a Stop Payment on the cheque issued previously and process my payment as per
the option selected below after the Stop Payment of the instrument is confirmed.
Refund Cheque
NEFT (NEFT form & required documents enclosed)
"à[³ \à>àìt¡ W¡àÒü ë™ "[®¡®¡à ºàÒüó¡ Òü[X*ì¹X ìA¡à´šà[> Òü[“¡Úà [º[³ìi¡l¡ ‡à¹à "à³à¹ >àì³ š[º[Î >´¬¹ ............................. -&¹ \>¸ [¹ó¡à“¡/"=¢ šøƒàì>¹ l¡üì„ìŸ šøƒv¡¡ ëW¡A¡[i¡ "à[³ &J>*
®¡àUàÒü[> A¡à¹o l¡üv¡û¡ ëW¡A¡[i¡ "à[³ šà*Ú๠šì¹ ëÎ[i¡¹ ë³Úàƒ l¡üv¡ão¢ ÒìÚ ëKìá /Òà[¹ìÚ ìKìá /"à³à¹ A¡àìá ëÎ[i¡ &ìÎ ìš]áàÚ[>¡ú "à[³ [>[ÆW¡t¡ A¡¹[á ë™ "à[³ &Òü ѬãA¡à¹>à³àÚ Ñ¬àÛ¡¹ A¡¹à¹ šì¹ ™[ƒ "à[³
ëÎ[i¡ šàÒü t¡àÒìº ëÎÒü ëW¡A¡[i¡ "à[³ ¤¸¤Ò๠A¡¹ì¤à >à /®¡àUàì¤à >à¡ú &Òü [®¡[v¡ìt¡, ">åNøÒ A¡ì¹ šè줢 šøƒv¡ ëW¡A¡[i¡¹ \>¸ "=¢ šøƒà> ë¹à‹ (Сš ëšì³@i¡) \à[¹ A¡¹ç¡> &¤} Îà‹>[i¡¹ \>¸ Сš ëšì³@i¡ [>[ÆW¡t¡
Òìº [>ì³¥ [>¤à¢[W¡t¡ [¤A¡¿ ">åÎàì¹ "à³à¹ "=¢ šøƒàì>¹ šø[yû¡Úà [>ÍšÄ A¡¹ç¡>¡ú
[¹ó¡à“¡ ëW¡A¡
&>Òü&ó¡[i¡ (&>Òü&ó¡[i¡ ó¡³¢ * ">¸à>¸ šøìÚà\>ãÚ A¡àK\šy &¹ ÎìU Î}™åv¡û¡ A¡¹à "àìá)
Bank Account Details Required For Direct Account Transfer ιàÎ[¹ "¸àA¡àl¡üì@i¡ i¡öàXó¡à¹ A¡¹à¹ \>¸ šøìÚà\>ãÚ ¤¸àS¡ "¸àA¡àl¡üì@i¡¹ [¤¤¹o
Bank Name ¤¸àìS¡¹ >à³
Bank Account Holder’s Name
¤¸àS¡ "¸àA¡àl¡ü@i¡ ‹à¹ìA¡¹ >à³
Bank Account Number
¤¸àS¡ "¸àA¡àl¡ü@i¡ >´¬¹
Account Type (Saving / Current / NRE / NRO)
¤¸àS¡ "¸àA¡àl¡üì@i¡¹ ‹¹> (Îe¡Ú/A¡àì¹@i¡/&>"à¹Òü/&>"à¹*)
Bank Branch IFSC Code
¤¸àìS¡¹ ÅàJ๠"àÒü&ó¡&Î[Î ëA¡àl¡
Declaration and Authorisation šø`¡àš>
&¤} "[‹A¡à¹ šøƒà>
Policyholder’s / Claimant’s Signature*:
*(We might contact you for verification of your details prior to payout)
š[º[Î ‹à¹ìA¡¹ / ƒà[¤ƒàì¹¹ ѬàÛ¡¹*:
*("à³¹à "=¢ šøƒà> A¡¹à¹ šè줢 "àš>๠[¤¤¹o ™àW¡àÒü A¡¹à¹ \>¸ "àš>๠ÎìU ë™àKàì™àK A¡¹ìt¡ šà[¹)
Declarant’ Signature*:
šø`¡àšìA¡¹ ѬàÛ¡¹ *:
Declarant Name & Address:
*In case of signature in vernacular / thumb impression, this declaration should be made by a person of standing whose identity can easily be established but not
connected with Aviva Life Insurance Company India Ltd. *A self-attested copy of the photo identity proof of the Declarant is required.
šø`¡àšìA¡¹ >à³ * [k¡A¡à>à:
*ѬàÛ¡¹ ™[ƒ "àe¡[ºA¡ ®¡àÈàÚ A¡¹à ÒÚ¡ /¤õ‡ý¡àUåìË¡¹ áàš ë>*Úà ÒÚ t¡àÒìº ëÎìÛ¡ìy &Òü ìQàÈoà &³> &A¡\> [¤[ÅÊ¡ ¤¸[v¡û¡¹ ‡à¹à¡ δšà[ƒt¡ Òìt¡¡ Òì¤ ™à¹ š[¹[W¡[t¡ ÎÒì\ [>[ÆW¡t¡ A¡¹à ™àÚ [A¡”ñ [™[>
"[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹X ìA¡à´šà[> Òü[“¡Úà [º[³ìi¡l¡-&¹ ÎìU ™åv¡û¡ >>ú *ìQàÈoàA¡à¹ã¹ &A¡[i¡ Ѭ-šøt¡¸[Út¡ Î[W¡y š[¹W¡Úšìy¹ A¡[š šøìÚà\>ú
Customer Contact Number:
E-mail ID:
Please mention Policy Number on every document submitted In case we require further documentation, we may ask for fresh / further requirements
Payment will be processed post verification Company reserves the right to change the method of payment of unrealized cheque.
Òü쳺 "àÒü[l¡:
NøàÒìA¡¹ ì™àKàì™àìK¹ >´¬¹
">åNøÒ A¡ì¹ šø[t¡[i¡ ƒà[Jº A¡¹à >[=ìt¡ š[º[ι >´¬¹ l¡üìÀJ A¡¹ì¤>A
"à³à샹 ™[ƒ "à¹* >[=šìy¹ šøìÚà\> ÒÚ t¡àÒìº "à³¹à >tå¡> / "[t¡[¹v¡û¡ ìA¡à> "à¤Å¸A¡t¡à¹ ">åì¹à‹ \à>àìt¡ šà[¹
Ît¡¸t¡à
šø[t¡šàƒì>¹ šì¹Òü "=¢ šøƒàì>¹ šø[yû¡Úà δšÄ A¡¹à Òì¤ ">àƒàÚã ëW¡ìA¡¹ \>¸ "=¢ šøƒà> A¡¹à¹ š‡ý¡[t¡ š[¹¤t¡¢> A¡¹à¹ "[‹A¡à¹ ìA¡à´šà[> Î}¹Û¡o A¡ì¹¡ú
For Branch use only
Original Seen & Verified
ID Proof
Address Proof
Bank Statement
Others_______________________
No (Reason)________________________________________________________________________________
Signature Verified
Yes
No (Reason)_______________________________________________________________
Name of the Branch: _________________________________________________ Employee Code_______________________________________
Name of the Branch Employee: ___________________________________________ Signature of the Branch Staff: ________________________
ëA¡¤º³ày ÅàJ๠¤¸¤Òàì¹¹ \>¸
"àκ >[= ƒÅ¢> &¤} šøt¡¸àÚ> A¡¹à ÒìÚìá
š[¹W¡ìÚ¹ šø³àošy
[k¡A¡à>๠šø³àošy
¤¸à}ìA¡¹ ëСi¡ì³@i¡¡
">¸à>¸_______________________
>à (A¡à¹o) _______________________________________________________________________________
Ñà¬Û¡¹ štø¡¸àÚ> A¡¹à
Ò¸òà
>à (A¡à¹o)_______________________________________________________________
ÅàJ๠>à³: _________________________________________________ A¡³¢W¡à¹ã¹ ìA¡àl¡ __________________________________________________
ÅàJ๠A¡³¢W¡à¹ã¹ >à³: ___________________________________________ ÅàJ๠A¡³¢W¡à¹ã¹ ѬàÛ¡¹ : ____________________________________________
Documents Required For Direct Account Transfer / Payout Via Refund Cheque
ιàÎ[¹ "¸àA¡àl¡üì@i¡ i¡öàXó¡à¹ / [¹ó¡à“¡ ëW¡A¡ ‡à¹à "=¢ šøƒà> A¡¹à¹ \>¸ šøìÚà\>ãÚ >[=šy
1. In case the refund is required through NEFT, it is mandatory to submit a cheque leaf along with the bank statement.*
2. Latest 6 months’ Bank A/C statement OR self-attested copy of Bank Pass Book having the Bank A/C No. & date of account
opening.
3. Self- attested photo identity proof.
4. In case online bank statement is submitted, it is mandatory to get the statement attested by the bank. (i.e. bank stamp,
signature, employee name & employee code).
5. In case the original policy document is not submitted, a self attested copy of bank statement/copy of bank passbook is
mandatory from which premium is remitted showing remittance entry.
*Self-attested copy of Bank Pass Book should contain the name of the Account Holder, Account Number and IFSC Code.
1. [¹ó¡à“¡ ™[ƒ &>Òü&ó¡[i¡-¹ ³à‹¸ì³ A¡¹à¹ šøìÚà\> ÒÚ t¡àÒìº &A¡[i¡ ëW¡ìA¡¹ šàt¡à * ëÎÒü ÎìU ¤¸àS¡ ìСi¡ì³@i¡ ƒà[Jº A¡¹à "à¤[ŸA¡ú*
2. Îà´ß[t¡A¡ 6 ³àìι ¤¸àS¡ "¸àA¡àl¡ü@i¡ ìСi¡ì³@i¡ "=¤à Ѭ-šøt¡¸[Út¡ ¤¸àìS¡¹ šàÎ ¤Òü ™àìt¡ "¸àA¡àl¡ü@i¡ >}. &¤} "¸àA¡àl¡ü@i¡ ëJàºà¹ t¡à[¹J l¡üìÀJ A¡¹à "àìá¡ú
3. Ѭ-šøt¡¸[Út Î[W¡y š[¹W¡Úšyú
4. ">ºàÒü> ¤¸àS¡ ìСi¡ì³@i¡ \³à [ƒìº ¤¸àS¡ ‡à¹à ëÎ[i¡¹ šøt¡¸Ú> A¡¹à "à¤[ŸA¡ú (™=à ¤¸àìS¡¹ С¸à´š, ѬàÛ¡¹, A¡³ã¢¹ >à³ &¤} A¡³ã¢¹ ëA¡àl¡)ú
5. š[º[ι "àκ >[=šy \³à >à [ƒìº ì™ "¸àA¡àl¡ü@i¡ ë=ìA¡ [šø[³Úà³ šøƒà> A¡¹à ÒìÚìá ëÎÒü "¸àA¡àl¡üì@i¡¹ [šø[³Úà³ šøƒà> A¡¹à¹ ®å¡[v¡û¡ šøƒÅ¢> A¡ì¹ &³> Ѭ-šøt¡¸[Út¡ ¤¸àìS¡¹
ìСi¡ì³ì@i¡¹ A¡[š / ¤¸àìS¡¹ šàÎ ¤Òü-&¹ A¡[š \³à A¡¹à "à¤[ŸA¡¡ú
*Ѭ-šøt¡¸[Út¡ ¤¸àìS¡¹ šàÎ ¤Òü-& "¸àA¡àl¡ü@i¡ ‹à¹ìA¡¹ >à³, "¸àA¡àl¡ü@i¡ >´¬¹ &¤} "àÒü&ó¡&Î[Î ëA¡àl¡ =àA¡à šøìÚà\>ú
a) All supporting documents should be self attested by the policyholder.
b) The policyholder is required to visit the branch in person for submission of request. However there is an exception for NRI & PIO.
c) Exception for NRI & PIO: The NRI & PIO policyholders will have the option to get the photo ID attested as a true copy by either of the below:
1. The embassy in the country of residence.
2. Banker of the policyholder. 3. Notary/Gazetted officer equivalent who is authorized to attest documents
in the country of residence.
d) The policyholder is required to carry original documents for verification to the branch.
e) In case all premiums were paid by the policyholder either by cash or DD, the policyholder has to submit the ID/Age proof (submitted at the inception of the
policy) along with the payout request form (this is a mandatory requirement in case original policy document/ remittance proof is not submitted).
P¡¹ç¡â«šèo¢ i¡ãA¡à:
a) "à>åÈ[UA¡ γÑz >[=šy š[º[ι ‹à¹A¡ ‡à¹à Ѭ-šøt¡¸[Út¡ Ò*Úà \¹ç¡[¹¡ú
b) ">åì¹à‹ ƒà[Jº A¡¹à¹ \>¸ š[º[ι ‹à¹ìA¡¹ [>ì\¹ ¤¸[v¡û¡Kt¡ ®¡àì¤ ÅàJàÚ "àÎà šøìÚà\>¡ú [A¡”ñ &>"à¹"àÒü * [š"àÒü*-냹 ëÛ¡ìy ¤¸[t¡yû¡³ A¡¹à Ò줡ú
c) &>"à¹"àÒü * [š"àÒü*-냹 ëÛ¡ìy ¤¸[t¡yû¡³ : &>"à¹"àÒü * [š"àÒü* š[º[Î ‹à¹A¡¹à t¡à샹 Î[W¡y š[¹W¡Úšìy¹ &A¡[i¡ A¡[š ëA¡ "àκ ¹ê¡ìš [>³¥[º[Jt¡ ìA¡à> &A¡\> ¤¸[v¡û¡ ‡à¹à šøt¡¸[Út¡ A¡¹àìt¡
šàì¹>:
1. ¤Î¤àìι ëƒìŹ ƒèt¡à¤àÎ
2. š[º[Î ‹à¹ìA¡¹ ¤¸àS¡à¹
3. ë>ài¡à[¹/ëKì\ìi¡l¡ "[ó¡Î๠¤à γA¡Û¡ [™[> ¤Î¤àìι ëƒìÅ >[= šøt¡¸Ú> A¡¹à¹ \>¸ ">åì³à[ƒt¡¡ú
d) ™àW¡àÒü A¡¹à¹ \>¸ š[º[Î ‹à¹ìA¡¹ ÅàJàÚ "àκ >[=šy [>ìÚ "àÎà šøìÚà\>¡ú
e) ™[ƒ š[º[Î ‹à¹A¡ ÎA¡º [šø[³Úà³ >Kìƒ ¤à [l¡[l¡-¹ ³à‹¸ì³ šøƒà> A¡ì¹ =àìA¡> t¡àÒìº š[º[Î ‹à¹A¡ìA¡ ìš"àl¡üi¡ [¹ìA¡àìÚС ó¡ì³¢¹ ÎìU "àÒü[l¡ / ¤Úìι šø³ào šy (š[º[Î A¡¹à¹
Î³Ú ë™[i¡ ¤¸¤Ò๠A¡¹à ÒìÚ[áº) ƒà[Jº A¡¹ìt¡ Òì¤ (š[º[ι "àκ >[= / "=¢ šøƒàì>¹ šø³ào ƒà[Jº >à A¡¹ìº &[i¡ "¤Å¸ ®¡àì¤ šøìÚà\>)¡ú
A Joint Venture between Dabur Invest Corp. & Aviva International Holdings Limited
Aviva Life Insurance Company India Ltd
Head Office: Aviva Tower, Sector Road, Opp. DLF Golf Course, DLF Ph- V, Sector 43, Gurgaon-122003. Haryana India.
Registered Office: 2nd Floor, Prakashdeep Building, 7 Tolstoy Marg, New Delhi-110001. India
l¡à¤¹ Òü>쮡С A¡š¢ &¤} "[®¡®¡à Òü@i¡à¹>¸àÅ>ຠëÒà[Á¡}Î [º[³ìi¡ìl¡¹ &A¡[i¡ ì™ï= l¡ü샸àK
"[®¡®¡à ºàÒüó¡ Òü>[Î*ì¹X ìA¡à´šà[> Òü[“¡Úà [º[³ìi¡l¡
ëÒl "[ó¡Î: "[®¡®¡à i¡à*Úà¹, ëÎC¡¹ ì¹àl¡, [l¡&º&ó¡ Kºó¡ ìA¡àì΢¹ [¤š¹ãìt¡, [l¡&º&ó¡ ëó¡\ V, ëÎC¡¹ 43, P¡¹Kòà*-122003ú Ò[¹Úà>à Òü[“¡Úàú
[>¤[Þê¡t¡ A¡à™¢àºÚ: 2Ú t¡º, šøA¡àŃ㚠[¤[Á¡}, 7 t¡ºÑzÚ ³àK¢, [>l¡ü [ƒ[À-110001ú Òü[“¡Úà
Tel/ ëi¡[ºìó¡à>:+91 (0) 124 270 9000 Fax/ ó¡¸àG: +91 (0) 124 257 1210.
www.avivaindia.com Email/ Òü쳺 :[email protected]