APPLICATION FOR SURRENDER OF POLICY - …

1 APPLICATION FOR SURRENDER OF POLICY . z Amount payable on SURRENDER of the POLICY / full withdrawal of the units is as per the POLICY terms & conditions. POLICY Name POLICY Number Name of Proposer First Name Surname Current Address City State Pin Code Current Contact Numbers Mobile STD Residence STD Office Ext. Email Electronic Payout Methods Please tick one of the options : National Electronic Fund Transfer (NEFT) Electronic Clearing System (ECS) Direct Credit (select banks). If none of the above options are selected, the default option will be Cheque. Please attach a cancelled copy of your cheque if any of the above payout option is selected. Full Name of Account Holder Full Name of the Bank Branch Name Account Type Current Savings Please strike off unfilled cells wherever applicable. Bank Account No MICR Code (Only mandatory for ECS mode) (You can get this code from your cheque book). IFSC Code (Only mandatory for NEFT Mode) ( You can get this code from your bank). The Payout mode selected in this form would be used by the Company to make all subsequent payout(s) to the Proposer.

2 Payouts would be in accordance and subject to the terms and conditions of the POLICY . I would not hold ICICI Prudential Life Insurance Co. Ltd responsible in cases of non-credit to my bank account or if the transaction is delayed or not effected at all for reasons of incomplete/incorrect information. Further, the Company reserves the right to use any alternative payout option including a demand draft/payable at par cheque inspite of opting for Electronic payout Method. Responsibilty of providing IFSC code lies with the customer. Please note that IFSC code for RTGS & IFSC code for NEFT may be different. Proposers Signature ACKNOWLEDGEMENT OF APPLICATION FOR SURRENDER OF POLICY . Proposal / POLICY No. Stamp Name of POLICY Holder Branch Name DD / MM / YYYY. May 2007. Received by Note: Please save this acknowledgement till the transaction is complete. The APPLICATION will be effected on receipt of this form at an ICICI. Prudential authorized centre, subject to terms and conditions mentioned in the POLICY document.

3 1. In case the POLICY is absolutely assigned please specify in whose favour the payment of the SURRENDER proceeds should be made: Assignor Assignee I / We have enclosed the POLICY document Yes No I/ We understand that the SURRENDER of the POLICY or full withdrawal of units results in the termination of the POLICY and that I/we are required to return the Original POLICY Document to the company. I/ we also understand and agree that the POLICY shall be deemed to have been duly surrendered and the company discharged of all liabilities under it upon the payment of the SURRENDER value, notwithstanding the non-production of the Original POLICY Document to the company, for any reason. Where the POLICY is not submitted to the Company, the POLICY owner hereby agrees to indemnify the Company against all liabilities that the Company may incur on account of any claim being made by any other person on the basis of possession of the POLICY document or otherwise. I/we also understand that the contract of insurance shall be deemed to have been duly terminated on my/our signing this APPLICATION form for SURRENDER of the POLICY .

4 Please affix Re 1/- revenue stamp & sign across the stamp Date : Signature of Proposer or Life Assured (in case D D M M Y Y Y Y Place the POLICY is on own life). Date : Name, Signature (& rubber stamp for corporate/ D D M M Y Y Y Y Place firm) of Assignee in case of absolute assignment Relationship of witness with Proposer Witness Contact Number Witness Name & Signature Date : D D M M Y Y Y Y Place As per the new IRDA guidelines, the cut off timings for NAV APPLICATION in respect of allocation and redemption of units stands revised to pm with effect from June 1st 07. This implies that if the APPLICATION for SURRENDER is received up to on a weekday (Mon - Fri), the same day's unit value will be applicable. However, if the APPLICATION for SURRENDER is received after a weekday, then the next working day's unit value will be applicable (when the applicable day is not a valuation day, NAV of the next immediate valuation day would be considered). National Electronic Fund Transfer (NEFT) is a funds transfer from one bank branch to another provided these bank-branches are participating in the network system.

5 Indian Financial System Code (IFSC code) for NEFT will be available from the bank branch where you hold your account. Electronic Clearing System (ECS) is a method of funds transfer where funds are processed through Clearing Houses created by RBI. MICR. code can be obtained from the cheque credit received will depend on the customer's ECS location . Direct Credit is a method of funds transfer from one bank to another bank (destination bank) provided ICICI Prudential has a tie-up with the destination bank. Please contact any of our touch points to know more about any of the Payouts Mode mentioned above. Kindly call our Customer Service Toll Free Number 1-800-22-2020 from your MTNL or BSNL line Call Center timings: to Monday to Saturday (except national holidays). Communication Address: ICICI Prudential Life Insurance Company Ltd., Vinod Silk Mills Compound, Chakravarthy Ashok Road, Ashok Nagar, Kandivali ( E ), Mumbai 400 101.