Policy Document Waiver Form

PSNF525021011602
CANA
Policy Document Waiver Form
Declaration by the Policyholder/s
I/We,__________________________________________________________________________________ (name of the policyholder/ s )

the Policyholder/s under insurance Policy number_______________________ issued on _____________ (referred to as “the Policy
Document”) by HDFC Life Insurance Company Limited (referred to as “the Company”) do hereby make the below mentioned request with
respect to the policy held by me/ us.
Type of Request Surrender Maturity Free Look Cancellation

(Tick correct option)
The above referenced Policyholder(s) do hereby solemnly affirm as follows:

I/ we submit the above selected request, however I/ we submit the above selected request,however I/ we am/are not in possession of
the original policy document. Hence, I/we request the Company to waive the requirement for submission of the original policy
document.
I/ we agree that the Policy Document will be treated as cancelled hereafter. Neither I/We or my/our legal heir/ beneficial owners nor any
third party will present the Policy Document in the future for any payments or entitlements.
I/we confirm that I/ We or my/ our legal heir (i) have not assigned, pledged or in any way disposed off or dealt with the Policy Document
nor have I/We created any encumbrance on the Policy Document and agree to not do the same anytime in the future, or (ii) shall not
make any misrepresentation or commit any fraud in connection with the Policy Document at any time after the date of this declaration.
I/we agree that after processing this request, the Policy Document and my/ our rights created under the Policy Document stand null and
void.
I/ we agree that the Company shall not be liable for the payment of any benefits against the Policy Document once this request is
processed.
I/ we agree to cooperate with the Company in case of any enquiry/ investigation that may be initiated by the Company in connection
with the Policy Document.
I/ we declare that the Company is discharged off all its liabilities mentioned in the Policy Document and I/ We relinquish any further claim
on the Company once this request is processed.
I/ we shall not hold the Company accountable for any loss incurred by me/ us due to processing of my/ our request by the Company.
I/ we agree to indemnify/defend and hold harmless the Company and its officers, directors, employees, representatives, agents,
against all claims, demands, actions, suits, proceedings, losses, damages, liabilities, costs, charges, expenses (including legal expenses)
or obligations, which may be brought or commenced against the Company, in connection with the Policy Document
SIGN HERE
DD/MM/YYYY
Date of Declaration: __________________________
Place: _____________________________________
Signature/Thumb Impression of the
Policyholder/s
I hereby declare that I have explained the contents of this application form to the Policyholder/s in _____________ language and have
truthfully recorded the answers provided to me. I further declare that the Policyholder/s has signed/affixed his/her thumb impression in
my presence.
DD/MM/YYYY
Name: ____________________________________________________ Date: __________________ Place: ______________________
Signature: ________________________ Address: ___________________________________________________________________
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 us on 022-68446530 (Call charges apply). Available Mon-Sat from 10 am to 7 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
SIGN HERE
Employee ID: _______________________________ Employee Name: ___________________________________
Branch Code: _______________________________ Branch Name: _____________________________________ Employee Signature

Policy Document Waiver Form

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Policy Document Waiver Form

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PSNF525021011602

Policy Document Waiver Form

Declaration by the Policyholder/s

I/We,__________________________________________________________________________________ (name of the policyholder/ s )

Type of Request Surrender Maturity Free Look Cancellation

The above referenced Policyholder(s) do hereby solemnly affirm as follows:

Signature: Address: ___________________________________________

Employee ID: _ Employee Name: _____

Branch Code: _ Branch Name: _______ Employee Signature

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