Sub: Declaration for Name of Life insured / Proposer / Nominee / Appointee
for Proposal # __________
Dear Sir,
I Mr. / Ms. / Mrs. _________________________________ have applied for an Insurance
plan in your company, I have submitted below mentioned document As a proof where in there is minor mismatch in the name and hence I would like to declare that all the names mentioned below belongs to the same person
Name as per Name as per Proof
Proposal Form Bank Record Adhaar Card PAN Card ID Proof (other)
Hence, Request you to consider my name as per the ------------------------------ and process my application
Thanks & Regards,
Signature of Declarant: _______________________________
Name of Declarant : _______________________________
Sribe Details : Declaration by the person filling in this Name declaration (Applicable only where the declaration is filled in by the scribe or signed in vernacular language) I,________________________________ have explained to the applicant, the content of this name declaration & Proposal Submitted to KLI, I also confirm that the applicant has signed /Affixed his / her thump impression in my presence.
Scribe’s Relationship with Applicant _____________________Mobile No _______________
Address of Scribe: ___________________________________________________________ ___________________________________________________________________________
Signature of Scribe: ________________ Signature of Applicant : ___________________
Date : _________ Date : ___________ Place : __________ Place : ___________
