NBRF194624012011 | Comp/Jan/Int/5020 | CVT: 23/01/21

For Official use only

New Business Alteration - Branch:
Receipt Date & Time:
Edit Servicing Form Received by:
Interaction ID:

Please submit valid supporting documents for signature verificaton.

* Indicates mandatory fields.

Application Number * : 1100113665566

Change in contact details Policyholder Life Assured Payer

Email ID:______________________________________________ Mobile no.: ___________________________________________________________

Note : Contact details will be updated for all future commucications. The above mentioned contact number will be considered as consent to communicate with him/her on the
contact details provided herein.

Address Change/ Pincode Policy holder Life Assured Nominee/Beneficiary Appointee

a.These changes are applicable to all policies held under your Client ID b. If the Nominee/Beneficiary address is different from the address of the Life Assured, then please use
a separate form.
Permanent Address Communication Address

Note: Latest address proof is mandatory as per AML Guidelines for change in Communication Address. Address proof is not mandatory for Change in Permanent Address.

2911-2869 BATTLEFORD ROAD

Address House/Flat no.: _____________________________________________________________________________________________________
MISSISSAUGA, ON
Street/Area: ______________________________________________________________________________________________________________

MISSISSAUGA
City/Disctrict: ___________________________________________________________________ ONTARIO
State: ___________________________________

Pincode: L 5 N 2 S 6 CANADA
Country: _________________________________

Name Change Policy holder Life Assured Nominee/Beneficiary Appointee Payor

First Name Last Name

Name to be changed to: _____________________________________________________________________________________________________
Note - If you are a married woman with a change in surname, please submit a copy of your Marriage Certificate. For any other request involving singificant changes in the name,
please submit identity proof having revised name.
*ID proof is mandatory for changes in LA/Proposer name.

Change in Date of Birth Proposed policy holder Life Assured Nominee/Beneficiary Appointee

Revised Date of Birth: D D M M Y Y Y Y

Note: Correct DOB proof /Illustration is required for conventional plan, and if there is any difference in age.

Rectification in Gender Life Assured Policyholder Nominee/Beneficiary Appointee

Male Female
Note
1. ID proof is mandatory for change in gender. 2. If gender selected as Female, please fill the below medical questionnaire.

Past Medical History (Female) Yes No

1) Do you have a history of past abortion, miscarriage, caesarean section or complication during pregnancy? Or have you given
birth to a child with any congenital disorder like Down Syndrome? (If yes, please complete Special Women Plan Questionnaire)

2) Have you ever had any disease of uterus, cervix or ovaries? Or have ever undergone hysterectomy?

3) Are you presently pregnant? If Yes, how many weeks: ________

Change/Addtion of Nominee/Beneficiary

1 Nominee/Beneficiary Name*: 2 Nominee/Beneficiary Name *:

Date of Birth*: D D M M Y Y Y Y Date of Birth*: D D M M Y Y Y Y

Relationship with the Life Assured*: Relationship with the Life Assured*:

Percentage of Entitlement*: Percentage of Entitlement*:

Address of Nominee/Beneficiary: _______________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________
*Note. 1) Beneficiary should be blood relative. 2) If Nominee/Beneficiary is minor, please fill Appointeee section below. 3) If the Nominee is other than blood relative, Moral
Hazard Questionnaire is required. 4) In case of more than two Nominees, please provide details separately duly signed by Proposer. 5) Nominee's address details are mandatory.

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 Addition/Change of Appointee

Appointee Name: Date of Birth: D D M M Y Y Y Y

Relationship with the Nominee/Beneficiary*:

Address:
I hereby accept my appointment as an Appointee to receive the proceeds under the policy on behalf of the Beneficiary/Nominee who is a minor.
DD/MM/YYYY SIGN HERE
Date : __________________

Place : __________________

Change in Occupation Student Unemployed Self-Employed Salaried / Service House WifeSignature of Appointee*

Parents total Life Cover (INR)*Last Standard Passed Name of employer/company#

Current Standard Work Place Address
School Name & address Annual Income (INR)
Designation
Industry

Note: Student ID card is mandatory if occupation changed to Student.

If occupation is changed to Housewife or Unemployed, the remaining details are not required to be filled.
*Applicable only if occupation to be changed to Student. #Applicable only if occupation to be changed to Self employed or Salaried.

Change in Height Change in Weight

Revised Height details In: Ft Inches Revised weight details (in kgs)

Change in Habits

Alcohol Tobacco

Alcohol (Beer/Wine/Spirit/Others) No. of units per week (Please note: 125 ml of wine = 1 unit / 330 ml of beer = 1 unit
30 ml any other spirit = 1 unit )
Tobacco (Cigar/Cigarette/Bidi/Chewing Tobaccao) No. of units per day 1 Cigar/Cigarette/Bidi/Chewing Tobaccao = 1 Unit

Change in Resident Status

Life Assured Policyholder

OCI PIO NRI Foreign National Resident Indian

Note - In case resident status is changed to OCI / PIO / NRI / Foreign national, then provide overseas address by filling up section 2 along with overseas address proof.
Change in Plan details (Applicable only for annuity products)

Change in source of business Open Market Option HDFC Life pension policy NPS Other insurance company

Existing policy no. PRAN ______________________________

Note - In case source of business is HDFC life pension policy, provide existing policy number & annuity value. B. In case source of business is NPS, please provide PRAN.

Annuity Value: 100% of vesting amount 2/3rd of vesting amount

Change Plan details

Premium Amount Policy term Sum Assured Premium Frequency Premium paying term

Revised Plan Details

Note: Revised illustration is mandatory to fill.

Any other details need to change

_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________

Declaration of the Policy holder

I have understood the meaning and the scope of this change request form and take complete responsibility for the change submitted by me herein.
SIGN HERE
Policyholder’s Name: _______________________________________________________________________
PRAVEEN KUMAR RAJAVELU
Date: _________________
DD/MM/YYYY
06/12/2024
Chennai
Place: _________________ Signature of Policyholder

Third Party Declaration

The person who has affixed his/her thumb impression or has signed in vernacular/ has not filled this application form. I hereby declare that the content
of this application form has been explained to him/ her and I have truthfully recorded the answers provided to me. I further declare that the said person
has signed or affixed his/her thumb impression in my presence. SIGN HERE
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
DD/MM/YYYY
Date: _________________ Place: _________________ Signature of Third Person

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 1860-267-9999 (local charges apply). DO NOT
prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm | Email – [email protected] | [email protected] (For NRI customers only) Visit – www.hdfclife.com
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