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POLICY AMENDMENT REQUEST FORM (A) SECTION A Policy No. 1. Change in Address Address Please write in (BLOCK LETTERS) Home Work Alternate/Permanent City Pin Mobile* Tel* * Mandatory E-mail Please indicate your preference for preferred mailing address Home Work Alternate/Permanent Note: In case total Annual Premium exceeds Rs. 10,000, including all the policies, Please provide a copy of self attested supporting address proof for new address. The Supporting address proofs are as follows: (Please check the appropriate) Passport, Voter's Identity Card, Driving License, Ration Card Telephone Bill, Electricity bill (not older than six months) Credit Card or Bank statement, which is not more than 3 months old. 2. Change in Name: Policy Owner: Life Insured: Letter from a recognized 'public authority' or public servant verifying the mailing address Affidavit Issued by a gazetted officer. Gazetted officer should be of Central or State Government. Valid lease agreement along with rent receipt, which is not more than 3 months old. (Title) (First Name) (Middle Name) (Last Name) Note: Please provide us with a certified copy of the supporting document along with the Affidavit. 3. Change in Nomination: From To Relationship DOB (If minor i.e. under age 18) Note: If nominee is a minor, please name a person (''Appointee'') to receive policy proceeds in the event of death of life insured, while the nominee is still a minor. Please provide below the following information for " Appointee " - Name of the Appointee: Relationship to Nominee: Address: Appointee's Signature: 4. Change in Bonus Option: (Tick to indicate Bonus Option required) Cash PUA Premium Offset 5. Change in NFO: (Tick to indicate NFO required) Reduced Paid Up Extended Term Insurance SECTION B 6. Addition/Change/Deletion in Riders: A-Addition C-Change D-Deletion A C D Riders (Tick to indicate) Term Personal Accident Benefit Rider (PAB) Dreaded Disease Payor Rider Term Rider Term R & C (5 year) Waiver of Premium (WOP) Coverage Amount Premium amount Effective Date Current Occupation Effective Date NA NA NA NA Note: Health declaration form is required for all addition of rider. Life insured may be required to under go medical tests Payor questionnaire and Date of birth proof required for addition of Payor rider Any addition of rider / option shall be subject to the company underwriting the risk and the company shall not be liable until such time it has underwritten the risk and issued the rider / option contract to the policy holder. I fully understand the meaning and scope of the Policy Amendment request form and the questions / amendment requests contained above and am submitting the completed Policy Amendment request form of my own volition. Name of Policy Holder: (Mention complete name) Date: Signature of Policy Holder: (Should match with policy records) Place: MNYL APA 28032009 Version 1.1 Max New York Life Insurance Co. Ltd. 3rd Floor, Operation Center, 90 A, Udyog Vihar, Sector – 18, Gurgaon – 122015. Amsure Helpline : 1800-180-1288 (Toll Free), e-mail : amsure.helpdesk@mexnewyorklife.com. Visit us at : www.amsure.in
