Quotation for Surrender Request - ULIP Policies

Date: 24/04/2014 To, Mr.RAEES AHMAD RAEES AHMAD MOH MIRDGAN BIJNOR UTTAR PRADESH Ref: Policy No: LN130900001582 on the life of Mr/Mrs/Ms Mr.RAEES AHMAD Dear Sir / Madam, Surrender Request Reg. We are in receipt of your request for Surrender of the above mentioned policy. The surrender quotation is given below. The Surrender value mentioned below is as on the date and may vary depending on the date of the Surrender application. processing of S O MR ABDUL AZIZ

Quotation:
Plan:
Fund SHRI PLUS No of Units NAV(23/02/2012) Fund Value
` 3830.88

Maximus ULIF00301/07/06MAXIMUSFND128

231.4675

16.5504

Fund Value = No: of Units in the Fund A/c x N.A.V as on the date of surrender quotation = ` 3,830.88 /Basic Fund Value TopUp Fund Value Less : Basic Surrender Charges @25.00% on Base Fund Value TopUp Surrender Charges Other deductions Total deductions O/S Policy Deposit Top Up Amount Not Underwritten Net Amount of Surrender Value Payable Yours Sincerely,
` 957.72 ` 0.00 `0 ` 957.72 ` 0.00

3,830.88 0.00

0.00
` 2,873.16

[AUTHORISED SIGNATORY]

SURRENDER DISCHARGE FORM

Policy No: LN130900001582 on the life of Mr/Mrs/Ms Mr.RAEES AHMAD I/We, Mr.RAEES AHMAD the Proposer / Life Assured / Assignee(s) do hereby acknowledge receipt of a sum of EIGHT HUNDRED SEVENTY-THREE AND SIXTEEN PAISE ONLY (in words) RUPEES

Date: 24/04/2014

TWO THOUSAND

` 2,873.16 (approx) in full

satisfaction of all my claims and demand in respect of surrender value against the above mentioned policy.

Note: The Surrender value as mentioned above may vary depending on the date of request, monthly processing charges till the date of processing the application, N.A.V as on date of acceptance or approval of a surrender request etc.
Declaration :

I/We hereby declare that I/We have not served on any office of the Shriram Life Insurance Co. Ltd., any notice of assignment/reassignment in respect of the above policy except those if any, already registered with Shriram Life Insurance Co. Ltd., nor shall I/We serve on any office of the said company any notice of assignment or reassignment before payment of the surrender.
t Present address to which cheque is to be sent: t Payee details to issue Account Payee cheque:
Bank A/c No: Name of the Bank:

Dated at

this

day of

20

Signature of Policyholder / Assignee(s) in English (or) Vernacular Language:

1. 2.

. .

Please affix
` 1 Revenue Stamp and sign across the

W In the presence of WITNESS: Signature I Full Name T Address N E SS

If the application is signed in a vernacular language and with the help of a scribe, then please fill & sign the following:

DECLARATION BY PERSON FILLING THE FORM (For form filled in by a scribe for forms signed in vernacular languages)

I of

having known the policyholder for a period (Yrs / Months) do declare that "I have explained the nature of contents of this form to the policyholder, which forms the basis for

accepting this request to surrender his/her policy".

Signature of Scribe (for forms signed in vernacular language)

In case if the policy is conditionally assigned, then the policy holder as well as the assignee(s) should sign the Discharge Form.