Tata AIA Life Insurance Company Limited

Request For Change Form

Policy Number ____________________________

Name of Policyholder ______________________________________________

Name of Insured ______________________________________

PAN No of Policyholder (Mandatory)_________________________________

Part A (Please tick the appropriate box)

Change Type

Details

Remarks

Add 1 _________________________________ Add2 _______________________________

Change of Mailing Address
- Must be a local address in India
- To be filled in case of Ownership
change

Add 3 ________________________________ Landmark ____________________________

City __________________________________ State ________________________________
Pin ____________ Mobi No __________________ Landline No ____________________
E-mail ID ____________________________________________________________

Change of Ownership
- For Death of Original Owner
- For Minor Insured becoming Major

Relationship with Insured __________________________ Age _________ (in Years)

Addition/Change of Contingent
Policyholder

Name of New Contingent Policyholder _________________________________________

Pls. fill address details of new Policyholder in above

'Change of Mailing Address' section
_____________________________
Signature of Original Policyholder

_________________________
Signature of New Policyholder

Relationship with Insured________________________________ Age ______________

Insured's Particulars
Policyholder's Particulars

Name ______________________________________________________________________
Sex

Male

Insured

Female

Date of Birth ________________________________ (DD / MM / YYYY)

Applicable only to Juvenile Policies

Attach gazette copy for Name
change
Attach age proof (Birth
Certificate/School
Certificate/Passport etc.) for DOB
Change

Reason for Change

_____________________________________

Change of Signature

Policyholder

(Attach address proof:- Bank

statement/ Passport / Driving License
/ Utility Bills (utility bills not more than
6 months old)

Name of New Policyholder _____________________________________________________

1. RFC not to be filled for:

- Transfer of Ownership rights
(Assignment of Policy)
- Please fill separate Assignment
form
2. Attach ID and Address proof of the
new Policyholder (Mandatory)

Correction of

_______________________
Address Proof provided

_____________________________
Old Signature

______________________________________

Note: All policy transactions in future shall be processed on the basis of the authorization by the above
signature

Change of Premium Mode

__________________________
New Signature
For Credit Card
CC Debit Authorization Form & Self
attested Copy of CC (front side)
Annual (once a year)
Semi-annual* (twice a year)
For SI through below banks
HSBC - SI Form pre-attested by
HSBC Bank
Quarterly* (four times a year)
Monthly* (twelve times a year)
SBI - SI Form & Original
Personalized Cancelled Cheque
United Bank of India - UBI SI Form &
Original Personalized Cancelled
(*applicable only for payment through Credit Card (C.C), Standing Instructions (S.I.), Direct Debit (D.D.) & Cheque
ECS)
For ECS/Direct Debit
ECS & DD Form & Original
Personalized Cancelled Cheque

Reduced Paid Up

Reduced Paid Up

Change in NFO Option

Reduced Paid Up

APL/ Advance against Cash Value

Yes

No

To be filled in case of change in tax

residential status: Residence of Tax
Purposes in Jurisdiction(s)outside
India
Others

Available only after 3 premiums has

been paid

If Yes then mandatorily fill the

NRI/OCI/PIO/ FN Questionnaire/
FATCA and CRS-Self Certification
form

Part B (Please tick appropriate box. Health Certificate is required except for reduction of face amount or deletion of rider(s))
Details

Change Type

Remarks

Basic Plan Name: (Original) ___________________________________________________________

(New) _______________________________________________________
Change of Basic Plan
Basic Sum Assured: (Original) _________________________________________________________

For Change in Plan & SA

1. Health Certificate
2. New Sales Illustration Sheet
3. Policy Document (Original Policy)
4. New Modal Premium

(New) _________________________________________________________
For Addition/Increase in Sum
Assured (SA) of Riders
Addition

Deletion

Change Rider Sum Assured

1. Health Certificate
2. New Sales Illustration Sheet
3. New Modal Premium

Rider Name ____________________________ Sum Assured ______________________

Addition
Change of Rider (s)

Deletion

Change Rider Sum Assured

Rider Name ____________________________ Sum Assured ______________________

Addition

Deletion

Change Rider Sum Assured

Rider Name ____________________________ Sum Assured ______________________

Increase

Decrease

For Increase in Sum Assured

1. Health Certificate
2. New Sales Illustration Sheet
3. New Modal Premium / Back
Premium

Increase / Decrease in Sum Assured

Old sum assured__________________ New Sum Assured___________________________

New Occupation _______________________________________Since _D D /M M /Y Y Y Y _

Change of Occupation

Exact Nature of Daily Duties_____________________________________________________________

Employers Name and Address__________________________________________________________
____________________________________________________________________________________
Employer's Phone No: ______________________________________

Are you a Politically Exposed

Person

Yes

No

If "Yes" please provide details

Declaration & Authorization

No request shall be deemed to be treated valid and effective unless received by Tata AIA Life Insurance Co. Ltd. (hereinafter referred to as the Company) during the life time of the
Insured and is finally accepted by the Company.
The receipt of this form by the agent does not constitute receipt / acknowledgement by the Company.
I/We understand that (i) the Company may be unable to process this application if I/we fail to provide any further information requested by the Company and (ii) I/we have the right to
obtain access to and to request correction of any personal information held by the Company concerning me/us.
Undertaking by Policyholder for Unit Link policies only
I, _______________________________________________________________________________________, understand and undertake that the total premium paid till date (including
the previously paid premium), shall be allocated and applied to the units, based on the NAV of either of the following:
(a) the underwriting date + 1 working day or
(b) date of receipt (in case of local cheque) / clearance (in case of outstation cheque) or
(c) date of completion of all formalities, whichever is later.
______________________________

______________________________________

________________________________________

Signature of Insured

Signature of Policyholder/ Assignee/

Trustee (if other than Insured)
Date:

Signature of Witness/ Assignee/

Trustee (if other than Insured)
Date:

Date

DECLARATION IN CASE THE POLICYHOLDER IS ILLITERATE OR SIGNING IN VERNACULAR:

I_________________________________________________________________ (name) with __________________________ (identify type) __________________________ (identity
number) hereby declare that I have explained the contents of the Request for Change Form to the Policyholder in _______________________ language and that the Policyholder has
signed / affixed his/her thump impression on the Request for Change Form after fully understanding the contents thereof.
Signature of the Declarant ____________________________________

Signature/ Thumb impression of Policyholder _____________________________________________

Signature of the witness ____________________________________

NOTE:
The declarant has to be 21 years old or above and should be a person,other than the beneficiary of this policy.
Tata AIA Life Insurance Company Ltd. (IRDA of India Regn. No.110) (CIN - U66010MH2000PLC128403)
Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013
For more Information, contact your advisor or call on our Helpline No 1-860-266-9966 (local charges apply) or SMS Service to 58888 or e-mail us at Customercare@tataaia.com or
visit our website www.tataaia.com
L&C/Misc/2016/Jul/335
Version 5.1