AD000101

Change in Communication Address

Dated: ________________ Ref.: Policy No: Policy Holder: From (Old Address) (Please fill in capital letters and leave a space between each part of the address) Flat/Bldg. No Street Area City State Res: Off: E-mail: Land Mark: To (New Address) (Please fill in capital letters and leave a space between each part of the address) *Flat/Bldg. No *Street *Area *City *State MobileNo: PinCode:

*PinCode:
MobileNo:

* *

Res: Off:

E-mail: Land Mark: *Mandatory Fields Please send all future correspondence to the new address mentioned above. Note: In case of any change in communication address, a valid address proof is required List of Valid proofs: Telephone Bill, Bank Letter / Account statement, Water Bill, Electricity Bill, Valid Passport, Valid Driving License, Ration card, ESI Card, Domicile certificate, Company Lease Agreement / Rent Receipt, Employers Certificate, Ration Card. Statements/Receipt/Bill should not be more than six months old from the request submission date. Signature of Policy Holder: ________________________________________
Version 1.0 ING Vysya Life Insurance Co. Pvt. Ltd, Registration No. 114, National Operations Office: Gold Hill Square, I Floor, 690, Hosur Road, Begur Hobli, Bangalore 560 068, India. Toll Free: 1800 425 8228, SMS: +91 98808 88228 Page 1 of 1