Annexure.

Vinay3000p 02-2021

LIC
LFE INSURANCE CORPORATION OF INDIA
Life JnsuranceCorporation of Jndia
Date

Visakhapatnam Division
Cover Place
Interview for Retention of insurance
with
Questionnaire to be submitted by the Policy holder
Form
Surrender Application Discharge

Name of Policyholder
Policy No
Question
Options
Question
No
1. Urgent Financial need

2 Not satisfied with terms and

Reason for Surrender of the Policy conditions of the plan

3 Not satistified with service

4. Any other reason

2 Are you aware that Surrender of policy shall YES/ NO

result into loss of Life Cover ?

Are you aware that Surrender of policy may YES/ NO

3
be financially disadvantageous ?

Are you aware of the approximate

4
Surrender Value for your policy ?
RS
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Signature of Policy holder

understood the various aspects of Surrender of may policyarnd Iam signing the
Ihereby declare that i have
the sarm.
discharge form after understanding

Signature of the Policyholder

Name of the Policyholder

Address

AYMODe Contub