Surrender Request Form
Surrender Request Form
Surrender Request Form
Name Name
PFOO5
Branch Address & Contact Numbers
BAJAJ ALLIANZ LIFE INSURANCE COMPANY LT
GE Plaza, Airport Road Yerawada, Pune 411006
Electronic Payment:
This mandate is a standing instruction to Bajaj Allianz Life Insurance Co Ltd, to transfer the amount to pe paid to the policy
holder electronically into his bank account.
Electronic Payment Fund Transfer will be applicable to Surrenders, Partial Withdrawal, Cancellation of Proposal, Annuity,
Loans Survival Benefits and Maturity.
Note: Cancelled copy of Cheque/ Bank Statement/ Bank Passbook Copy not more than 6 months old as on date to be submitted along
with Electronic Payout Request.
Bank Name:
Branch Name:
MICR Code
IFSC Code:
The payout mode selected in the Form will be used by company to generate any payouts to the policy holder (Claimant). Payouts
would be done in accordance and subject to terms and conditions of the policy
_____________________________ ___________________________________
Signature of Policy Holder Signature of Bank Account Holder
Banks Verification
Stamp & seal of Bank for Verifying Customers Bank Account Number
PFOO5
Branch Address & Contact Numbers