Partial Withdrawal/ Full Withdrawal/ Surrender Request Form

Policy Number: Application Number of Met Loan Assure:

Date (dd/mm/yyyy):

Please paste recent colour passport size photograph

Name of the Policy Owner

Contact number (Mandatory): including country code ____________________________________ Email ID: ________________________________ (The Contact details mentioned above will be updated for future correspondence) Nationality:(Only applicable for Non-Indian citizens)____________________________________________________Country of Birth: ________________________________________ PAN No.#: (Self-attested PAN copy to be submitted with PAN details)

Is there a change in Address- Yes No Current mailing address of the Policy Owner (Mandatory) In case of a change in address, please raise a request for address change with valid proof.

MANDATORY Requirements to be submitted by the Policy Holder- (requests received without the specified documents would be rejected):

a) Original Policy Document/Certificate of insurance (for Met Loan Assure) is required to be submitted for making request for policy surrender. In case of Partial Withdrawal request, Original Policy Document needs to be produced by the policy owner in person or through authorized representative. Policy Owner Walk-In at PNB MetLife branch is mandatory for submission of Policy Surrender requests along with original ID proof, failing which such requests will not be processed.

b) In the event of the policy owner having lost/ misplaced the original policy document and choosing to make policy surrender request/partial withdrawal request using a duplicate policy document/ Indemnity for lost/ misplaced policy, the Policy Owner Walk-In at PNB MetLife branch is mandatory for submission of such request along with original ID proof, failing which such requests will not be processed.

c) Self attested Identity Proof & Address Proof Copy, as part of KYC requirement- in case of auto vested policy, the KYC and bank details of the new Policy Owner would be required

d) Bank Account Details along with original cancelled cheque / Self attested passbook copy / Self attested Bank statement authenticating Policy Owner account details for direct credit. In

case if the cancelled cheque doesn’t carry the policy owner’s name and account number imprinted in it, passbook or bank statement bearing pre-printed account number and name to be attached along with request form

e) For customer Walk-ins the original ID proof of the Policy Owner to be mandatorily displayed at the time of request submission failing which the request will not be processed.

f) In relation to Requirement (a), partial withdrawal request if received from anyone else other than the customer, then, in such scenario, written and signed authorization letter from

Policy Owner and id proof of the person who submitted the request has to be submitted to PNB MetLife, failing which such request will not be processed.

g) No objection certificate/Clearance certificate from the bank to be submitted for Met Loan Assure I apply to, please tick (√) Partial withdrawal Surrender/ Full withdrawal of my policy by withdrawing all the units/full cash value of my policy o Partial withdrawal (in Rs.) ______________________________________________from the Unit Account of my policy Or in case of %, as per the table below

Fund Option %Withdrawal

Preserver

Protector

Moderator

Balancer

Accelerator

Multiplier

Virtue

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PNB MetLife India Insurance Company Limited Registered office: Unit No. 701, 702 & 703, 7th Floor, West Wing, Raheja Towers, 26/27 M G Road, Bangalore -560001, Karnataka. IRDA of India Registration number 117.

CI No. U66010KA2001PLC028883, Call us Toll-free at 1-800-425-6969, Website: www.pnbmetlife.com, Email: indiaservice@pnbmetlife.co.in or write to us at 1st Floor, Techniplex -1, Techniplex Complex, Off Veer Savarkar Flyover, Goregaon (West), Mumbai – 400062. Phone: +91-22-41790000, Fax: +91-22-41790203

Note: 1. If the requested partial withdrawal value is greater than the maximum eligible partial withdrawal value, the maximum eligible value will be paid.

2. In the event that a partial withdrawal results in the surrender value (being the fund value less applicable surrender penalty) of the policy falling below the threshold limit#, policy will be

terminated and applicable surrender value will be paid. (#Please refer ‘Auto Foreclosure clause’ as mentioned in Product T&C)

3. Amount payable on Surrender/ Full Withdrawal of the units is as per policy terms & conditions. The Surrender/ Full Withdrawal of the units’ results in termination of the contract and all rights/ title and interest under the policy shall stand extinguished.

Payment Details: Payout will be done through Direct Credit (Direct Transfer to your Bank Account)

Policyholder’s name as per the Bank Account

Bank Name:____________________________________________________________________________________________ Branch Name:__________________________________________________________________________________________ Bank Account Number:

Bank Account Type: □ Savings □ Current □ NRE* □ NRO * In case of NRE customer, please provide the Customer Declaration- Repatriation Request & bank certificate for Repatriation

IFSC Code*- (*You can get this code from your Bank) Note:

1. I understand that payout under the policy shall be strictly in accordance with the policy terms and conditions. Also, any payment shall be subject to the last payment realization.

2. If application for Unit Linked Product is received up to 15:00 hrs IST on a business/ working day, the same day`s unit value will be applicable while processing the request. However, if the application is received after 15:00 hrs, then the next declared NAV will be applicable.

3. I hereby declare that the particulars given in this form are true, correct and complete in all aspects.

4. I take full responsibility of genuineness and correctness of the details filled herein.

5. I understand that in case of a mismatch in address or valid address proof not being submitted, My Surrender/Partial Withdrawal request will get rejected.

6. I understand that incase of any change in my contact details from what is available with PNB MetLife, I need to regularise the same by providing the necessary documentation prior to PNB MetLife processing my request. I also understand that my request for the Fund transfer to my New Business application would be affected only after proper updating of my contact details. I agree with PNB MetLife to reserve its right to make the payout to my registered account in case of any contradictory on insufficient details.

7. If the transaction is delayed or not effected at all for any reasons due to incomplete or incorrect information, I shall not hold PNB MetLife responsible in any manner whatsoever. Further, I understand that PNB MetLife shall not be held responsible for any non-receipt of payment on account of wrong/ incorrect/ incomplete information given by me in this form.

8. I also understand and agree that PNB MetLife reserves the right to use any alternative payout method (via cheque) incase the requisite information for Direct credit is not received or if the request is rejected by the bank.

9. I understand that PNB MetLife will be communicating through telephone calls, SMS, or emails for providing details of transactions, payment reminders, etc. and that these shall not be construed as unsolicited commercial calls/ e-mails.

10. I understand that PNB MetLife may reject my request in case of non-contactibilty

11. I also understand, PNB MetLife may reject my request in case original identity proof is not displayed at the time of request submission

12. # In accordance with Section 194DA of the Income Tax Act, introduced by the Finance Act 2014 and effective from 1 October 2014, If your policy is not exempt under Section 10(10D)

of the Income Tax Act, an amount equivalent to 2% on the payout amount exceeding INR 99,999 in a financial year would be dedu cted at source and deposited into the Central Government treasury. A TDS certificate would be issued to you within the stipulated timelines. In case your PAN is not registered with PNB MetLife, a higher rate of TDS (20%) will be applicable as per the income tax regulations and therefore, we request you to submit a copy of your PAN in case of it not being submitted earlier. Tax is as per the Income Tax Act, 1961 & subject to any amendments made thereto from time to time

Signature of Policy Owner/Assignor In case of the policy being conditionally assigned*, request should be signed both by the Assignee & Assignor

Signature of Assignee In case of the policy being absolutely assigned, request should only be signed by the Assignee

* Assignor signature would not be required in case of conditional assignment done to secure a loan To be filled by branch Services (Mandatory) 1. Please tick the appropriate - □ Partial Withdrawal □ Full Withdrawal/ Surrender 2. Request received from □ FA □ SM □ Sales personnel □ Specified Person (SP) □ Customer □ Customer Representative □ Bank □ Courier (Please Note – Policy surrender request have to be submitted in person by the policy owner) 3. In case of request submission through a 3rd party, customer authorization letter for submission of request and a Self -Attested ID proof of the authorized representative to be submitted along with the request for further processing. 4. For All Surrender/Partial Withdrawal requests, Branch Services person to mandatorily OSV the policy document for processing the request 5. In case of thumb impression request to be witnessed by PNB MetLife employee

11 digit IFSC

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Acknowledgement Slip

Received a request for ______________________________ against Policy Number _______________________________________ on ______________________________ at ______________________________ am/pm Employee Code _________________________ Employee Name _______________________________________________________ Date and time Stamp / Seal of Branch

Customer Service Toll free: 1800-425-6969 (8:00 am to 8:00 pm)

Mail us at indiaservice@pnbmetlife.co.in

Version 4.5