FORMFORCHANGEOFNOMINATION

Date d d m

NameofthePolicyholder

Address:

ContactNo
EmailID

m y

PolicyNo

Allfieldsaremandatory(Atleastonecontactnoismandatoryforprocessingyourrequest.Contactnos.mentionedabovewillbeupdatedforfuturecommunication)

NOTICEOFNOMINATION
To
SBILifeInsuranceCo.Ltd
Branch________________

DearSir,
Re:NoticeforchangeinNomineeforPolicyNumber

IherebygiveyounoticethatIhavenownominatedthefollowingastheperson(s)towhomthemoneyssecuredbytheabovePolicyshallbepaidintheeventofmy
death.Ialsoconfirmthatthisnominationshallautomaticallycancelallpreviousnominationsmadebymeandnamedinthetext/videendorsementstotheabove
Policy.

Name

*DateofBirth

RelationshipwithInsured

CommunicationAddress

* In case the NOMINEE is MINOR, APPOINTEE DETAILS form is also to be MANDATORILY filled

Ihavereadandunderstoodalltermsandconditionsgivenattheendofthisform.
PleaseacknowledgereceiptofthisnoticeandtheOriginalPolicyDocumentandreturnthePolicyDocumentafterregisteringthenominationinyourbooks

Yoursfaithfully,

______________________________________
#
SignatureorThumbImpressionofPolicyholder

EndorsementforNomineeonthePolicyDocument

Iherebynominatethefollowingastheperson(s)towhomthemoneyssecuredbytheabovePolicyshallbepaidinthe
eventofmydeath.Thisnominationshallcancelallpreviousnominationsmadebymeandnamedinthetext/videendorsementstotheabovePolicy.
Name
DateofBirth
RelationshipwithInsured
CommunicationAddress

_____________________

____________________________________________

SignatureofWitness

SignatureorThumbImpressionofPolicyholder

Name&AddressofWitness________________________________________________________________________________
#

IncaseofsignaturesinavernacularlanguageorThumbImpression,thevernacularlanguagedeclarationbelowistobefilled.

DECLARATIONFORSIGNINGINVERNACULARLANGUAGE/THUMBIMPRESSION
CertificationwhereLifeAssuredhassignedinavernacularlanguageorhasaffixedthumbImpression

IherebydeclarethatIhavereadoutandexplainedthecontentsofthisformtothePolicyHolderin______________LanguageandthatIhavetrulyandcorrectly
recordedtheinformationgivenbyhim/herandthathe/shehasaffixedhis/hersignature/thumbimpressionontheproposalforminmypresence,afterfully
understandingthecontentsthereof.

___________________________________________
_______________________________________________

SignatureofthePersonmakingtheDeclaration
Signature/ThumbImpressionofthePolicyHolder

Name&Address_______________________

Terms&Conditions
1)
2)
3)
4)
5)
6)

The registration of nomination is subject to the receipt of this notice and the form by SBI Life Insurance Co. Ltd
All previous nominations and / or Appointee shall be automatically cancelled on execution of this form and the nomination and/or Appointee last received by the company
shall prevail over all previous nominations and/or Appointee.
In case of more than one nominee, a joint discharge voucher would be taken from all the nominees and the claim proceeds would be paid accordingly.
If nomination is in favour of a minor, an appointee who is a major must be named. Please fill the Appointee form.
On Assignment of a policy the existing nomination automatically stands cancelled..
The Company expresses no opinion as to the validity of the nomination

SBILifeInsuranceCoLtd|CorporateOffice:Natraj,MVRoad&WesternExpressHighwayJunction,Andheri(East),Mumbai400069

PS18/Ver.2.1/07 Mar 2013

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