8/10/2019 e Policy Conversion Form

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ePolicy Conversion Form

All fields with (*) are mandatoryNote: Please complete the form in CAPITAL LETTERS.

BranchSeal

This is to acknowledge the receipt of application for conversion of policy into an E-policy(electronic policy).

Others:ACKNOW

LEDGEMENT

SLIP

Customer

Executive Signature:

Service

Date:

Policy Number: Date: D D M M Y Y Y Y D D M M Y Y Y Y

Documents received: Original Policy Document Valid Address Proof

PHO

NEANDEMAIL

DETAILS

E-mail ID*:

LandlineResidence:

LandlineOffice:

Mobile:* Alternate Mobile:

AlternateE-mail ID:

I request Exide Life Insurance to convert below mentioned policies in to electronic policies.

I hereby declare that above mentioned details are true to my knowledge and I consent to having the above policies convertedin to electronic policies

DECLARATIO

N

Signature / Thumb Impressionof the Policy Owner*:

#

thumb impression. Must be witnessed by someone other than the advisor /agent/employee of the company)(Applicable when the policy owner is illiterate or suffering from disability due to which writing is restricted and affixing his

Date YYYYMMD D

#Name & Address of the Witness* :__________________________________

____________________________________________________________

Witness Signature*#

City: State: PIN:

Address:

ADDRESS

l Is the address in your policy the same as mentioned above?

l If No: Please submit the address change request form available on our website exidelife.in or visit our Exide Life Insurance Branch, along with validaddress proof for us to update the address in our records

Yes No

1) Do you already have the eIA with any Insurance Repository? If yes, please provide the below information:

a) eIA number b) Name of the Insurance Repository

2) eIA not available - I would like to open an eIA with (Please tick any one of your preferred choice and complete the eIA form)

1) NSDL Database Management Limited

2) Central Insurance Repository Limited

3) SHCIL Projects Limited

4) KARVY Insurance Repository Limited

5) CAMS Repository Services Private Limited

INSURANCEREPOSITORY

THINGSTO

REMEMBER l

l Creation of an e-Insurance Account (eIA) is subject to submission and validation of required documentation

l A policy holder can have only one e-Insurance account with any one of the 5 insurance repositories.

l Physical copies of policy documents held by existing customers will stand null and void once conversion to e-policies is complete

l Any and all changes in personal details (address, bank details etc.) shared with the chosen Insurance Repository will be incorporated and intimatedto all concerned insurance companies

l Any and all changes related to the policy itself will be forwarded to respective insurance companies for execution. The same will also reflect in thee-policy

Opening an e-Insurance Account (eIA), converting your policies in to e-policies is absolutely free

Call : 1800 419 8228; +91 80 4134 5444 Email : customer.service@exidelife.in Visit : exidelife.in

Formerly ING Vysya Life Insurance Company Limited)

Write: Exide Life Insurance Company Limited, 1st Floor, Gold Hill Square, No. 690, Hosur Road, Begur Hobli, Bangalore - 560068

IRDA Registration No. 114 CIN: U66010KA2000PLC028273

Registered and Corporate Office: ING Vysya House, 5th Floor, #22, M.G. Road, Bangalore - 560001, India.

POLICY

DETAILS

Existing Policy:

Policy Holders Name*:

New Policy:Policy Number:

e-PolicyConversionForm/

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