REFUND REQUEST FORM ��5 fclaidl �laf PAGE I 1 / \.Iii I 1

Mandatory documents of policyholder- Self attested Photo ID & Address Proof, PAN,Customised cancelled cheque/Pass-book,Policy document/Indemnity bond (as applicable)1.1'")fc.1�£1l�!iall &�f<lr<'.lle1 f.�l<l"n- �C°& �l�S &'"lit �,mfsJ �cil ��allltlal'"l ��1q\ i:lai,!i'U.ltl(f.),s ?iu�(-5 il!i/ \.fl�- '!i!i, 1.1'"llcl� f.�l<l<r / (/"��i!I c.t'"lo-s ( (ii� �crc.t)

D Proposal not received D Excess Premium Refund D Unclaimed Amount (Individual/Group)J.l�IQ lllH aie/1 q�pflla'i<'.llt ��S �!iltal'"l f.lQ'") aitrr(�lscl"IC1/ ?!1.f)

IRDA REGN. NO. 142

Application No. _________ Policy No. _________ COi No. (Group Policy) ________ _<lj;>_� ai. c1'"l18� ai. �<11'"l<111Efai. (�\.I c1'"l18�)

Name of Policyholder: DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD c1'")18�Em8ci 011l-i: Transaction ID: Transaction Date: Amount: 8e1le1 <111Efsl: 8e1le1 c11ilui: ;>.8a-i:

------------

(Transaction details are mandatory if refund request is for 'Proposal not received')/("lil ��sail fclaidl 'J.l<.c11q J.llH 01l11' l-ile cii<'-1 c118e1le1all fclo1c11 $<-Rr<'.l1c1 f9)ADDRESS AND CONTACT DETAILS (Self attested KYC documents mandatory)/��atl� �� �"48 (ti:i1d1 (8q1�� E.c<11c1cil �c-� �h}s 8Nlci �(��1c1)

Flat/Plot No.:$81!/ 1..Cili! ai.: DDDDDD Buildin9 Name: DDDDDDDDDDDDDDDDDDDDDD fGl�"l1011l-i: Road / :iis: DDDDDDDDDDD Landmark: DDDDDDDDDDDDDDDDDD8cr5l-il8: City/District�1fi;,_/ Rrc-c11: DDDDDDDDDDDDDDD �:7:DDDDDDDDDDDDDDDD Pin Code / �01 815 : DDDDDD Con�act No.: DDDDDDDDDDDDDDDDDDDDDDD$101 01.: Email ID/ �Ef"Ci: DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD PAN / i:i01: DDDDDDDDDD (mandatory/$<.Rr<'.llc1')

Bank Account Details {Mandatory) / ola8 ltl1c11afl (q:>1c11 ( &�Rf.!.llc1)

Account l:lolder's Name: DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD \tllc11 £11;>_81011l-i:

�!���,!�e: DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD Branch Name: DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD�11\tllci 011l-i:

�!�����o.: DDDDDDDDDDDDDDDD IFSC Code: DDDDDDDDDDDD <111Efil$il?i� 815! MICA Code: DDDDDDDDDDDD *Loan NC No.: DDDDDDDDDDDDDDDDill-l<IIIEkfl<lll<.815: *Cil01 \tllc11 ai.: **Digital NC No.: DDDDDDDDDDDDDDDDD **lsRrw ui1c11 ai.:

(*mandatory for payment of Assigned policy)(*il?ilEfcrs c111?i�oll �8qen a.lie $<.Rr<'.llc1)

(**mandatory for payment to Union Bank of India NRE and Union Bank of India Assigned policy)(**�f;;i"-101 Glcr8 <111$ Efio-s<'.11 il01<111;>_Ef<11.;i �rai"-101 Glcr8 <111$ Efio-s<'.11 il?ilEfcrs \.Ill?!� a.lie $<.Rr<'.!1c1)

Note: Account has to be Active and at least 6 months to 1 year old / a11·a: ui1g �� 1?1� -YI� <11;;J !il-i�!i.11 6 .11@a11dl 1 q-.f 1.'!! t?'I� -YI�.DECLARATION BY POLICYHOLDER/ NOMINEE/ �1r?i�E.11�8/ o11�afl .stl�I "Yl��o11�

I hereby declare that I am the rightful policyholder/nominee of this policy and understand that this payout is due to me as per the terms and conditionsof the policy contract. In this regard, I hereby provide complete KYC details of self and undertake to abide by all the terms and conditions of the policycontract. Star Union Dai-ichi Life reserves the right to reject the request if the condition as specified in the policy document is not fulfilled. i<113! °lrlfi<-81§ 1<111 c1118�a11 i""'"<'-1 c1118�£11;,_5/ a111a'ioll § <11.;i ?il-lj §8 c1118�a11 5ma1i rai"-ll-i'I <11.;i �1;,_c11 <ll'?!?il;>. <111 �5q� l-i.;i 8� f9. <111 �c.if:ll-li i<113! c11c11oll ��eY1q1""�(qo1c11 <1111;! § <11.;i c1118'2fl 8m<>11 ?icf rai<'.ll-il <11.;i �1;,_c11cl \.ll(i01 5;,_q1ofl (,Ji"-1£lil <1111;! §. cm �rai"""' EIEf-� Ci1Ef$ \.Iii?!� Ecc11cl0rni rait1mc1 �1;,_c1 \.l��eY"' 8;>.IEJ'tll<'.I c1'1 fclaicfl0151;,_q1a11 <11�81� m1c16.

Date/ e11�111: Place / �<11: Policyholder's / Nominee's signature: ---- ------- "l'l��all�!i�all�..n��=

-g:.c:-------------------------------------------------------------------------------------------------------------:>c(;--ACKNOWLEDGEMENT SLIP - REFUND REQUEST FORM

��·:u ��E.- ��s fclaidl ijlaf Policy No./COI No./Application No. Type of Request: __________ c1'1f?i� ai./ �<lll<IIIEfai./ <11;>_� ai. ------------ fclaicfl0111-l81�: __________ _

IRDA REGN. NO. 142

Policyholder's/Norryinee's Name: DDDDDDDDDDDDDDDDDDDD c1'118�£l1;,_5/ a1W1oll'?! a11l-i: Thank you for choosing Star Union Dai-ichi Life Insurance. Your request will be processed in 10 days subject to documents being complete

iJ��s] CilEf�ofl �?ic.on 8'2CII v!EH d,jl'2) <>ii(%'. d,jli] fc1oic/l E�lcl°!l '!_ie\ 8'2Cll;;J >alf./lal 10 ftq�,jj J<il;"-118'21'11.

Branch Date/Time Stamp (Affix stamp in this box only)

�11ui1oll c11ilui/ ?il-i"-1 ?ii� c"hc1(<111 \tllalll-ii "lr ce;i.\.l Ci"IIQ��)

REFUND REQUEST FORM ��5 fclaidl �laf PAGE I 2 / \.Iii I 2

IRDA REGN. NO. 142

Policyholder/Nominee has affixed thumb impression OR Policyholder/Nominee has signed in vernacular OR Policyholder/Nominee has not filled the Application. \./1��8!<8 I o11ra'loll =oi"J._61ci roi�11o1 (i"llaj E9 'l>ll'.ICJI \./l��tm8/ o11ra'loll :l-l1E�18 <'il"<,l�i �cll 8� 'l>ll'.ICJI \./l��Ems 'l>l<� <'iii o1 (?l<'.I. I Mr./Ms./Dr./��/ ��ell/ s'J. -------------------------------------

Address /�<o11tl having known the Policyholder/Nominee for a period of (month/years); do declare that I have explained the contents of this form to the Policyholder/Nominee in his/her language and have truthfully recorded theanswers provided by him/her. I further declare that the Policyholder/Nominee has affixed his signature/thumb impression in my presence.

\./l��WW,;i ��<'.l"IIClllefl 911� § 'l>l,;i �i?l 9116< 81 § 8 if \./1��81W,;i �I �'J;ifo11 tl6il'l>ll dofl/ denofl <'ill,ll�i ��911'-?.ll E9 'l>l,;i doll/ deno11 cml �\./l?lCil G"ciiJo/l ��I� <>118 8il E9. � �?] i1\./1219116< 81 § 8 \./1��81<8 �Iii �l�E"n�i �I �cl]/ =oi"J._61ci roi�11o1 81 E9.

Date/ c11�111: _____ _ Place /�<11: __________ _

FOR OFFICE USE ONLY/ �5cl 81�kt�atl <3'-1�1:>I �ll

Signature verified: D YES / t?I �cllofl fq-'ij�ofl<'.l dl d\./l�IEJ':

D NO/ o11

Signature of Declarant: <rli�o11tl B<al l<ofl <ial:

Branch Date/Time Stamp (Affix stamp in this box only)

Bank/Branch staff signature/ 6'.ia8/ �11\Jlloll 5;ifiuiloll �cll: ____________ _ �11\Jl 1oll d 1i11J1 / ��<'.I � 1ei cea-\./ ( 'I>{ I \Jl lal I� i '¥ U;J.\./ (i"IICl��)

Branch Checklist / �111111all �a�:ce:

Documents as per Unclaimed documents requirement list /E1ci1 o18<'.lfo11 Ecci1cl'ilofl �1C1�<'.l8d1�1oll <".11El �'?!�I< Ecci1cl'il: D Yes/t?I Cancelled Cheque in original / Pass Book Copy (self attested) /4!._C118a�c-s il 8/ \./1� '18 5'Jt./l (ilc� i1eces): D Yes/t?I Photo ID proof (self attested} /�1e1 �1EJ'sl �<IC!I (ilc� i1eces): D Yes/<?1 Address proof (self attested) /�<o11�1o11 �m'J (?le� i1eces ): D Yes/<?1 Customer Signature Verified /�1t?8oll �clloll fq,1rnoll<".1d1 d\./1�1Ef: D Yes/<?1

D No/o11 D No/o11 D No/o11 D No/o11 D No/o11

Please visit our website www.sudlife.in and check the 'Whats New?' section on the home page for Unclaimed Amount. Submit the documents required basis the 'Reason' provided against your policy.

All proofs submitted to be attested by policyholder .In case of Death-Unclaimed amount ; proofs should be attested by the Nominee.

@\./<'.II 'l>l�1il clui�1Efe www.sudlife.inoll fqf3.5e 8il 'l>l,;i 'l>lo18C�Efa-s <8� �,e t?I� t1'¥ \./< 'c.t?'J{� a� . .?' fq(lll"I ��I. d�lil \./1�� �1.i1 '1>11\./Cll�i �lclCil '81<121',;i �181� Ecdlcl'il 'ij\./<d 8il.

Documents Required-Unclaimed Amount /:uuq��a E'M1<lorl- 'btaiac-lEfa-s <Bill Reason - Termination/Excess Premium/Annuity/ Surrender 1. Cancelled cheque 2. Bank Statement 3. Address Proof 4. Photo Identity Proof 5. PAN copy6. Passbook Copy with name, address and account detailsama1- <-1i111IH/ q� lllfil�ill/ il�ffc!l/ �\./<c11. 8a�C-Sil8 2. a8ci roiclEal, 3. �<all;fllall �<ICll, 4. �lei 'l>llfft,ioZzl J.!§, 5. t1o1 8it./l, 6. all;fl,�<<>llt! 'l>j,;i \Jlldloll fcl:,ldl �lei \./1�'18 8it./l

Reason -Excess Premium (Group Policy) 1. Name of Member 2. Loan Account No. ( duly attested by the Bank) 3. Savings BankAccount No. (duly attested by the Bank)ama1- q�ll]fil�ill (ij\l 'l'I��} 1. ��'?_!oll;fl 2. Cilo1 \Jlldl ai. (6'.ia8cml <'-1'1"<'.I i1zus) 3. ;ilfq:,� 6'.ia8\Jtl,jai.( 6'.ia8 �l<I <'.11"<'.I i1ZcZ5)

�q ijl.l<d 8Nlo11 �<IC!l�l l.ll��W<8 i1hes 8<Cllo11 <6si'I. 9il Sl'.l­�o18c'ltla-s <8;fl (?l<'.I di �<IC!I <>11fa'lofl �l<I i1ZcZS 8<Cllo11 <6si'I.

Cancelled cheque with pre-printed name of the account holder / Self attested Bank Statement / Pass Book attested by bank submitted is mandatory \JlldlW<8o11 �qtlr�d oll;fl �lei 8a�C-S i!8/ ;ilc� i1ZcZ5 6'.ia8 roiclEai/ 6'.ia8 �l<I i1ZcZ5 \.II� '18 �l.l<d 8<Cllci �<�<'lid E9.

Star Union Dai-ichi Life Insurance Company Limited Registered Office: 11th Floor, Vishwaroop I.T. Park, Plot No. 34, 35 & 38, Sector 30A of IIP, Vashi, Navi Mumbai - 400 703.

'ii': 18002668833 (Toll free) / 022-39546300 (landline) - 8:00 am to 8:00 pm (Mon - Sat). Email: customercare@sudlife.in I Website: www.sudlife.in I IRDA Regn. No. 142 I C.I.No. U66010MH2007PLC174472

:cm �raii!lal E.Uf-ENI CilOij ff���a� 5\.lafl r?t�l5 aff€len�c1 81.!lfc.ti!I: 11;fll ;fJICll, fq�q�\.j �mftl \.118, '-C·ik ai. 34, 35 �,;i 38, ii&<. 30i1 �I� �l�IENI, q1�n. c,jq] tluiEJ'- 400 703.

tt: 18002668833 ( c.lC� �) / 022-39546300 ( c,:iO"SC�l8o1) -�q118efl <Id 8 (c11a-iq1< -�1raici1<). �Efc�: customercare@sudlife.in I cl0ic11El'e: www.sudlife.in I �l�l<&lil a1'if.ll?n ai. 142 I C.1.No. U66010MH2007PLC174472

SUD/Sept-2015/RFormNer3/Guj Trademark used under licence from respective owners /"�5;fll8 '2ivifo<1 JJ1fi'tsl tff21eil c,11klcr� �501 6.

REFUND REQUEST FORM ��5 fclaidl �laf PAGE I 3/"llli I 3

Documents Required-Unclaimed Amount /<>11q�.!!8 e.M1<l-il- <>lot5<1Ef.l.s <Bat

Reason - Claims / 51<121- e.1q1<>11 Requirements for Individual Death Claim (Claims settled but not paid) Q115d::>IC1 J!,� EICII Jj IZ. 'l>IICl�<'.l5C11'l>ll ( EICII \le11CIG !?.l<'.ll t'!l<'.l \ll21 �5qen al 5m/'eJ.!I) 1. Nominee's Death Certificate2. Succession Certificate from Court of Law 3. Bank details of the Beneficiary mentioned in Succession Certificate 1. a11(a°:la/la11 J!,�all Elute-ti2. 51<'.1Elall 5JZ \,ll�efl ���lal ���8G 3. �5��1"1 ���8GJjj GC-<ifillc1 CilC'llefTa/1 ola5a/l fq::>1c11Requirements for Group Surrender (MATA) Claims (EFT Rejects)�\,I �\,1'2c1 (i1Jj'l>Jl'2i!1i1) EICll'l>ll ( ��i!1 "151'2) JjlZ 'l>JICl�i!.15c11'l>ll1. KYC of Life Assured2. Bank details of the Life Assured - Cancelled Cheque with pre printed name/

Bank Pass book copy1. c/lra:ie1cisc.i1<'.I� 2. c/l{a":ic1all ola5a/l fq::>1c11- �q�fsec1 allJj �lel8a�f5'215 I olo-5\,II� 'd5 5Jtfl Requirements for Individual / Group Death Claims (EFT Rejects)Q115d::>1C1 / �\,I J!,� EICll'l>ll ( ��i!] "151'2) JjlZ, 'l>JICl�i'.15C11'l>ll1. KYC of Nominee2. Bank details of the Nominee - Cancelled Cheque with pre printed name/

Bank Pass book copy1. a11ra:ia11cisc.i1.!I�2. a11(a°:la/la/l ola5a/l fq::,1e11- �q�fl.C1 allJj �lel 8a�C-S '215 / ola5 \,II� 'd5 5Jtfl Requirements for Maturity Claims - Non Pension a:i��i!1 EICll'l>ll JjlZ <>IICl�i'.15c11<>!1- allot ll�lal1. KYC of Policyholder 2. Bank details of the Policyholder - Cancelled Cheque with pre printed name/

Bank Pass book copy3. Original Policy Document4. Maturity Discharge Voucher duly filled and signed 1. c111?i�f.ll'25<j8Clli'.I�2. \llfc-t�tll'2sa/l ola5a/l (q::>1(11- �q�rsee1 allJj �lel 8a�C-S '2)5 / ola5 \,II� 'd5 51tfl 3. �01 \llf?i� EMlc1'lr 4. a:i��i!1 fsc2.l1"i c.i1G<-1'2 ci�eY C'lil.;i �cll �1eiRequirements for Maturity Claims - Pension ,slsa�t'1�1al (qoicll JjlZ :1.1!?.lJj �(a°:l<'.!Jj :1.11fi:e1 ��C1 �01 c11/?i� EMl'1'lr�\,1'2C1 5il.1 . KYC of Policyholder2. Bank details of the Policyholder - Cancelled Cheque with pre printed name/

Bank Pass book copy3. Original Policy Document4. Maturity Discharge Voucher duly filled and signed 5. Annuity Option Sheet duly filled and signed 6. Proposal Form duly filled and signed

(where Fund Value is equal to or more than Rs. 5 lacs)7. Age Proof (where Fund Value is equal to or more than Rs. 5 lacs 1. c11fc-t�tll'25<j8Clli'.I� 2. c11fc-t�tll'25a/l ola5a/l fq::,1e11- �q �fl.C1 allJj �lel 80-�C-S '215/ ola5a/l \ll�'d5a/l al5Ci 3. �011..l'lfc-t� E�c11c1'lr 4. i'.ll"i!.I C'i�� <>1.;i �cll 5�� a:J��i!1 fsc2.l1"i c.i1G<-1'25. <'-11"<'.I (li�� 'l>l.;i �cl] 5�� 'bl�Efi!1 (q5(-\,I \,1?156 . .!II".!! (li��'l>l.;i �cl]5��:I.IMICI \,1?15 ('l/Jji �s�� 5 C-tl\,J 'l>l!?.ICII c.i�el<'-1)7. GJj'2ot1 �m1 ('l/Jji �s�� s cw,i 'l>l!?.lc.i1 c.i�e1<'.I)

IRDA REGN. NO. 142

Ru

900980089: 0012341 I 10

Customer Service Touch Points g!l(i8 i!q1 �'-l§ �C/1:

Toll Free No/ e'ic-t � ai: 18002008833 or / 'l>J!?.lc.i1 Land line No/ auSC-tleJ'ot ai: 022 39546300 {Charges apply/ Eil c-tl"�

Timing/�Jji'.I: 8:00 am to 8:00 pm (Mon - Sat) (�1Jj-�1rai) Email Id/ EMEJ'c-t <>11EJ'sl: customercare@sudlife.in

Star Union Dai-ichi Life Insurance Company Limited Registered Office: 11th Floor, Vishwaroop I.T. Park, Plot No. 34, 35 & 38, Sector 30A of IIP, Vashi, Navi Mumbai - 400 703.

'ii': 18002668833 (Toll free)/ 022-39546300 (landline) - 8:00 am to 8:00 pm (Mon - Sat). Email: customercare@sudlife.in I Website: www.sudlife.in I IRDA Regn. No. 142 I C.I.No. U66010MH2007PLC174472

:cm �raii!lal E.Uf-ENI CilOij ff���a� 5\.lafl r?t�l5 ot1'€mn�c1 81.!lfc.ti!I: 11JjJ Jjl01, fq�q<"l'-1 <>11Eftl '-118, l,(·lk ai. 34, 35 <>l,;i 38, il&'2 30� <>ii� <>ll�IENI, q1�n. a1cn tlv1Ef- 400 703.

tt: 18002668833 ( c.lC-t ,sl) / 022-39546300 ( c:iaSC-118"1) - �qi� Sefl <Id 8 (�'Ja-iql< - �1raic.i1<). �Efc,: customercare@sudlife.in I clv1�1Efc.: www.sudlife.in I <>11EJ�,11�&l� "11€.ll?n ai. 142 I C.1.No. U66010MH2007PLC174472

SUD/Sept-2015/RFormNer3/Guj Trademark used under licence from respective owners /�5.Hl8 '2ivifo<1.H1fi'tsl 1.ff21eil c,11klcr� �501 6.