FOR OFFICE USE ONLY
Policy Number Received Date
Assignment Form
Policyholder (I.e. Assignor) Contact Details
Landline No. (Residence): Mobile No. (Mandatory):
Landline No. (Office): Email ID: _______________________________________________________________
STD Phone
Are you a US Citizen or US tax resident Yes No If Yes, Please provide TIN: ___________________________________________________
All communications will be on the e-mail id mentioned above (if available). The mode of communication from and to the company would include electronic mode like sms, email etc.
Please tick 'Physical copy' if you want to receive communication in electronic form as well as physical Copy
Physical Copy:
Declaration
(Please read the Instructions/Notices mentioned overleaf before filling up this form)
I/we
(Name of the Assignor) First Name Middle Name Last Name
have read and understood the Instructions/Notices mentioned overleaf and I/We hereby give you notice that I/We have assigned the above Policy to:
Name of the Assignee:
First Name Middle Name Last Name
Status of the Assignee: Bank/Financial Institution Relative of the Assignor10 Others11
Relationship with the Assignor: ____________________________________________________________________________________________________________
Address of Assignee:
City State Pin Code
Landline No. (Residence): Mobile No. (Mandatory):
Landline No. (Office): Email ID: _______________________________________________________________
Occupation: _______________________________________________
Date of Birth: D D M M Y Y Y Y
Signature of the Assignor : Signature of the Assignee8 :
Endorsement
I/we
(Name of the Assignor) First Name Middle Name Last Name
as the beneficial owner/s of Policy No. issued by Go Digit Life Insurance Limited for the
Sum Assured of have assigned the said Policy to the Assignee mentioned here in below:
Name of the Assignee: (Please where ever is applicable)
Individual:
First Name Middle Name Last Name
Financial Institution/Bank:
Type of Assignment
(Please tick whichevr is applicable)
I/We have absolutely assigned the Policy to the Assignee mentioned hereinabove.
I/We have conditionally assigned the Policy to the Assignee mentioned hereinabove, on the condition that the Policy shall
revert to me/us in the event of: ___________________________________________________________________________________
Consideration:
(Please tick whichver is applicable)
I/We have received as consideration from the Assignee in respect of the aforesaid assignment.
I/We have assigned the Policy out of natural love and affection and I/We have not received any consideration from the Assignee.
Date to __________________________________ , this _____________________________ day of __________________________________
Signature of the Assignor : Signature of the Assignee8 :
Date of Birth: D D M M Y Y Y Y
Vernacular Declaration
DECLARATION* IN CASE THIS ASSIGNMENT FORM IS ALLED BY A PERSON OTHER THAN THE P OLICYHOLDER OR SIGNED IN VERNACULAR LANGUAGE:
Declaration by Policyholder:
I hereby declare that the contents in this form have been fully explained to me and I declare that whatever is stated hereinabove has been recorded as per the information provided
by me.
Thumb Impression/Signature of the Policyholder :
Declaration by person filling the form:
I have explained the contents of this form to the Policyholder in ________________________ language and I have correctly recorded the answer provided to me. I further declare
that the Policyholder has signed/affxed his/her thumb impression in my presence.
Declarant's Name:
First Name Middle Name Last Name
Declarant's Address:
City State Pin Code
Date of Birth: D D M M Y Y Y Y
Declarant's Signature: Date:
*"The person giving this declaration can be any person other than Introducing Advisor or MOA or MOM.•
l/we agree that the Company may provide/transfer/retain any information available with the Company related to me/us, obtained in connection with processing of my proposal
or the policy and servicing thereof to any reinsurers, insurance association, medical registrar, statutory authorities/bodies or services providers engaged by the Company for
policy servicing related activities without any further reference to me/us.
I/we agree that the Company may share my/our information with other insurers for the underwriting and claims settlement purposes.
l/we understand that i/we have an option to review and correct the information already provided or not to provide the data or information sought, also, at any time while
availing the services or otherwise, i/we have an option to withdraw my/our consent for sharing of data given earlier, such withdrawal of the consent should be sent in writing to
the Company. In the case i/we do not provide or later on withdraw my/our consent, the Company shall have the option not to provide me/us the services.
Date: Signature of the Policyholder:
Place: _____________________________
1. All the information is to be filled in BLOCK LETTERS.
2. All fields are mandatory.
3. The term Assignor stands for the current Policyholder, who intends to assign the Policy, whereas the term Assignee stands for the person in whose favour the Policy is to be
assigned.
4. The assignment of a Policy shall automatically cancel any nomination made in the Policy, except for assignment in favour of Go Digit Life Insurance Limited ('the Company') in
which case the rights of the nominee would get affected to the extent of the Company's interest in the Policy.
5. The Company expresses no opinion as to the legality or validity of the assignment.
6. Partial assignment of a Policy is not allowed.
7. This assignment shall not be effectual against the Company unless this Assignment Form is duly completed and delivered, accompanied by the original Policy Bond to the
Company.
8. In case of assignment in favour of a financial institution/bank, the financial institution/bank should affix its stamp and should be countersigned by its authorised signatory.
9. In case where the assignee is a minor, the legal/natural guardian of the minor shall sign on behalf of the minor.
10. Relative shall mean and include only the father, mother, spouse and child/children of the Assignor. In case of assignment in favour of a relative, documentary proof (preferably
ration card) mentioning the relation therein should be produced along with this form.
11. In case of assignment to third party/(ies), other than relatives/banks/financial institutions, the Assignor should submit identification proof, residential proof and income proof of
such third party.
12. The witness should be a person competent to contract.
IRDAI Registration number: 165, CIN: U66000PN2021PLC206995. Registered Name: Go Digit Life Insurance Limited, Registered Address: Ananta One (AR One), Pride Hotel
Lane, Narveer Tanaji Wadi, City Survey No.1579, Shivajinagar, Pune – 411005, Maharashtra, Corporate Office Address: Atlantis, 95, 4th B Cross Road, Koramangala Industrial
Layout, 5th Block, Bengaluru-560095, Karnataka, Help line no.: 9960126126, Website: [Link]/life
"Digit Life Insurance” trademark belongs to Go Digit Life Insurance Limited (“the Company”). “Digit” logo is registered trademark of Go Digit Infoworks Services Private Limited
and is used by the Company under sub-license from Oben Ventures LLP. © Go Digit Life Insurance Limited 2024.
Beware of Spurious/Fraud Phone Calls: IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public receiving such
phone calls are requested to lodge a police complaint.