Policy Number: 0645617890

1633_1633ASF_0645617890

Assignment Form and Notice of Assignment

(As an endorsement on Policy)
Instructions For Filling Up The Form
1. Please answer all questions. 2. Please tick the box where appropriate. 3. Please strike out parts which are not
applicable and write 'N.A.'. 4. Strokes of the pen, dots and dashes will not be accepted as replies. 5. This form is to be
filled by the proposer himself/herself in BLOCK LETTERS in black or blue ink. 6. The proposer must sign any cancellation
or alteration. 7. Insurance is a contract of utmost good faith, which requires the Insurer, proposer and life to be insured
to disclose all material facts. In case of any doubt as to whether a fact is material or not, the fact should be disclosed. As
the statements in this proposal constitute warranties, complete and accurate information must be given. 8. The
proposer must sign on each page. 9. KYC documents of Policy Holder and witness will be required.
DOCUMENTS REQUIRED:
1. KYC documents of Assignor, Assignee, Witness & Declarant (in case of Vernacular and/or Thumb Impression).
2. Policy Bond
3. Declaration form signed by Assignee (DECLARATION UNDER INCOME-TAX (11TH AMENDMENT) RULES, 2015, in
case of assigning a policy to an individual)
INSTRUCTIONS:
Please read the Instructions/Notices mentioned here under before filling up this form. All fields are compulsory:
1. The term Assignor stands for the current policyholder who intends to assign the policy whereas the term Assignee
stands for person/institution in whose favor the policy is to be assigned.
2. The assignment shall cancel any nomination made in the policy, subject to section 39 (4) of the Insurance Act,
1938. Nomination, which has been cancelled consequent upon the assignment, the same shall stand automatically
revived when the policy is reassigned in favor of the Policy Holder.
3. Company expresses no opinions as to legality or validity of assignment
4. The notice in writing of the assignment and the said assignment form is to be duly signed by the Assignor and
Assignee.
5. 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 and the Company has accepted assignment and
intimated the same.
6. In case of assignment in favor of Financial Institution/Bank, the Financial Institution/Bank should send request
letter with seal and signature of the authorized signatory on its letter head.
7. In case where the Assignee is a minor, the Natural/Legal Guardian of the minor shall sign on behalf of the minor. In
such cases, KYC of the Natural / Legal Guardian appointee is to be submitted.
8. Relative shall mean Father, Mother, Brother, Sister, Spouse, Son, Daughter, Grandmother and Grandfather. In case
assignment is in favor of relatives, documentary proof (preferably Ration Card) mentioning the relation therein
should be produced along with this form.
9. Witness and Declarant should be different persons and competent to contract as per the provisions of Indian
Contract Act, 1872.
10. Unless specifically mentioned all assignments shall be deemed to be absolute.
11. In case, the policy is assigned to a person other than Relative or Bank/Financial Institution, Assignor shall mention
value of consideration received and provide the proof thereof for assignment of policy.
12. Assignment to/by all corporate entities would require authorization letter from authorized representatives on its
letter head. This would constitute all Institutions / Societies other than the Nationalized Banks.

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 Details of Assignor

a) Policy Number: __________________________________________________ Date: _____________________

b) Life Assured’s Name: ________________________________________________________________________

c) Policy Holder’s Name: _______________________________________________________________________

d) Mobile:_______________________ e) Alternate No: _________________ f) Email: _____________________

g) PAN: _________________________________ h) Aadhaar: ________________________________________

__________________________________ ____________________________________
Signature / Thumb impression of Assignor Signature / Thumb impression of Assignee

Notice of Assignment
I_________________________________________________________________ (Name of Assignor) have read
and understood the Instructions/Notices here in above and I hereby give you notice that I have Assigned policy
no.____________________________________ to _________________________________________________
(Name of Assignee)

Status of Assignee: Bank/Financial Institution__ / Non-Profit Organization __/ Relative of Assignor __/ others ___/
Consideration________.

Relationship with the Assignor_________________________Reason for Assignment________________________

Details of Legal guardian (to be filled if assignee is minor)

Name of Legal Guardian ___________________Date of Birth _________ Gender: Male_______ /Female_________

Relationship with Assignee____________ Address of Legal Guardian _____________________________________

Contact No. (Mobile no.)________________Contact No. (Tel no.)______________ Email_____________________

KYC of Assignee / Legal Guardian

Identity Proof____________________ Address Proof ____________________Proof of Payment_______________

PAN_________________

Documents Submitted:

PAN card copy_______________ Form 60____________ Aadhaar Number ______________________

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___________________________________ ________________________________________________
Thumb Impression/Signature of Assignor Thumb Impression/Signature of Assignee/ or Legal Guardian

Recent Passport size

Recent Passport size
Photograph of
Photograph of
Assignee/ Legal
Assignee (minor)
Guardian

Form of Assignment
I_____________________________________________________________ (Name of Assignor) as the holder of
the policy/ beneficial owner/s of the policy no.________________________________ issued by Bajaj Life
Insurance Limited for Sum Assured of ` ______________________________ have assigned the said
policy to ___________________________________________________________ (Name of Assignee) and confirm
the following.

(Please tick on the appropriate selection)

Assignor Assignee Either
Future Premium will be paid by Assignor Assignee Both
Future Communication to be sent to

In case of Partial Assignments

Assignor Assignee Either
Policy Amendment will be done by Assignor Assignee Both
Fund Switching and apportionment will be done by
Original Policy Bond will be held by Assignor Assignee

Type of Assignment (Please tick whichever is applicable)

I ________________________________________________________________________________ the
original Policy Holder of the aforementioned policy have absolutely assigned the policy to the Assignee
mentioned herein above.
I _____________________________________________________________________________, the original
Policy Holder of the aforementioned policy have conditionally assigned the policy to the Assignee mentioned
herein above, on the condition that policy will revert to me in the event of
________________________________________________________________________________________
_____________________________________________________________________________
(On occurrence of the event, necessary proofs to be submitted whenever required for reverting policy to the
Assignor.)
I_____________________________________________________________________________, the original
Policy Holder of the aforementioned policy have partially assigned the policy to the Assignee mentioned in
above, for a sum of ` ______ /_______% of benefits secured under the policy.

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 Consideration (Please tick whichever is applicable)

I hereby confirm that I have received sum of ` ______________________________________________________

(Rupees___________________________________________________________________________________)
as consideration from Assignee for the aforesaid assignment.

Or

I hereby confirm that, I have assigned the policy “out of love and affection” and have not received consideration from
the Assignee.
Disclaimer:

Application for request of assignment can be rejected on specific grounds and rejection letter will be sent to the
Policy Holder. Policy Holder can approach within 30 days to IRDAI in case not satisfied with the decision.

Place____________________ Place____________________

Date_______________ Date_______________

Thumb Impression/ Thumb Impression/

Signature of Assignee Signature of Assignor

Witness Particulars
Name of Witness_____________________________________________________________________________

Address____________________________________________________________________________________

Contact No. (Mobile no.) ______________________Place _____________________Date___________________

Aadhaar Number_______________________

Signature of Witness

Declaration
Declaration In Case:
i) If this Application Form is filled by a person other than the Policy Holder or Assignor or Assignee Or/And ii) If Policy
Holder or Assignor or Assignee has either put thumb impression or signed in regional/local language.
I have explained the contents of this form to the Assignor in __________________________ language and I have
correctly recorded the answers provided to me. I further, declare that the Assignor has signed/affixed his / her thumb
impression in my presence.
Declarant_____________________________________________________________________________________

Address______________________________________________________________________________________

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Contact No. (Mob) _______________________________Place ____________________Date________________

Aadhaar Number ___________________________ PAN ___________________________________

Signature of Declarant
(Declarant should sign in English Language only)

Declaration by Assignor/Assignee

I hereby declare that the content and purport of this form have been fully explained to_____________________
(Name of person filling the form) in the language understood by me and I declare that whatever has been stated
hereinabove has been recorded by ____________________________________________ (Name of person filling
the form) as per information provided by me.

Signature of Assignor

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Bajaj Life Insurance Ltd. Regd. Office Address: G.E Plaza, Airport Road, Yerawada, Pune - 411006 | [Link]. 116.| Mail us: customercare@[Link] | Call on:
02067121212 | Fax: (020) 6602 6789 | CIN: U66010PN2001PLC015959. The Logo of Bajaj Life Insurance Ltd. is provided on the basis of license given by Bajaj Finserv Ltd.
to use its “Bajaj” Logo.

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