PSNF048123062340 | Comp/Jun/Int/5288
Name Declaration & Date: DD/MM/YYYY Time:
Branch :_____________________
Specimen signature form Received at branch on:________________ Received by:__________________
Personal Details
Name of Policyholder/s:___________________________________________________________________________________________________________
Policy No.:___________________________________ Client ID:________________________________________
<Name of the Policyholder>
I hereby declare that ____________________________________________________________________________________________________
and _________________________________________________________________________________________ are names of one and the same
person. I hereby agree to indemnify, defend and hold harmless HDFC Life and its agents, employees or directors against any claim, loss, damage, costs,
charges and expenses that HDFC Life incurs or may incur due to the declaration made by me herein.
Note: For any major name mismatch (addition / change of middle name correction of name leading to different pronunciation), please fill and submit change in name form.
I, _________________________________________________________ hereby declare that my specimen signatures in short, full, vernacular
language and in all different styles are as mentioned below.
I hereby agree to indemnify, defend and hold harmless HDFC Life and its agents, employees or directors against any claim, loss, damage, costs, charges
and expenses that HDFC Life incurs or may incur due to reliance on the specimen signatures provided by me below.
SIGN HERE SIGN HERE SIGN HERE
DD/MM/YYYY
Date:_________________
Place:_________________
Specimen 1 Specimen 2 Specimen 3
In case the policy is
DD/MM/YYYY
Date: ____________ SIGN HERE assigned, please provide DD/MM/YYYY SIGN HERE
Date: ____________
signature of the Assignee
with seal Place: ___________
Place: ___________
Signature of Policyholder (wherever applicable): Signature of Assignee
Third Party Declaration
this application form has been explained to him/ her and I have truthfully recorded the answers provided to me. I further declare that the said person has
SIGN HERE
DD/MM/YYYY
Date:_________________
Declarant Name & Address: _________________________________________________
_______________________________________________________________________ Place:_________________ Signature of the Third Person
HDFC Life Insurance Company Limited (HDFC Life). CIN: L65110MH2000PLC128245.
Regd. Off:
Customer Acknowledgement Copy (Name Declaration & Specimen signature form)
Policy No.: Interaction ID: _____________ Received by: _________________________
DD/MM/YYYY HDFC Life Stamp
For queries or more information, call us on 022-68446530 (Call charges apply).
Email – service@[Link] | nriservice@[Link] (For NRI customers only) Visit – [Link]
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