Surrender Request Form - Super Suraksha / Dhanaraksha / RinnRaksha Date: ____________ SBI Life Insurance Company Ltd, Branch _____________________. Dear Sir / Madam, Re: Foreclosure / Surrender of Loan account no. ______________________ under Dhanaraksha /Super Suraksha/ Rinn Raksha Policy (Tick any One). I have foreclosed the loan as on __________ (loan closure date) and the captioned loan account is closed as on date. I request you to foreclose / surrender the policy & refund the surrender amount as per terms and conditions of the products at the earliest. Thanks & Regards, __________________________________________ Name of the member(s): Date: Place: Recommendation from banker The loan account no. ______________ (New No.) /________________(Old No.) was covered under Dhanaraksha SP / Dhanaraksha LPPT /Super Suraksha/ Rinn Raksha. The loan account has been foreclosed on____________. The original Certificate of Insurance is enclosed herewith / not received (Tick any one). We have no objection in the member surrendering the policy. Bank seal: Name of branch manager:_______________________ Name of the bank branch:_______________________ Branch code: _________________________________ Date:___________ PS‐43 / Ver 2.0 / 25.09.2014 Page 1 Of 2 Copy of PAN Card PAN * Residential Status : Resident NRI ^ Contry of Residence___________________ Instructions : 1) TDS at 2% is deductible on payments which are not exempt under Sec. 10(10D) of IT Act 1961, 2) *TDS rate shall be 20% if PAN is not provided 3) ^ TDS rate shall be 30.9% for NRIs for payment upto Rs. 1 Cr and 33.99% for payments above Rs. 1 Cr. BANK SEAL Signature of Branch Manager Signature of member(s) Signature of Member(s) Signature of branch manager SBI Life Insurance Company Limited. Reg. & Corp Office: "Natraj", M.V Road & Western Express Highway Junction, Andheri (East), Mumbai 400069. IRDA Regn. No. 111 Tel No. (022) 61910000 Central Processing Center: Kapas Bhavan, Plot No.3A, Sector No.10, CBD Belapur, Navi Mumbai 400614