Fill in Nominee Change Declaration

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Nominee Change Declaration

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You, the Policyholder
The policy and the earlier nomination
The new nomination
Signing the declaration

Step 1 of 4

You, the Policyholder

Your full name (the Policyholder)Needed

For example: Simran Kaur Bajwa

Your parentage or spouse descriptionNeeded

For example: daughter of Sardar Baldev Singh Bajwa

Your age in yearsNeeded

A plain number. Digits only — no words and no units beside them.

For example: 39

Your full residential addressNeeded

House / flat / plot no.

Street, sector or locality

City area and PIN code

More details — you may leave these

Your occupationYou may leave this

For example: Service

Your ID referenceYou may leave this

For example: PAN AFZPB6543M

Name of every joint Policyholder joining in this declarationYou may leave this

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DECLARATION FOR CHANGE OF NOMINATION UNDER AN INSURANCE POLICY

I, __________, __________, aged about __________ years, resident of __________, being the holder of the Policy described below, do solemnly declare and affirm as follows.

1. THE POLICY

2. THE EXISTING NOMINATION

3. REASON FOR THIS CHANGE

4. THE NEW NOMINATION

4.1 Under section 39 of the Insurance Act, 1938, I nominate the following person or persons to receive the money secured by the Policy in the event of my death, cancelling every nomination I have previously made on the Policy:

6. WHEN THIS CHANGE TAKES EFFECT

7. REQUEST

8. UNDERTAKING

VERIFICATION

JURAT (where this declaration is sworn or affirmed)

_______________________________
NOTARY PUBLIC / OATH COMMISSIONER (only where this declaration is sworn)
(Signature, seal, registration number, and serial number in the notarial register, if applicable)

This notice is given under the Digital Personal Data Protection Act, 2023.

Personal data in this document is collected only to record and communicate the stated change of nomination, identify the Policyholder and every nominee named, verify the facts stated in this declaration, and retain an evidentiary record of the change.

If the change is not registered, personal data will be retained for 90 days and then erased. If it is registered, the record will be retained for the term of the Policy plus 12 months, except where a named statutory or regulatory record-retention period requires longer retention.

Data minimisation: this document does not collect a full Aadhaar number, an Aadhaar-card copy, a password, or bank credentials, and none should be written into it. Use masked account or identity references where an identifying reference is genuinely necessary.

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