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PLI/RPLI Nomination Change Form

This document is a request form for registration or change of nomination for a PLI/RPLI insurance policy. It collects information such as the name, occupation, and contact details of the insured, policy details including the number, type, sum assured and premium ceasing age. It also collects details of up to three nominees including their name, relationship, share percentage, contact details, and details of an appointee if any nominee is a minor.

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Geethanjali Rajanala
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8K views2 pages

PLI/RPLI Nomination Change Form

This document is a request form for registration or change of nomination for a PLI/RPLI insurance policy. It collects information such as the name, occupation, and contact details of the insured, policy details including the number, type, sum assured and premium ceasing age. It also collects details of up to three nominees including their name, relationship, share percentage, contact details, and details of an appointee if any nominee is a minor.

Uploaded by

Geethanjali Rajanala
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Insured Person Details
  • First Nominee Details
  • Additional Nominee Details

Request for Registration/ Change of Nomination in respect of PLI/ RPLI Policy

(refer Section 39 of Insurance act 1938) (Not applicable in case of policy under MWPA 1874)
(Please fill in the columns in CAPITAL letters)

1. Name of Insurant (Mr./ Mrs./ Ms.)


First Name Middle Name Last Name

2. Occupation

3. Communication Address

Village Taluka
City District
State Country PIN

4. Particulars of Policy:
i. Policy No. ii. Policy Type

iii. Sum Assured iv. Date of Acceptance v. Premium Ceasing Age


` / - / / Years

5. a. State particulars of the nominees (not more than three Nominees)


i. Sole/ First Nominee Details- (Mr./ Mrs./ Ms.)
First Name Middle Name Last Name

Relationship: Share %age: % Gender: M F

Date of Birth: / / Age: Years

Communication Address

Village Taluka
City District
State Country PIN

Phone No. E-mail ID (If any)

ii. Second First Nominee Details- (Mr./ Mrs./ Ms.)


First Name Middle Name Last Name

Relationship: Share %age: % Gender: M F

Date of Birth: / / Age: Years

Communication Address

Village Taluka
City District
State Country PIN

Phone No. E-mail ID (If any)


iii. Third Nominee Details- (Mr./ Mrs./ Ms.)
First Name Middle Name Last Name

Relationship: Share %age: % Gender: M F

Date of Birth: / / Age: Years

Communication Address

Village Taluka
City District
State Country PIN

Phone No. E-mail ID (If any)

b. Appointee Details (If nominee is minor)


First Name Middle Name Last Name

Relationship: Gender: M F

Date of Birth: / / Age: Years

Communication Address

Village Taluka
City District
State Country PIN

Phone No. E-mail ID (If any)

Date:________________
Signature of Insurant
Name:………………………
Phone no.: …………………
Office:………………………
Residence: …………………
Mobile no.: …………………

Signature of Witness 1:
Name:…………………………….
Phone no.:……………………….
Office:……………………………
Residence: ……………………..
Mobile no.:………………………

Signature of Witness 2:
Name:…………………………….
Phone no.:……………………….
Office:……………………………
Residence: ……………………..
Mobile no.:………………………

Request for Registration/ Change of Nomination in respect of PLI/ RPLI Policy (refer Section 39 of Insurance act 1938) (Not
iii. Third Nominee Details- (Mr./ Mrs./ Ms.) First Name Middle Name Last Name

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