Contact Details Updation Form

CONTACT DETAILS UPDATION FORM

(The below mentioned details will be updated in our system)

PARTICULARS OF THE POLICY HOLDER

Policy No.

Client Id

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U

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F

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T

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E

M

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D

D

L

E

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Name of the Policyholder

Contact Numbers (with STD codes)

Residence

Mobile

Office

Email:

Pin Code:

Do your bit for a greener world and switch to e-communication. Kindly mark if you would like to receive your communication through electronic mode.

DECLARATION

I understand that by submitting this form I am authorizing Kotak Mahindra Old Mutual Life Insurance Limited (the Company) to send all future communication relating to

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the said policy on the contact details mentioned hereinabove.

I further understand that the Company will be sharing all the information relating to the said policy on the contact details mentioned in this form and I have no objection to the

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same.

I hereby authorize the company to call and/or send any SMS in relation to any transactions or servicing pertaining to the said policy on the contact details mentioned in this

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form and I have no objection to the same.

Note: In order to abide by the Foreign Account Tax Compliance Act (FATCA), kindly submit a Insurance FATCA Declaration, separately, if the answer to any of these questions

is a ‘yes’: (i) Are you a citizen of any other country apart from India (dual or multiple citizenship); (ii) Are you a resident (for tax purposes) of any other country other than India;

(iii) Do you hold a green card of USA or any similar card for any other country?

I/We confirm that I/we shall report any future changes in my/our tax status to Kotak Life Insurance within 30 days of such change. I/We also confirm that until I/we provide a

written intimation about any such changes, Kotak Life Insurance may presume that there is no change in my/our tax residency status and consider my/our earlier submitted

declarations, if any, as valid. I understand that for any queries about my/our tax residency, I/we have to consult my/our own tax consultant.

Signature of Policy Holder/Assignee

Date

D

D

M

M

Y

Y

Y

Y

Place

(Should be the same as that in the proposal form)

DECLARATION BY THE PERSON FILLING IN THE FORM (For forms filled in by a scribe or for forms signed in vernacular languages)

I, ____________________________________ (Full Name of Scribe) have explained to the Proposer, that the answers to the questions form basis of the contract of Insurance between the

Company and the Proposer and that if any untrue statement is contained therein the Company shall have the right to vary the benefits which may be payable and further if there has been any

non-disclosure of material facts the policy may be treated as void and all premiums paid under the policy may be forfeited to the Company.

Address of the Scribe:

Signature/right thumb impression of the policy holder

Date

D

D

M

M

Y

Y

Y

Y

Signature of the Scribe

Signature of the advisor/broker as witness

Place

FOR OFFICE USE

Signature of Branch Official

Date

D

D

M

M

Y

Y

Y

Y

Place

Kotak Mahindra Old Mutual Life Insurance Ltd.

IRDAI Regn. No. 107, CIN: U66030MH2000PLC128503, Regd. Office: Kotak Mahindra Old Mutual Life Insurance Ltd., 2nd Floor, Plot # C-12, G-Block,

BKC, Bandra (E), Mumbai- 400 051.

Insurance is the subject matter of the solicitation.

CC\PS\Contact details CNG\003

ACKNOWLEDGEMENT

We acknowledge the receipt of your request for ________________________________________________ for policy no. _____________________________________.

Date

D

D

M

M

Y

Y

Y

Y

Branch Name

Signature of branch co-ordinator

Name of Branch Co-ordiniator

Kotak Mahindra Old Mutual Life Insurance Ltd.

IRDAI Regn. No. 107, CIN: U66030MH2000PLC128503, Regd. Office: Kotak Mahindra Old Mutual Life Insurance Ltd.,

2nd Floor, Plot # C-12, G-Block,

BKC, Bandra (E), Mumbai- 400 051.

Insurance is the subject matter of the solicitation.

CC\PS\Contact details CNG\003

To register SMS REGL <policy number> <date of birth>to 5676788*

With the Online Policy Manager you can:

Eg: If your policy is 104790 and DOB is 7th April 1970, then type

Now manage

• Get instant access to policy details

REGL 104790 07/04/1970 and send to 5676788, And receive:

• Track policy performance

your policy,

• Switch your monies between various funds

• Transaction notifications

at the click

• Change policy details

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• Premium payment reminders

• Make online payments

of a button!

• Acknowledgments of your requests

FOR THE NEW

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• Value Added Services: you can request for important information

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Message

such as NAV details, whenever you require

It’s fast. It’s free. It’s convenient!

Service

Write to us at :

1800 209 8800 (toll free)

Fax: 022 - 66200550

Customer Care, Kotak Mahindra Old Mutual Life Insurance Limited,

Building No. 21, Infinity Park, Off Western Express Highway, Goregaon

Mulund Link Road Malad (E), Mumbai – 400 097.