1. The policyholder is requesting cancellation of their life insurance policy within the freelook period and a refund of premiums paid. 2. The policyholder cites disagreement with the policy's terms and conditions as the reason for cancellation. 3. The form collects the policyholder's details, policy information, bank account information, and signatures for processing the cancellation and refund.

1. Freelook Cancellation Request
Policy No.:___________________________ Date:_____________________________
Dear Sir,
Please cancel my policy under freelook period & refund the amount for the below mentioned reason.
 I do not agree with Terms & Conditions of the Policy
 Others (Please specify): _____________________________________________________________________________
For ULIP Products NAV, Please refer point no 2 of the Terms & Conditions on Page 2
Name of the Policy Holder :__________________________________________________________________________________________
Address:________________________________________________________________________________________________________
City:_______________________________ State __________________________________Pin Code______________________________
Mobile No:_________________________ Land Line __________________Email ID ____________________________________________
Bank Account Details
Policy Holder Name as per Bank Records:______________________________________________________________________________
Bank Name ____________________________________________Branch____________________________________________________
Bank Account No._________________________________________________________________________________________________
IFSC Code ______________________________________________________________________________________________________
* Payment will be credited to the given bank account except in the case where the banks are not participating in Electronic Clearing
_______________________________ _______________
Signature of Policy Holder Date (DD/MM/YY)
Attach Cancelled Cheque Here
Policy holder’s signature to be taken on cancelled cheque. Cancelled cheque should bear the name of the policyholder/account holder's name & IFSC / RTGS /
NEFT Code. In the absence of these details, the applicant needs to submit a recent bank statement of the same Bank Account. The bank a/c number should be
clear & visible (please do not cross on a/c no.). If such details are not available direct transfer would not be an option.
For the official communication of Reliance Life Insurance co ltd only
Reliance Life Insurance Company Limited. (Reg. No. 121)
Registered Office:-H Block, 1st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai, Maharashtra 400710, India
Corporate Office- 9th & 10th Floor, Building No 2, R-Tech Park, Nirlon Compound, Goregaon (East) Mumbai 400063, India.
Phone No- 1800 300 08181/30338181 Email: rlife.customerservice@relianceada.com Website: www.reliancelife.com
Freelook Cancellation Form Version 1.5 Feb ’2011.

2. Terms & Conditions
1. Charges levied & Taxes applicable will be deducted from the premium amount/Fund Value as mentioned in the terms & conditions of the
policy document.
2. In the event of a ULIP policy :
2.1 RLIC shall also be entitled to repurchase the unit at the price of the units on the date of cancellation over & above the charges & taxes
mentioned in point no 1 (above)
2.2 If the request for freelook cancellation is received :
2.1 before 3.00 pm, NAV of date of application shall be applicable.
2.2 after 3.00 pm, NAV of next working day shall be applicable.
3. The Contract shall be terminated upon payment of the refund money and the same shall be treated as valid discharge for Reliance life
Insurance Compnay Limited (RLIC)
4. In any circumstances RLIC shall not pay the refund amount in the form of cash
5. If the electronic credit is not affected, delayed or credited to wrong account due to incorrect or incomplete information provided, RLIC shall
not be held responsible now or in future for such losses.
6. In the event the credit is not affected by your banker for any reason, RLIC reserves the right to make payment through cheque/DD.
7. All the above requisitions shall be processed as per the terms & conditions as mentioned in the policy contract and will be binding.
8. In case of submission of cancelled cheque leaf from NRE A/c, Payment may be credited thru Cheques.
9. In case of Assigned policies, Policy Holder who owns the title & interest of the policy will eligible to apply for the termination of the contract.
I understand & agree to all the above terms & conditions as referred above.
_____________________ ___________
Signature of Policy Holder Date (DD/MM/YY)
**********************************************************************************************************
If Signature is in Vernacular, please complete the following declaration:
I hereby declare that I have fully explained/translated the contents mentioned in the pay out form to (Name of policy owner) and I further
declare that he/she/they fully understood the meaning thereof.
______________________ __________________
Signature of declarant (Declarant should not be an employee/ advisor of RLIC) Date (DD/MM/YY)
Name & Address of
declarant________________________________________________________________________________________________________
I hereby confirm that I have been explained the contents in _____________________________ (Language) and have understood the same.
–––––––––––––––––––––––– __________________
Signature of policy holder Date (DD/MM/YY)
__________________________________________________________________________
FOR BRANCH USE ONLY (Please Tick Off)
 Signature Proof Attached
 Cancelled Cheque Leaf
 Given Account No matches with Account No in the attached Cancelled Cheque/Bank Statement
 Request Time Stamp Affixed
 Check, if Policy is assigned or Not (Yes/No)
 Check, any loan taken from the policy (Only for Traditional Plans) (Yes/No)
…………………………………………………………………(Tear Here)………………………………………………………
Customer Acknowledgement
Policy No.:____________________SR No:_________ ___________ ___ Date:______________________
For the official communication of Reliance Life Insurance co ltd only Name & Sign of CCE Branch Stamp & Date
Reliance Life Company Limited. (Reg. No. 121)
Registered Office:-H Block, 1st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai, Maharashtra 400710, India
Corporate Office- 9th & 10th Floor, Building Insurance No 2, R-Tech Park, Nirlon Compound, Goregaon (East) Mumbai 400063, India.
Freelook Cancellation Form Version 1.5 Feb ’2011.