MetLife India Insurance Company Limited. (Insurance Regulatory and Development Authority Life Insurance Registration No.

117) Registered Office: Brigade Seshamahal, 5, Vani Vilas Road, Basavanagudi, Bangalore - 560 004, www.metlife.co.in, Fax: +91-80-4150 6969

DualSignature/ChangeinSignatureRequestForm
PolicyNumber NameofthePolicyOwner F I R S T N A M E M I D D L E N A M E S U R N A M E Date D D M M Y Y Y Y

Mobileno.:________________________

EmailID:___________________________________

Pleasetick(asapplicable) DualSignature/ChangeinSignaturefor
Declaration:

Dual Signature Proposed /Policy Owner

Change in Signature Proposed/Person Insured

I ______________________ hereby declare that both the signatures as appearing below are my signatures. I furtherdeclarethateitherofthesignaturesisvalid.
DD/MM/YYYY For Dual Signature : Specimen Signature 1 Signature of PI/PO For Dual Signature : Specimen Signature 2

or
For Change in Signature: Current Signatures as appearing in MetLife Records

or
For Change in Signature: Signatures to be updated in MetLife Records

SiGN SIGN SIGN

SIGN SIGN SIGN

I hereby confirm having read and understood all the policy terms and conditions including those applicable to this request. I understand and acceptthatmyrequestshallbeprocessedinaccordancewiththetermsandconditionsofthepolicyandthatIshallbesolelyresponsibleforall theconsequencesarisingoutofthisrequestincludinganyincorrectorincompleteinformationcontainedherein.

SignatureVerification: Option 1:
I have attached the self attested copy of one of the documents which has my new signatures.

Passport

Driving License

Pan Card

Option 2: The signatures are attested by a Bank

Attestation by Bank : Bank Name : Bank Signature and Stamp

Bank Address :

Date :

Customer Service Toll free: 1800-425-6969, OR Call on: +91 -80 -2650 -2244 (8:00 am to 8:00 pm) Mail us at indiaservice@metlife.com

Version 2.1

MetLife India Insurance Company Limited. (Insurance Regulatory and Development Authority Life Insurance Registration No. 117) Registered Office: Brigade Seshamahal, 5, Vani Vilas Road, Basavanagudi, Bangalore - 560 004, www.metlife.co.in, Fax: +91-80-4150 6969

Option 3: The signatures are attested by a Gazetted Officer

Attestation by Gazetted Officer*: Name : Gazetted Officer Signature and Stamp

Address : Date: * Please refer to the Gazetted Officer listing for details

Customer Service Toll free: 1800-425-6969, OR Call on: +91 -80 -2650 -2244 (8:00 am to 8:00 pm) Mail us at indiaservice@metlife.com Version 2.1

MetLife India Insurance Company Limited. (Insurance Regulatory and Development Authority Life Insurance Registration No. 117) Registered Office: Brigade Seshamahal, 5, Vani Vilas Road, Basavanagudi, Bangalore - 560 004, www.metlife.co.in, Fax: +91-80-4150 6969

Acknowledgement Slip

Received a request for ______________________________ against Policy Number _______ __________________________ On _________________ at ____________________ am/pm Received By: Employee Name __________________ Employee Code ___________________ Date and time Stamp / Seal of Branch

Customer Service Toll free: 1800-425-6969, OR Call on: +91 -80 -2650 -2244 (8:00 am to 8:00 pm) Mail us at indiaservice@metlife.com

Version 2.1