We are in receipt of your request for Surrender of the above mentioned policy. The surrender quotation is given

below. The Surrender value mentioned below is as on the date and may vary depending on the date of processing of

the Surrender application.

Surrender Request Reg.

Dear Sir / Madam,

Ref: Policy No: LN130900001582 on the life of Mr/Mrs/Ms Mr.RAEES AHMAD

UTTAR PRADESH

BIJNOR

MOH MIRDGAN

RAEES AHMAD S O MR ABDUL AZIZ

Mr.RAEES AHMAD

To,

Quotation for Surrender Request - ULIP Policies

Date: 24/04/2014

Plan: SHRI PLUS

Quotation:

Fund

No of Units Fund ValueNAV(23/02/2012)

16.5504 231.4675 ` 3830.88Maximus -

ULIF00301/07/06MAXIMUSFND128

Fund Value = No: of Units in the Fund A/c x N.A.V as on the date of surrender

quotation = ` 3,830.88 /-

Basic Surrender Charges @25.00% on Base Fund Value

O/S Policy Deposit

[AUTHORISED SIGNATORY]

Yours Sincerely,

Net Amount of Surrender Value Payable

Total deductions

Other deductions

Less :

Basic Fund Value

` 957.72

` 0

` 957.72

` 0.00

` 2,873.16

Top Up Amount Not Underwritten 0.00

TopUp Fund Value

TopUp Surrender Charges

0.00

` 0.00

3,830.88

SURRENDER DISCHARGE FORM

Policy No: LN130900001582 on the life of Mr/Mrs/Ms Mr.RAEES AHMAD

I/We, Mr.RAEES AHMAD

the Proposer / Life Assured / Assignee(s) do hereby acknowledge receipt of a sum of RUPEES TWO THOUSAND

EIGHT HUNDRED SEVENTY-THREE AND SIXTEEN PAISE ONLY (in words) ` 2,873.16 (approx) in full

satisfaction of all my claims and demand in respect of surrender value against the above mentioned policy.

Note: The Surrender value as mentioned above may vary depending on the date of request, monthly processing

charges till the date of processing the application, N.A.V as on date of acceptance or approval of a surrender request

etc.

Declaration :

I/We hereby declare that I/We have not served on any office of the Shriram Life Insurance Co. Ltd., any

notice of assignment/reassignment in respect of the above policy except those if any, already registered with Shriram

Life Insurance Co. Ltd., nor shall I/We serve on any office of the said company any notice of assignment or

reassignment before payment of the surrender.

Present address to which cheque is to be sent: Payee details to issue Account Payee cheque:t t

Bank A/c No:

Name of the Bank:

Dated at this day of 20

Signature of Policyholder / Assignee(s) in English (or) Vernacular Language:

Please affix

` 1 Revenue

Stamp and sign

across the

1. .

2. .

W In the presence of WITNESS: Signature .

I Full Name

T Address

N

E

SS

« If the application is signed in a vernacular language and with the help of a scribe, then please fill & sign the following:

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

I having known the policyholder for a period

of (Yrs / Months) do declare that "I have explained the nature of contents of this form to the policyholder, which forms the basis for

accepting this request to surrender his/her policy".

Signature of Scribe (for forms signed in vernacular language) .

« In case if the policy is conditionally assigned, then the policy holder as well as the assignee(s) should sign the Discharge Form.

«

24/04/2014Date: