{"id":1913,"title":"POLICY LOAN REPAYMENT FORM","purpose":"service","insurer":{"slug":"star-union-dai-ichi-life-insurance","name":"Star Union Dai-Ichi Life Insurance Company Limited"},"source_pdf":"https://dxwkpt4djlxwl.cloudfront.net/Policy_Loan_Repayment_Form_c2c2916918_1d845b9e64.pdf","sha256":"80d45532b708e2c07f025f4dd096b2b5f6c9312b3dfeadf46467bc05d4d78c20","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by the policyholder to repay a loan taken against their insurance policy, either partially or fully.","notes":["Loan repayment through Credit Card is not allowed.","In case of policy surrender, maturity or death claim, outstanding loan and interest will be deducted from policy moneys.","Reassignment documents must be submitted after full loan repayment to get the policy reassigned.","Use original documents and self-attested PAN where required.","The acknowledgment slip is filled by the office staff."],"title":"POLICY LOAN REPAYMENT FORM","submit":{"to":"","how":"","address":""},"purpose":"service","sections":[{"title":"Policy Details","fields":[{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"PAN No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Policyholder:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Assignee:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Life Assured is a Minor Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Are you resident of jurisdiction outside India? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Are you tax resident of jurisdiction outside India? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If any answer above is Yes or country is other than India, submit FATCA/CRS self certification","type":"text","label":"Country of residence/ tax residence","options":[],"required":null,"pdf_field":""},{"help":"Specify amount for part or full repayment","type":"choice","label":"I, Policyholder of the above mentioned policy, have availed a loan under the above mentioned Policy No. and would like to make a:","options":["Part repayment of Rs.","Full repayment of the outstanding loan Rs."],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Payment Details","fields":[{"help":"Provide cheque number or transaction ID","type":"text","label":"Cheque No. / Transaction ID No. (If payment is done through EFT / NEFT):","options":[],"required":null,"pdf_field":""},{"help":"Enter the repayment amount in rupees","type":"amount","label":"Amount (Rs.):","options":[],"required":null,"pdf_field":""},{"help":"Name of the bank from which payment is made","type":"text","label":"Bank Name:","options":[],"required":null,"pdf_field":""},{"help":"Branch of the bank","type":"text","label":"Bank Branch Name:","options":[],"required":null,"pdf_field":""},{"help":"Bank account number used for payment","type":"text","label":"Bank Account No.:","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Acknowledgment Slip","fields":[{"help":"","type":"text","label":"Policyholder/Assignee's Name:","options":[],"required":null,"pdf_field":""},{"help":"Name of the staff acknowledging","type":"text","label":"SUD Life Sta Name:","options":[],"required":null,"pdf_field":""},{"help":"Signature and stamp of staff","type":"signature","label":"Signature & Stamp:","options":[],"required":null,"pdf_field":""}],"filled_by":"office staff"},{"title":"FATCA/CRS Declaration","fields":[{"help":"Enter full name","type":"text","label":"I,Mr./Ms./Dr.","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Policy Holder","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Third Party Declaration","fields":[{"help":"Name of declarant","type":"text","label":"I Mr./Ms./Dr.","options":[],"required":null,"pdf_field":""},{"help":"Declarant's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Duration known to policyholder","type":"text","label":"having known the policyholder for a period of (month/years);","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Declarant","options":[],"required":null,"pdf_field":""},{"help":"Declarant's occupation","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Declarant's PAN number","type":"text","label":"PAN No.","options":[],"required":null,"pdf_field":""}],"filled_by":"third party"}],"deadlines":["Submit a new FATCA/CRS form within 30 days if any information changes"],"applies_to":"","attachments":["Loan Repayment Form","Policy Re-Assignment form (if full repayment)","Self-attested PAN","FATCA/CRS self certification (if applicable)"],"declarations":["The policyholder confirms the residency and tax residency information is true and correct.","The policyholder accepts the FATCA & CRS Terms and Conditions.","The policyholder agrees to provide updated information if any changes occur.","The policyholder understands the company does not provide tax advice on CRS/FATCA.","The policyholder authorizes sharing of information with regulators and intermediaries as required.","The third party declares having explained the form contents to the policyholder and witnessed the signature/thumb impression."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/star-union-dai-ichi-life-insurance/1913-policy-loan-repayment-form"}