#### Life Insurance Act 1995 | Date of transfer | Signature of transferor | Signature of transferor’s witness | Full name of transferee | Address of transferee | Occupationof transferee | Signatureof transferee | Signatureof witness of transferee | Date of transfer of registration by the life company | Signature of principal executive (or authorised person) of the life company | | ---------------- | ----------------------- | --------------------------------- | ----------------------- | --------------------- | ----------------------- | ---------------------- | --------------------------------- | ---------------------------------------------------- | --------------------------------------------------------------------------- |

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