NACH / ECS / AUTO DEBIT MANDATE INSTRUCTION FORM
F O R
UMRN
O F F I C E
I/We hereby authorise
)
Max Life Insurance Co. Ltd.
D D M M Y Y Y Y
Date
Utility Code
U T I B 0 0 2 9 1 0 0 0 0 1 2 4 8 4
to debit (tick )
SB CA CC SB-NRE SB-NRO other
Bank A/C Number
CREATE
MODIFY
With Bank
CANCEL
an amount of Rupees
FREQUENCY
Name of customer bank
Monthly
Reference 1
IFSC
or MICR
`
Quarterly
Half Yearly
Yearly
As & when presented
Policy Number
Reference 2
Period
From
D D M M Y Y Y Y
To
X X X X X X X X
Until Cancelled
or
O N L Y
U T I B 0 0 0 0 2 4 8
Sponsor Bank Code
Tick (
U S E
DEBIT TYPE:
Fixed Amount
Maximum Amount
Phone No.
I
E-mail ID
Signature
Name
1 Primary Account Holder
2 Joint Account Holder 1
3 Joint Account Holder 2
This is to confirm that the declaration has been carefully read, understood and made by me/us
Policy Number
Account Number
First Name
Middle Name
Last Name
Account Holder Name
9 Digit MICR Code
Refer - 9 digit code as appearing on the cheque copy issued by bank & if it starts from "000" please obtain correct code from bank branch
Bank Name ______________________________________________________________________________________
Branch Address ___________________________________________________________________________________
Account Type
Tick ( ) any one
Savings A/C
Current A/C
Cash Credit A/C
Joint A/C
In case of Current Account affix Proprietor Firm/Company Stamp on Mandate
Relationship of Account Holder with life insured
In case of Joint Account Tick ( ) any one
Document attached
Cancel Cheque
Self
Spouse
Jointly Owned
Bank Passbook
Parent/Child
Either or Survivor
Bank Statement
Finacle Copy
Proprietor Stamp
Mandatory
Mandatory
Mandatory
Proprietorship stamp require
if Current Account
Signature of Policyholder
(As on policy application)
Signature of Account Holder
(As per bank records)
Signature of Joint Account Holder
(As per bank records)
Bank's Stamp
Date
Signature of Bank authorised signatory
D D M M Y Y Y Y
Signature of Authorised Official from the bank
Note:- ECS will be debited from your account within 4 days from due date, unless a specific draw date is opted.
Specific draw date options are : Draw Dates:
4th
8th
Applicable for monthly mode only if difference between due date & selected draw date is less than 15 days.
Declaration by Policy Owner
I/We clarify that the particulars furnished herein are correct and complete and to the best of my knowledge.
This is to inform that I/we have registered for RBIs Electronic Clearing Service/NACH/Direct Debit Instruction for premium payment to Max Life Insurance, to be made from my/our
above mentioned bank account with your bank. Also I/we understand that the above instruction can be withdrawn/cancelled after due intimation by giving an advance notice of 15 days
and with the consent of Max Life insurance Co. Ltd. for the payment of due premiums. I/We will ensure sufficient balance in the funding account on the date of execution. In case,
NACH/ECS/Direct Debit instruction is unsuccessful due to financial reasons, the NACH/ECS/Direct Debit instruction will be presented again for clearance. I/We will bear the bounce
charges for transactions that have been unsuccessful due to financial reasons. I/We agree in case NACH/ECS/DD facility is withdrawn by the Company any time, subsequent due
premiums would be paid through other modes as stipulated by the Company. In case of subsequent bounce with financial reasons, your policy premium payment method will be
changed to cheque/cash. ECS would not apply for all such plans where the premium amount/top-up would increase as per the feature. ECS registration is subject to policy issuance.
June 2015/Version 1.8
