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    Primary Account Holder Joint Account Holder 1 Joint Account Holder 2

    Uploaded by

    Varun Nagpal
    This document is an NACH/ECS/Auto Debit Mandate form authorizing Max Life Insurance Co. Ltd. to debit premium payments directly from a bank account. It provides details for setting up the direct debit including the bank account number, debit type and frequency. The policy owner declares that the information provided is correct and understands that the ECS instruction can be withdrawn with 15 days advance notice to the insurance company.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Primary Account Holder Joint Account Holder 1 Joint Account Holder 2

    Uploaded by

    Varun Nagpal
    247 views1 page
    This document is an NACH/ECS/Auto Debit Mandate form authorizing Max Life Insurance Co. Ltd. to debit premium payments directly from a bank account. It provides details for setting up the direct debit including the bank account number, debit type and frequency. The policy owner declares that the information provided is correct and understands that the ECS instruction can be withdrawn with 15 days advance notice to the insurance company.

    Original Description:

    ecs mandate form max life insurance

    Original Title

    Manadate Form

    Copyright

    © © All Rights Reserved

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    This document is an NACH/ECS/Auto Debit Mandate form authorizing Max Life Insurance Co. Ltd. to debit premium payments directly from a bank account. It provides details for setting up the direct debit including the bank account number, debit type and frequency. The policy owner declares that the information provided is correct and understands that the ECS instruction can be withdrawn with 15 days advance notice to the insurance company.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    247 views1 page

    Primary Account Holder Joint Account Holder 1 Joint Account Holder 2

    Uploaded by

    Varun Nagpal
    This document is an NACH/ECS/Auto Debit Mandate form authorizing Max Life Insurance Co. Ltd. to debit premium payments directly from a bank account. It provides details for setting up the direct debit including the bank account number, debit type and frequency. The policy owner declares that the information provided is correct and understands that the ECS instruction can be withdrawn with 15 days advance notice to the insurance company.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    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

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