NACH / ECS / AUTO DEBIT MANDATE INSTRUCTION FORM
UMRN Date
Sponsor Bank Code U T I B 0 0 0 0 2 4 8 Utility Code U T I B 0 0 2 9 1 0 0 0 0 1 2 4 8 4
I/We hereby authorise Max Life Ins urance Co. Ltd. to debit (tick ) SB CA CC SB-NRE SB-NRO other
Tick ( )
Bank A/C Number
CREATE
MODIFY With Bank IFSC MICR
CANCEL an amount of Rupees `
FREQUENCY Monthly Quarterly Half Yearly Yearly As & when presented DEBIT TYPE: Fixed Amount Maximum Amount
Reference 1 Phone No. Maximum period of validity
D O N O T F I L L of this mandate is 40 years
Reference 2 E-mail ID
only.
“I agree for the debit of mandate processing charges by the bank whom I am authorizing to debit my account as per latest schedule of charges of the bank.”
understood & made by me/us. I am authorizing the user entity/Corporate to debit my account, based on the instructions as agreed and signed by me.I
have understood that I am authorized to cancel/amend this mandate by appropriately communicating the cancellation/amendment request to the User entity/corporate or the bank where I have authorized the debit.
Period
Signature
From Signature of Primary Account Holder Signature of Account Holder Signature of Account Holder
To
Name 1. 2. 3.
Maximum period of validity of this mandate is 40 years only.
Name As per Bank Records Name As per Bank Records Name As per Bank Records
Note:-In addition to policy premium, customer is advised to add 10% in the mandate amount to keep provision for future increase in statutory
tax. Mandate should not be older than 120 days ie 4 months.
Yes, I have attached blank cancelled cheque leaf with pre-printed name.
The premium will be debited on due date or within next 4 days. However, the customer who opted for monthly mode payment can opt for 4th or 8th as draw date
if it falls within 15 days of the due date.
Relationship ofAccount Holder with life insured Self Spouse Parent/Child
In case of Joint Account Tick ( ) any one Jointly Owned Either or Survivor
Document attached Cancel Cheque Bank Passbook Bank Statement Finacle Copy
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 RBI’s 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 Also I/we understand that the above instruction can be withdrawn/cancelled after due intimation
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
all such plans where the premium amount/top-up would increase as per the feature. ECS registration is subject to policy issuance.
Proprietorship stamp require Signature of Policyholder Signature of Account Holder Signature of Joint Account
if Current Account (As on policy application) (As per bank records) Holder(As per bank records)
as per our records.
Bank’s stamp:-
March 2024/ Version 1.12
