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NEFT Mandate

This document is a mandate form for policyholders of Max Life Insurance to provide their bank account details for receiving electronic fund transfers through NEFT. The form requests the policyholder to provide their name, bank account type (savings or current), bank name, branch address, IFS code, account number, mobile number, and email. The policyholder must attach a cancelled cheque or bank statement/passbook and authorizes Max Life to use their registered ECS account for future payouts through NEFT. The policyholder declares that the provided details are correct and assumes responsibility for any excess funds deposited or funds not deposited due to incomplete information.

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376 views1 page

NEFT Mandate

This document is a mandate form for policyholders of Max Life Insurance to provide their bank account details for receiving electronic fund transfers through NEFT. The form requests the policyholder to provide their name, bank account type (savings or current), bank name, branch address, IFS code, account number, mobile number, and email. The policyholder must attach a cancelled cheque or bank statement/passbook and authorizes Max Life to use their registered ECS account for future payouts through NEFT. The policyholder declares that the provided details are correct and assumes responsibility for any excess funds deposited or funds not deposited due to incomplete information.

Uploaded by

Girish
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Nationalized Electronic Funds Transfer- Mandate Form

(To be filled in by the Applicant in BLOCK LETTER)

Max Life Policy No.

Particulars of Bank Account of Policy holder: (Bank Account should be in the name of policyholder)

A/C Holder’s Name : ____________________________________________________________

Type of Bank Account : (Choose (√) any one) {Savings A/C / Current A/C )

Bank Name : ____________________________________________________________

Branch Address: : ___________________________________________________________________

___________________________________________________________________

IFS Code (Indian Financial System Code):

Bank Account Number: (As appearing on the cheque/bank statement/passbook)

Mobile Number :

E-Mail : _________________________________________________________________________

Yes, I have attached a cancelled cheque or it’s Photocopy.

(In case cancelled cheque is not provided:- Please provide photocopy of latest bank statement / passbook or get this NEFT form attested by your bank)

I authorize, Max Life Insurance Co. Ltd. to use my registered ECS A/c for disbursing all future policy payouts through NEFT. (ECS A/c detail is
mentioned above)

NRI accounts are guided by FEMA regulations: We are not accepting NRI account for NEFT so you are requested to not provide NRI account for fund
transfer.
Notes:
 I hereby Certify that the particulars furnished above are correct and as per best of my knowledge.
 I undertake to refund any amount that is credited to my account either in excess or which is not due to me, at any time.
 After submission of NEFT details, if there is any change in bank details then fresh mandate form will have to be submitted.

DECLARATION: In case of non credit to my bank account with/ without assigning any reasons thereof or if the transaction is delayed or not effected at
all for reasons of incomplete/incorrect information, I would not hold Max Life Insurance Co. Ltd. responsible in any manner whatsoever. The Company
reserves the right to use any alternative payout option including demand draft/ payable at par cheque in spite of opting for Direct Credit option.

Policyholder’s Signature : ___________________________________

Date (DD/MM/YY) : __________________________________ _________________________________


Signature & Seal of Bank Authority
For Max Life use :
I have verified the above mentioned particulars with supporting documents and found complete & correct for NEFT processing,

CSE Name, Emp Code & Sign with Date: ______________________________________________________________________________

MAX LIFE INSURANCE CO. LTD


Operation Center, 90-A, Udyog Vihar, Sector-18, Gurgaon-122015, Haryana Registered Office: Max House, 1 Dr Jha Marg, Okhla, New Delhi-110020, India
Nov/2014-15

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