REQUEST FOR ELECTRONIC POLICY PAYOUT

Policy Number
Name of
Policy holder
Mr./Ms./Mrs. First Name Surname

Mobile number Aadhaar number PAN

I confirm that the Aadhaar number provided by me is correct. I authorize ICICI Prudential Life Insurance Company Ltd to access my details from UIDAI for
verification and update my Aadhaar number in all my insurance policies.

Trustee Details (Required to be filled, only in case it is an MWPA Policy)

Trustee Name
Mr./Ms./Mrs. First Name Surname

Trustee Aadhaar No. Trustee PAN

I confirm that the Aadhaar number provided by me is correct. I authorize ICICI Prudential Life Insurance Company Ltd to access my details from UIDAI for
verification and update my Aadhaar number in insurance policies.

Your bank account details to receive policy benefits

Name of Customer/Trustee*
(as mentioned in the bank account and printed on your cheque)
*In case it is an MWPA Policy, Trustee Bank account details are required to be filled.

Name of Bank

Branch Address

Account Type Current Account Savings/ NRO Account NRE Account

CBS
Bank Account No. PERSONAL BANKING : SAVING ACCOUNT DATE ....................
PAY ................................................................................................................................................
Bank account number as printed on your cheque ................................................................................................................................................... OR BEARER
RUPEES ...................................................................................................
Rs.
..................................................................................................................
IFSC Code of Bank SBGEN A/c No. ANWB
005070123756

ICICI Bank Limited

MICR Code of Bank Prabhadevi Branch
Ground Floor, Kala Academy, Ravindra Natya Mandir
Prabhadevi Mumbai - 400 028
Amit Wadekar
RTGS / NEFT IFSC Code : ICIC0000057
9 digit code as appearing on the Cheque copy issued by bank.
|| 338894|| 400229013|: 000000|| 31

Branch Address MICR Code IFSC Code Name

Bank Account Number

Signature of Policyholder Signature of Trustee Place: Date: DD/MM/YYYY

SUBMIT THIS FORM WITH THE FOLLOWING DOCUMENTS:

Cancelled cheque of your bank account. Your bank account number and name should be printed on the cheque.
Signed copy of Aadhaar card and PAN card.

YOU CAN SUBMIT THIS FORM AND DOCUMENTS THROUGH ANY OF THESE OPTIONS:

@ Email:
Email the scanned copy of the documents to lifeline@iciciprulife.com with your policy number

Branch:
Submit the documents at any of our branches. To locate the nearest branch, visit www.iciciprulife.com/branchlocator.

Courier: Courier the documents to

#Payout Department#, ICICI Prudential Life Insurance Co. Ltd., Unit No. 1A & 2A, Raheja Tipco Plaza, Rani Sati Marg,
Malad (East), Mumbai- 400 097.

ACKNOWLEDGEMENT SLIP
This is to acknowledge the receipt of application for electronic policy payout

Policy Number : Date : D D M M Y Y Y Y

Signed Cancelled Cheque STAMP

Documents Submitted : Self Attested Photo ID
&
TIME
Received By

Registered Address:- ICICI Prudential Life Insurance Co. Ltd.,1089, Appasaheb Marathe Marg, Prabhadevi, Mumbai-400025. IRDAI Regn No. 105. CIN: L66010MH2000PLC127837.
Insurance is the subject matter of the solicitation. Comp/doc/Mar/2018/1057.