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7S Electronic Payout Mandate PDF

This document is a request form for an electronic payout of a life insurance policy benefits. It requests the policy number, policyholder and trustee details if applicable, bank account information of the policyholder or trustee for the payout, and includes a checklist of required documents to submit including a cancelled cheque and signed PAN card. The form can be submitted by email, in person at an ICICI Prudential Life Insurance branch, or by courier to their payout department address provided.

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Sunil Sulakhe
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739 views1 page

7S Electronic Payout Mandate PDF

This document is a request form for an electronic payout of a life insurance policy benefits. It requests the policy number, policyholder and trustee details if applicable, bank account information of the policyholder or trustee for the payout, and includes a checklist of required documents to submit including a cancelled cheque and signed PAN card. The form can be submitted by email, in person at an ICICI Prudential Life Insurance branch, or by courier to their payout department address provided.

Uploaded by

Sunil Sulakhe
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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REQUEST FOR ELECTRONIC POLICY PAYOUT

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

E-Mail ID Mobile number

PAN

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

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

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

ICICI Bank Limited


Prabhadevi Branch
Ground Floor, Kala Academy, Ravindra Natya Mandir Amit Wadekar
MICR Code of Bank Prabhadevi Mumbai - 400 028
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 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/Oct/2018/410/1681.

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