Neft form Version 10



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Nationalised Electronic Funds Transfer - Mandate Form  

(To be filled in by the Applicant in capital letters) 

  Yes, I have attached a cancelled cheque or its photocopy. 

 

No (Please provide photocopy of latest bank statement/passbook or get this NEFT form attested by your bank)



Signature & Seal of Bank Authority

 ________________________

Policyholder's Signature

Date:


D D

M M


Y Y Y Y

For Max Life use 

I have verified the above mentioned particulars with supporting documents and found them complete and correct for 

NEFT processing.

CSE Name________________________________________________ Emp. Code___________________________________

Signature _________________________________Date: 

Name of the Policyholder: ________________________________________________________________________________

Policy No.: 

Mobile No.: 

Email: 

I accept to receive all future communication from Max Life Insurance vide email ID only (strike if you want to continue by hard copies).

Aadhaar No.:                                                                       



I hereby authorise Max Life to process my payouts to my Aadhaar linked bank account and to use the same to validate/update my KYC details.

Bank Details for NEFT

Type of Bank Account:          Savings

Current

NRO


Account Holder Name: ______________________________________   Bank Name: ______________________________

Bank Account No.: 

 

IFSC: 


PAN Number: 

          

          

          



Note: 

NRE accounts are guided by FEMA regulations: We are not accepting NRE account for NEFT so you are requested not to provide NRE 



account for fund transfer. 

• 

After submission of NEFT details, if there is any change in bank details then fresh mandate form will have to be submitted.  



Declaration: I hereby certify that the particulars furnished above are correct and as per the 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. 

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. 

Toll-free Helpline

Max Life Insurance Co. Ltd. Plot No. 90A, Sector 18, Gurugram, 122015, Haryana.



Important: DO NOT believe calls, SMS, emails offering discounts. Please pay only to HSBC Bank A/c no. <1165your policy no.> IFSC code - HSBC0110002

IRDAI Registration No. 104

D D

M M


Y Y Y Y

Ver: V1/Jun 2017





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