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:
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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
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Ver: V1/Jun 2017
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