nara Ramanan oOo HDFC Electronic Clearing Service (ECS)/ 1, Standing nstruction(S)/ || nexxenimnesoe Life Direct Debit (Please use aseparate request form foreach poi) |] Lastpremium due cate PolicyNumber. lan Type: [_]unitLinked 0602300004060) [_] conventional(0s02300002429) Poliyholdersname: Middle Name ast TorTheManager Uwe, the undersigned, hereby opt for the below mentioned option towards my policy premium payments (Tickwhicheveris applicable} Cstardingnstrucon wth ioFcBonkont [Severe CearngSenicefrslecedcisony [_]DkectOetitnonCsleaon seecteanksony) ‘*preferredbiling Date: day ofthe month (“Turn overleaf for yourpreferred dates table) **PreferredBillngDateoptionavailable ony for Customers whohaveopted for SIfacity with HOFC Bank only. Premiumamounttabedebited:® (inwords) Banker from werepenium wie debited oO (Created cheque coy heave metoned baka Sandor S/ ect Dat ay TeTanesntreaue Tne mantle te authored Saraoyortnton) Bankname adress digit MIcRNo (ot required for Sito HOFCBanktd/Drect Debt fam bankaccountofon€CS locaton Oo Frequency (ease tl Monthly /Quartry/HalfYeaiy/Annual—_TypeofAcout Les nearer Coren pene ota Propretayompnysstamponte mandi) DECLARATIONS FORAUTODEBIT UWeherbydecrethathe paricursgver above corectondconpets \wenerebyouthavze ebnk TeeProces Sloan atentemediaiestoconmuncatemy/utfundgacountrumberandany ter courts [as may ener 9 oFcLte HFCL forthespcti:puponctrecovrngy/ou HOF Le prenium payments tough debittrcton youu Uwe nerebyaumoraeHOFCLte he nstancect the standing nstructn/ EC Det Debalina eas o autor the bank Tech rcesSlutons i torecove the prem oye roughadretenbstomyloracauntwththermentenedtok the taactniayec nated ota ermons tncpletnorincrect fermi lathe HOFLivothe Barkortheaternemedares response Uwe age hatte caging the pansum ameunt a pe ny requir ne wl fur aresh mandate fersich hangin th remum aout eh siptsae ether mandates resausyghen \weageetnatinneeventatanvoltonbyme/sotanuncerakinconfrmedinteaglenentharén stalanounttoanevertt cefautintetemsotthelrsuancePalcy a HOFCLie _shlbeentfedoinchatheremaseaatbetaitntemectthptcyeqeenen, Ute are tatnthe veto tebnkbingunbleto deni my aout or wate fundorferany terrson. HOF Le shlbe enti deal why polynthe manner seerbninthepoky pours. lest payment recency anlar onerbeters the pecteddte. ie nee aurea to eit your acount th fe oun src tx andthe ee as maybe stipe the Govern omtne toting cote pen tated stove andtertispurpose otrtheorrevsedauthortyieqitedy you Bark, Policy Holders Signature: ate: **A/CHolders Name: ignature ("*itcitterenttrompolicy holder) Relationship with Policy Holder (Pease tick): Spouse/ParentSiblingChild_ Joint A’ holder's name: kindy cneckovereaformore dels Kindy submithmandate atleast 3 day prior tothe premium due date/prefeedbiling date Declaration tobemadebyathirdperson where: ‘The life assured has affixed his/her thumb impressior/has signed in vernacular/has not filed the application. hereby declare that | have explained the contents of thisapplication form tothelifetobeassured in, Janguageandhave truthfully recorded theanswersprovided tome urther declare thatthelifetobeassuredhassigned/affixedhismner thumb impressioninmy presence. Declarant Name Signature pate Declarant Address: ‘Tobefilledinby theaccountholder'sbank Centfedthatthe particulars furishedatthefrontarecorrectasperourrecords. BankStamp ‘Authorised Signatory of the Bank (CUSTOMER ACKNOWLEDGEMENT COPY (MANDATE FORM FORECS/SI/ DIRECT DEBIT) Policy: Polcyholdername: Branch: Branch Operations Officer Date: ne: Reueterathatent uta sity hana be smite te30 dap le nthereatpremnedate athe ewestHOFLe ranch usta acvatians eb ty hanebesamiteteas Saoybertotenen prema nena rvImportant Note: |= Anycancellation, corection,alterationete. should becountersignedby the Account Holder. For with HDFC Bank, premium willbe debited from your account onthe debit date. However, ifthe Ist attempt sunsuccessful,2 more attempts illbemadewithin the following consecutive day. ForSicases(HOFC Bank) the NAVallatted willbe the dateon which the bankaivesaconfirmationaf thedebit ForECSNAVwouldbeallocatedonthe basisofthedebitdate. Direct debit facility (non CS location isofferd by IICIBank. Citibank. Union Bankof nda, Bankof BaradaandAxisBank nly. Forbirect Debit. NAV willbeprovidedorthe day when thepaymentisreceivedintheHOFCLifeaccourt. Request frde-actvationof Auto debit facility hastobesubmittedatleast 5 dayspriortothenextpremiumduedate. ‘The premium willbe debited starting from the premium due date / Prefered biling date which occurs after the date ofthis mandate, Til thelast premiumdue date unless the mandateis revoked. Incase of ary increase” decrease in premium amount due to changes in payment frequency or any policy related changes including eduction in premium the existing debit instruction wil be de-activated, Hence, afresh direct debit mandate fs equired to be submitted at any HDFC Life branchatleast30dayspriortothenextpremiumduedate + Redtininpremiumisaprodut-speccaeratin Preferred Billing Dates of Debit 2 16 20 lisisisiisiss v v v v v v v v v 7 aisisisisisisisisl sidnsisisss saisdisinnns asics Reviveyourpoliey Sots mor! Vein nafe combregisterforMy Acount 23)! For more details, callus toll fre on 1800-209:7777 (Any phone}/ 1800-228 228 (BSNL/ MTNLY Emails servicoehateife.com. The call ‘View Premium Calendar, Pe Premium Online, racktluctuationsinthefund value, Print your Annol Premium Statement. DoaFundSwitch, centalsopentrom9am-opmall7¢ays, Life ee ronment ns