NACH Modified
NACH Modified
NACH Modified
PERIOD:
From D D M M Y Y Y Y Signature of Joint account holder in case
To 3 11 1
3 1 2
2 22 00 5
9 9
2 Signature of Primary Account holder it is not an either or survivor account Signature of Account holder
Or Until Cancelled 1. Name as in bank records 2. Name as in bank records 3. Name as in bank records
as agreed and signed by me. I have understood that I am authorized to cancel/amend this mandate by appropriately communicating the cancellation / amendment request to the
User Entity / corporate or the bank where I have authorized the debit.
Instructions
1.
2. Please provide a Cancelled Cheque with Pre-printed Account Holder Name & Bank Account Number. If Account Details are not Pre-printed on the
Cancelled Cheque, provide Bank Account Statement / Pass Book Copy containing printed Bank account details along with Cancelled Cheque.
3. Relationship of Account holder with Policyholder : Payor/ Self ( In case of other than payor or self-submit necessary KYC documents )
taxable limit and you do not have a PAN, please submit Form No. 60.
9. Please submit this form at your nearest Tata AIA Life Branch or Courier / Post it to the following address: Tata AIA Life Insurance Company Ltd. : B- Wing,
9th Floor, I-Think Techno Campus, Behind TCS, Pokhran Road No.2, Close to Eastern Express Highway, Thane (West), Pin Code - 400 607.
with my policy in the manner as described in the policy terms and conditions.I understand and accept that the transaction will be effected on the policy on the
due date (provided the day is working day). If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I shall not hold
Tata AIA Life responsible. I authorize the above mentioned bank to debit my bank account if my NACH mandate is active and until I give a written request for
cancellation of NACH. I hereby authorize Tata AIA Life, to re-debit my account with the mentioned bank to recover the premium payable. I understand and agree
that premium amount to be debited from my account may vary due to taxes and other statutory levies as may be applicable from time to time. I understand that
by only paying the outstanding premiums along with interest the policy will not be revived. I undertake to comply with all the formalities related to revival as may
be prescribed by the Company.
Tata AIA Life Insurance Company Limited ( IRDAI Regn. No.110 • CIN: U66010MH2000PLC128403). Registered & Corporate Office: 14th Floor, Tower A, Peninsula
Business Park, Senapati Bapat Marg, Lower Parel, Mumbai - 400013. Trade logo displayed above belongs to Tata Sons Ltd and AIA Group Ltd. and is used by Tata AIA Life Insurance
Company Ltd under a license. For any information including cancellation, claims and complaints, please contact our Insurance Advisor / Intermediary or visit Tata AIA Life’s nearest
branch office or call 1-860-266-9966 (local charges apply) or write to us at [email protected]. Visit us at: www.tataaia.com. • L&C/Misc/2022/Mar/0066 • Version 6.6
BEWARE OF SPURIOUS PHONE CALLS IRDAI is not involved in activities like selling insurance policies, announcing bonus or investment of premiums. Public
AND FICTIOUS / FRAUDULENT OFFERS receiving such phone calls are requested to lodge a police complaint