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Nationalized Electronic Funds Transfer-Mandate Form: (To Be Filled in by The Applicant in BLOCK LETTER)

This document is a mandate form for nationalized electronic funds transfer from an insurance company to a policy holder's bank account. It requests the transfer of payment for items like loans, surrenders, maturity claims or bonuses. It provides instructions on properly filling out the form and includes details about the policy holder's bank account, including the account name, number, type of account and IFSC/MICR codes. The policy holder signs to confirm the details and acknowledge that the insurance company won't be responsible if the transfer fails or is delayed due to incorrect information.

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Amit Bhargava
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
73 views

Nationalized Electronic Funds Transfer-Mandate Form: (To Be Filled in by The Applicant in BLOCK LETTER)

This document is a mandate form for nationalized electronic funds transfer from an insurance company to a policy holder's bank account. It requests the transfer of payment for items like loans, surrenders, maturity claims or bonuses. It provides instructions on properly filling out the form and includes details about the policy holder's bank account, including the account name, number, type of account and IFSC/MICR codes. The policy holder signs to confirm the details and acknowledge that the insurance company won't be responsible if the transfer fails or is delayed due to incorrect information.

Uploaded by

Amit Bhargava
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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Nationalized Electronic Funds Transfer- Mandate Form

(To be filled in by the Applicant in BLOCK LETTER)

To,
MaxNewYorkLifeInsuranceCompanyLtd.
90A,Sector18,UdyogVihar,Gurgaon122001
DearSir,

ParticularsofBankAccount:
A/CHoldersName

I________________________________________________holderofMNYLPolicynumber

Herebyrequestyoutotransferthebelowmentionedpayment/sdirectlytomyaccountas
perbankdetailprovided:

AsperrequirementsChoose()whicheverisapplicable:
LoanAmount

Surrender/PartialSurrenderAmount

MaturityClaim

BonusAmount

Others(Specify)_______________________________________________

Reissue/NonreceiptofchequeissuedbyMNYL(Pleaseprovidethe
ChequedetailsalongwiththeStopPaymentdeclarationmentioned
Below.)

StopPaymentDeclaration

I hereby request you to stop the below mentioned cheque issued to me and transfer the
amountdirectlytomymentionedbankaccount.

ChequeNo.:_________________________________________________________________

Dated________________________________________________________________

AmountingRs._________________________________________________________________

Further I declare that I would not present the abovementioned Cheque in the bank for
realizationinfuture.

PolicyHoldersSignature:

Instruction:

:________________________________________________________________

TypeofBankAccount
: (Choose()anyone){SavingsA/C/CurrentA/C/CashCredit/Others
(PleaseSpecify)}

BankName::________________________________________________________________

BranchAddress::________________________________________________________________

________________________________________________________________

It is important that for these electronic payment systems, the account


holders name must match exactly the name with bank records as well as
withourpolicyrecords.
In cases where beneficiarys bank account number & name is printed on
the cheque, bank attestation is not required. For all other cases bank
attestedNEFTmandateisrequired.
The customer who is willing to transfer the funds will be required to
providethe11digitsvalidIFSCCode,whichisapplicableforNEFTonly.
(anumberallottedtoeachparticipatingbanksbranch)ofthebranchwhere
thefundsneedtobetransferred.
CancelledchequeshouldbeattachedalongwiththeNEFTformat.
NEFTFormneedstobecompletedinallrespect.

NOTE:AsperRBI,allBanks/BranchneedtogivevalidIFSCcodeforNEFTapplicable
fortheirbranchonly.

MICRcode
: 9digits MICR codenumber of the bank andbranch appearing onthe cheque
issued by the bank. If it starts from 000, please obtain correct code from your Bank Branch. (Valid for
MICRenableofBranch)

IFSCcode(IndianFinancialSystemcode:11digituniquealphanumericcodedesignedtouniquely
identifythebankbranchesinIndia.(PleaseprovideBankattestationincaseIFSCcodeisnotmentionedon
thecancelledcheque)

AccountNumber:

(Asappearingonthechequebook)

MobileNumber:___________________________________________________________________________

EMail:___________________________________________________________________________

Yes,IhaveattachedacancelledblankchequeoritsPhotocopy

(Incasecancelledblankchequedoesnotbearaccountholdersname,pleaseprovidephotocopyofbank
statement/passbookorelseBankattestationisrequired)

IherebyCertifiedthattheparticularsfurnishedabovearecorrectandasperbestofmyknowledge.

PolicyholdersSignature:____________________________________________________________

Date
(MM/DD/YY):_____________________________________________________________

DISCLAIMER:Incaseofnoncredittomybankaccountwith/withoutassigninganyreasonsthereofor
ifthetransactionisdelayedornoteffectedatallforreasonsofincomplete/incorrectinformation,I
wouldnotholdMaxNewYorkLifeInsuranceCo.Ltd.responsible.Further,theCompanyreservesthe
righttouseanyalternativepayoutoptionincludingdemanddraft/payableatparchequeinspiteof
optingforDirectCreditoption.

Certification by account Holder Bank

Weherebycertifythattheaboveaccountnumberiscurrentlyoperationalandparticularsfurnishedabovearecorrectasperourrecordsandwehavenotedtheinstructions:

BankName&Address:_________________________________________________________________________AuthorizedSignatory:

_________________________________________________________________________BankStamp:

Date:

MAXNEWYORKLIFEINSURANCECO.LTD
OperationCenter,90A,UdyogVihar,Sector18,Gurgaon122015,HaryanaRegisteredOffice:MaxHouse,1DrJhaMarg,Okhla,NewDelhi110020,India

Ver1.0

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