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C286146429-NACHForm

The document is an auto debit mandate form for Tata AIA Life Insurance, authorizing the Bank of Baroda to debit a specified amount from the account for premium payments. It includes instructions for filling out the form, necessary documentation, and terms and conditions regarding the debit process. The form must be submitted to Tata AIA Life Insurance for processing, and it outlines the responsibilities of the account holder regarding sufficient funds and premium payment variations.

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ketulpatel597
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148 views2 pages

C286146429-NACHForm

The document is an auto debit mandate form for Tata AIA Life Insurance, authorizing the Bank of Baroda to debit a specified amount from the account for premium payments. It includes instructions for filling out the form, necessary documentation, and terms and conditions regarding the debit process. The form must be submitted to Tata AIA Life Insurance for processing, and it outlines the responsibilities of the account holder regarding sufficient funds and premium payment variations.

Uploaded by

ketulpatel597
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UMRN 2 1 0 2 2 0 2 5

Sponsor Bank Code Utility Code


Tick (✔)
I/We hereby authorize Tata AIA Life Insurance Co. Ltd.(D) to debit (tick ✔) SB / CA / Others / SB-NRE / SB-NRO
CREATE ✔
MODIFY X
CANCEL X Bank a/c number 4 1 0 2 0 1 0 0 0 1 2 6 7 9

with Bank BANK OF BARODA IFSC B A R B 0 C H O U H T or MICR

an amount in words twenty seven thousand nine hundred eighty one ₹ 27981

FREQUENCY X Mthly X Qtly X H-Yrly X Yrly ✔ As & when presented DEBIT TYPE X Fixed Amount ✔ Maximum Amount

Reference 1 C286146429 Phone No. 7424910228

Reference 2 Email ID [email protected]

I agree for the debit of mandate processing charges by the bank whom I am authorizing to debit my account as per latest schedule of charges of the bank.

PERIOD:

From 2 3 0 3 2 0 2 5 Signature of Primary Account holder Signature of Joint account holder in case Signature of Account holder
To 3 1 1 2 2 0 5 2
Or X Until Cancelled LALIT KUMAR

This is to confirm that the declaration has been carefully read, understood & made by me/us. I am authorizing the User entity/Corporate to debit my account, based on the instructions
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.

FORM FOR AUTO DEBIT OF PREMIUMS THROUGH NACH Policy Number C 2 8 6 1 4 6 4 2 9

Instructions

1. Please fill the form in block letters & overwriting / whitener usage is not allowed on the from

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 )

4. In case of a Current Account, please affix proprietor's stamp with the account holder's signature and mention proprietorship firm's name in the account
holder’s name column.

5. Thumb Impression is not allowed in the Account holder’s signature column. NACH is not offered to Illiterate account holders

6. The mandate instruction can be given upto 105% of annual premium to accommodate any changes in premium due to taxes, levies or any changes in the
premium as per the products specifications.

7. NAV would be allocated on the basis of the debit date.

8. As per Rule 114 B of the Income Tax Rules, 1962, it is mandatory for every person to quote his Permanent Account Number ( PAN ) in all documents
pertaining to payment of life insurance premium to an insurer aggregating to more than Rs.50,000/- in a financial year. In case your income is below the
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.

Terms and Conditions/ Declaration


I understand and agree that the submission of this form does not mean that the request will be processed. I agree that it would take approximately 30 working
days to register the request for NACH with the service provider and the bank, but it would also depend on the Bank and premiums due (if any), during this
period will need to be paid by cash/cheque/online. | undertake to keep sufficient funds in the account mentioned in the mandate as on the date of execution of
debit. agree that in the event of the Bank being unable to debit my account for want of sufficient funds or for any other reason, Tata AIA Life shall be entitled to
deal 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/Apr/0111 • Version 6.6

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