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Third_Party_Declaration_Format (2) (1)

This document is a declaration form for third-party payments related to life insurance premiums, including details about the payer and their relationship to the policyholder. It requires information such as the payer's name, address, PAN, and consent for KYC compliance. The form also includes a declaration from the policyholder confirming the payment and the accuracy of the provided information.

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Abhijith Ajayan
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© © All Rights Reserved
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Download as DOCX, PDF, TXT or read online on Scribd
10 views

Third_Party_Declaration_Format (2) (1)

This document is a declaration form for third-party payments related to life insurance premiums, including details about the payer and their relationship to the policyholder. It requires information such as the payer's name, address, PAN, and consent for KYC compliance. The form also includes a declaration from the policyholder confirming the payment and the accuracy of the provided information.

Uploaded by

Abhijith Ajayan
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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DECLARATION FOR THIRD PARTY PAYMENT

NOTE: Applicable for First Premium Deposit, Renewal Premium, Loan/Foreclosure repayment, Surrender reinstatement
repayment, Short Premium (SHP), Top-Up (Cheque / Demand Draft (with name of payer), Transfer of Funds.

Application No. / Policy No.

Payer Name
Salutation First Name
Surname

Receipt Number
Photograp
h of
Address
Payer

City State Pin Code

PAN or Form 60
*mandatory and as applicable and defined in Income-tax Rules, 1962

CKYC Number (If available)

I am issuing cheque / demand draft no. dated drawn on


bank for an amount of ` Rupees
only), OR request to transfer ` (Rupees only)
from policy no. (Source Policy), where I am the policyholder, towards premium deposit for application
no./policy no.
for the life insurance application submitted by the proposer/ policyholder Mr./Ms./Dr. .

Kindly note that I am paying on behalf of the above mentioned proposer/policyholder who is my/our
(mention relationship)
Are you a politically exposed person or a relative of a politically exposed person? Yes No

Politically Exposed Persons” (PEPs) are individuals who have been entrusted with prominent public functions by a foreign
country, including the heads of States or Governments, senior politicians, senior government or judicial or military officers,
senior executives of state-owned corporations and important political party officials.

I here by give consent and voluntarily submit my Aadhaar number to ICICI Prudential Life Insurance Co. Ltd. to fulfil "Know
Your Customer" requirements. I hereby consent to receiving information from Central KYC Registry through SMS/email on
the registered number/email address.

I/we also agree that the PAN details and other KYC information provided by me/us for any servicing requests may be used

COMP/DOC/Jul/
2023/77/3434
by the Company to download/verify my/our KYC documents from CERSAI*

I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake
to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or
misleading or misrepresenting, I am aware that ICICI Prudential reserves the right to take appropriate action.

Signature of Third Party Payer

DECLARATION (to be filled by Proposer/Policyholder)

I hereby confirm that Mr./Ms./Dr.


who is (Specify the relationship) is paying on my behalf for above application /policy no. I further
confirm that all the information given above is true and correct. I am aware that any refund with respect to this policy owing to
freelook cancellation, withdrawal of application, postponement, cancellation, etc. will be processed to the source from which the
premium was paid. Also, in case of receipt of premium from an unacceptable third party or non-submission of proper
documentation by an acceptable third party, the refund amount will be processed to the source. Payments other than those in
the nature of refunds will be processed to the proposer/beneficiary, as the case may be.

Date: D D M M Y Y Y Y

Signature of Proposer/Policyholder

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