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NEFT_Form_2425110669601_

This document is a National Electronic Funds Transfer (NEFT) mandate form submitted to the Life Insurance Corporation of India by policyholder Anil Dubey for receiving policy payments. It includes personal and bank account details, along with a declaration regarding the policy and attached documents such as a cancelled cheque and a copy of the PAN card. The policy number referenced is 228965158, and the form indicates consent to receive notifications via SMS or email.

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dnavya1009
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26 views1 page

NEFT_Form_2425110669601_

This document is a National Electronic Funds Transfer (NEFT) mandate form submitted to the Life Insurance Corporation of India by policyholder Anil Dubey for receiving policy payments. It includes personal and bank account details, along with a declaration regarding the policy and attached documents such as a cancelled cheque and a copy of the PAN card. The policy number referenced is 228965158, and the form indicates consent to receive notifications via SMS or email.

Uploaded by

dnavya1009
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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LIFE INSURANCE CORPORATION OF INDIA

NATIONAL ELECTRONIC FUNDS TRANSFER – MANDATE FORM

To
LIFE INSURANCE CORPORATION OF INDIA
Branch : 26 Service Request Number : 2425110669601
Sub : Receipt of policy payment through NEFT

I am giving below the details of my Bank account for receiving policy payment through NEFT.

Policy No: 228965158

(1) Name of policy holder/ claimant Anil Dubey


(2) Bank Name : State Bank of India (3) Account Type : Saving
(4) Account : 33561223195 (5) IFS Code : SBIN0016173
(6) Mobile : 7836880702 (7) E-Mail Id : [email protected]

(8) Bank Branch Address : C/O M/S DURGA BUILDERS, MAIN MANGAL BAZAR, KHODA,
DISTT. GAZIABAD, UTTAR PRADESH201301
(9) Are you willing to receive SMS/E-mail, on Yes
matters related to
->if cheque is not having the name of bank holder then
Photo copy of the page of Bank pass book containing
details of Bank accounts number, IFS code

->I authorize LIC of India to make any payments due to


me into this account and such payments made shall be
considered as valid discharge of all the liabilities copy of Pan card
against my policy for the purpose for which payment is
made

-> I declare that the above mentioned policy/ies


has/have not been assigned

I have enclosed the following document to this effect.


A. Cancelled cheque leaf
B. Copy of Pan card

___________________________
Signature of the policyholder Date :

Cancelled Cheque

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