MAX LIFE INSURANCE CO.

LTD
Operation Center, 90-A, Udyog Vihar, Sector-18, Gurgaon-122015, Haryana Registered Office: Max House, 1 Dr Jha Marg, Okhla, New Delhi-110020, India
Ver 3.0






Max Life Policy No.


Particulars of Bank Account of Policy holder: (Bank Account should be in the name of policyholder)

A/C Holders Name : ____________________________________________________________

Type of Bank Account : (Choose () any one) {Savings A/C / Current A/C )

Bank Name: : ____________________________________________________________


Branch Address: : ___________________________________________________________________


___________________________________________________________________
IFSC code (Indian Financial System code: 11-digit unique alphanumeric code designed to uniquely identify the bank-branches in India.


Bank Account Number: (As appearing on the cheque/bank statement/passbook)






Mobile Number :



E-Mail : _________________________________________________________________


Yes, I have attached a cancelled cheque or its Photocopy.

(In case cancelled cheque is not provided:- Please provide photocopy of latest bank statement / passbook or get this NEFT form attested by your bank)


I hereby Certified that the particulars furnished above are correct and as per best of my knowledge.



Policyholders Signature : ___________________________________


Date (DD/MM/YY) : __________________________________ _________________________________
Signature & Seal of Bank Authority


DISCLAIMER: In case of non credit to my bank account with/ without assigning any reasons thereof or if the transaction is delayed or not effected at
all for reasons of incomplete/incorrect information, I would not hold Max Life Insurance Co. Ltd. responsible. Further, the Company reserves the
right to use any alternative payout option including demand draft/ payable at par cheque in spite of opting for Direct Credit option.





Nationalized Electronic Funds Transfer- Mandate Form
(To be filled in by the Applicant in BLOCK LETTER)