AUTO PREMIUM PAYMENT SERVICE FORM

(APPS MANDATE)
To,
LIC Nomura Mutual Fund
NEW APPLICATION

CANCELATION OF MANDATE

(Please Tick Which

(A) Folio No :
(B) Investor Name :

(As appearin

(C) Name of Policy Holder:

(D) Guardian's Name:

(if

(E) Mobile No :
Please mention the following details:
Premium
Sr. Policy Number
No
No
Payment
..
Frequency
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Email

DOC

Premium
Amount

LIC NMF MICR CODE

Scheme Name
Plan
(Growth Option Only)
Refer Scheme Code*

36 -Liquid Fund

Regu

40 -Savings Plus

Dire

72 -Income Plus

# ( Please attache the photocopy of one of the document mention in the heading where the policy no. and life assure

I hereby declare that the particulars given above are correct and complete. I, being the holder of the above policy/po
willingness to remit the premium/s referred to above through participation in LICNMF Scheme and hereby authoriz
raise debits on LIC Nomura MF Scheme Account towards the premium/s due. If any transaction is delayed
all for the reasons of incomplete or incorrect information or non-availability of funds or closure of accounts etc.,I w
LICNMF, the AMC, the Trustees or Karvy responsible for the same. I understand that the first transaction after autho
one month time in getting the process commenced.
I have read and understood the terms and conditions printed on the reverse on the form and in agreement wit
All unit holder Must sign the mandate form

(Sign. 1sth Unit Holder/Guardian)

(2nd Unit Holder)

(3rd Unit Hold

TERMS AND CONDITIONS :

1

This facility is allowed only to LICMF unit holders who have invested in LICNMF Liquid Fund-Growth OR
LICNMF Savings plus Fund-Growth OR LICNMF Income plus Fund-Growth.

The APPS mandate form should be submitted in triplicate along with the photocopy of policy documen
status report/renewal receipt to POAs (Point of Acceptance) of LICNMF.If the same is not enclosed then
the mandate form will be rejected.

Policy holder name in the LIC policy and first unit holder name in the folio has to be identical. No third
party transfer will be allowed.

Debit dates are allowed only on 7th, 15th and 28th of every month; however the debit in the folio will
happen on the previous business day of the debit dates.

Unit holder to submit the form to LICNMF before 30 days in advance prior to premium due date.

Unit holder must maintain the sufficient balance in the folio to honour premium invoice.

Multiple folios/multiple schemes are not allowed for debit of single premium amount.

The minimum premium amount should be Rs.500/ and above.If the premium amount is less than
Rs. 500 then APPS mandate will not be registered.

Please note that premium amount along with the charges (if any applicable) will be debited from folio.

10 Before opting the Apps option, all the premium due must be paid by unit holders.
11 The premium will be paid on the due date. No grace period option will be available under the APPS.

12 Premium for policies registered through this mode cannot be paid at the branch cash counter of LIC or
through any other alternate channels. Premium can be paid at the cash counter of LIC only for dishono
cases.

13 If a unit holder desires to discontinue the facility, request for same should be given to the LIC servicing
branch at least 20 days in advance of the debit date of monthly mode policies and 30days in advance
other modes.

14 In case if the amount debited from investors account is refunded for any reason by LIC then the same
amount will be transferred to investor bank account registered with LIC Nomura Mutual fund.
15 amount will be transferred to investor bank account registered with LIC Nomura Mutual fund.

Nirav Jadav @ Rajkot Area Office, (M) 98987 33233, Mail : nirav.jadav@licnomuramf.

hich ever is applicable)

aring in LIC NMF Folio)

(As per LIC Policy)
(if Policy is for Minor)
(for LIC Database)

ODE : 999 901 999

an
Copy of Policy
Status Report
LIC Receipt #

egular
Direct

sured name is printed)

y/policies, express my
orize LIC of India to
yed or not effected at
.,I would not hold LIC,
uthorization may take
with the same.

Holder)

OR

ment/
then

hird

will

olio.

C or
honored

cing
nce for

ame

mf.com