ELECTRONIC CLEARING SYSTEM (E.C.

S) /
DIRECT DEBIT APPLICATION FORM
Section A
Instructions for Premium Payment through ECS Direct Debit Date:
(In case no option is selected, the default option will be ECS) D D M M Y Y Y Y
To,
ICICI Prudential Life Insurance Company Ltd.,
ICICI PruLife Towers,
1089, AppaSaheb Marathe Marg,
Prabhadevi, Mumbai – 400 025.
Dear Sir,
Re : Authorisation to pay Insurance Premium amount through Electronic / Debit Clearing System.

I, the undersigned hold a valid Policy bearing No. Or Application bearing No.
I, wish to avail of the direct debit facility and hereby express my unconditional consent to debit premium payment of my policy referred to
above through participation in the Electronic Clearing System (ECS) / Direct Debit. I understand and agree that the 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, hereby declare that the particulars given are correct and complete. I understand and accept that the transaction will be effected on the policy
due date (provided the day is a working day). If the transaction is delayed or not effected at all for reasons of incomplete or incorrect
information, I shall not hold the user institution (company) responsible. I agree to discharge the responsibility expected of me as a participant
under the scheme.

*Primary Account Holder’s Signature Joint Account Holder’s Signature 1 Joint Account Holder’s Signature 2 Policyholder’s Signature
(* Only if Primary Account Holder (Signature of all account holders is mandatory)
differs from Policyholder)

I hereby authorise ICICI Prudential to enable direct debit facility for my premium payments. The details of my Bank Account are mentioned below
Particulars of Bank Account (to be filled in CAPITAL letters)
a. Name of the Primary Account Holder (as in the bank account) :
b. Bank Name :
c. 9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank*
(*In case of ECS, kindly ensure that the first three digits of the MICR code that you fill in are all not zero.)
d. Account Type: Savings Account Current Account Cash Credit

e. Account Number : (As appearing on your cheque book)

Yes, I have attached a photocopy of a blank cheque or a blank cancelled cheque

Certified that the particulars furnished above are correct and as per our records.

Bank Stamp: Signature of Authorised Bank Official

The ECS / Direct Debit facility will be activated in your next billing cycle.

Section B
To be retained by your Bank premium dues on my ICICI Prudential Life Insurance Company Policy/
Policies. Mandate verification charges (if any) may be charged to my/
To,
our account.
The Manager I further request you to inform ICICI Prudential Life Insurance Company
Bank Name of any change in the status of my account. Incase I wish to revoke the
above authorisation for any reasons whatsoever, I undertake to inform
ICICI Prudential Life Insurance Company after giving an advance notice
Branch Address of two months in writing.

* Primary Account Holder’s Signature Policyholder’s Signature

Dear Sir/Madam, I, the undersigned hold a valid Policy number
(* Only if Primary Account Holder
and wish to avail of the Electronic Clearing
differs from Policyholder)
System / Direct Debit facility towards settlement of my Monthly / Half-
yearly / Yearly Policy Premium payments in favour of ICICI Prudential
Aug 2007

Life Insurance Company. I hereby authorise you to debit my Account

Joint Account Holder’s Signature 1 Joint Account Holder’s Signature 2
No. towards my
(Signature of all account holders is mandatory)

Please refer to the reverse for information on ECS / Direct Debit facility.

1
• ECS / Direct Debit works in a very simplified manner:
The Electronic Clearing System (ECS) / Direct Debit facility enables hassle-free premium payments. Premium Payment requests through
ECS / Direct Debit are sent to your bank as per the pre-determined schedule. Depending on your respective premium due date, the
• premium
The amountgets directly debited
mentioned inon your
this premiumisdue
mandate date for ECS
applicable for and Directamount.
Top-up Debit. Kindly note that the Direct Debit application would
• have to be successfully registered with your bank to enable the
The Renewal amount will be collected as and when due after adjustingpayment to be debitedfor
from your
any account.
balance lying in the contract.
Top-up NAV
•• Premiums in theapplicable will be post
following conditions may 2 notdays after the
be debited Renewal
on the premiumNAV.
due date:
• There 1) will
ECSbe a 1%under
locations charge for Top-up
non-rolling settlement category (Nasik, Aurangabad, Trichy, Madurai, Coimbatore, Kolhapur)
• The2)Electronic
If the premium due System
Clearing date falls on a holiday,
(ECS) in which
facility case
enables your account
hassle-free would be debited
premium on thepayments.
and top-up next working day
Bill
Junction is our authorized service provider for ECS and we offer you this service free of charge.
• The renewal amount will be collected as and when due after adjusting for any balance lying in the contract.
• ECS works in a very simplified manner:
Premium
• This Payment
ECS facility and Top-up
is currently availableamount requests
in 51 cities through
namely Agra, ECS areAllahabad,
Ahmedabad, sent to your bankAurangabad,
Amritsar, as per the Bangalore,
pre-determined
Baroda,
schedule. Hence, depending on your respective premium due date, the premium getsGuwahati,
Bhopal, Bhubaneshwar, Calicut, Chandigarh, Chennai, Cochin, Coimbatore, Delhi, Gorakhpur, directlyGwalior,
debitedHubli,
on your
Hyderabad, Indore, Jabalpur, Jaipur, Jalandhar, Jammu, Jamshedpur, Jodhpur, Kanpur, Kolhapur, Kolkata, Lucknow, Ludhiana,
premium due date for ECS and within 13 days for Direct Debit.
Madurai, Mangalore, Mumbai, Mysore, Nagpur, Nasik, Panjim, Patna, Pune, Raipur, Rajkot, Surat, Trichur, Trichy, Trivandrum,
Premiums in following
Udaipur, Varanasi, conditions
Vijaywada, Vizag. would not be debited on the premium due date:
1) ECS locations under Non-rolling settlement category
• The Direct Debit facility is available for all account holders of ICICI Bank, UTI Bank, IDBI Bank, IndusInd Bank, Kotak Mahindra Bank
2) If premium due date falls on Holidays then your account would be debited on next working day.
(all branches) and Punjab National Bank (select locations).

•• This
Payable at Par
facility ischeques
currently willavailable
not be accepted for ECS
in 26 cities payment
namely mode.
Ahmedabad, Baroda, Bangalore, Bhopal, Bhubaneshwar,
• Calicut, Chandigarh,
Charges applicable fromChennai,
the bank (ifCoimbatore,
any) would beGorakhpur,
borne by theGuwahati,
customer. Hubli, Hyderabad, Indore, Jammu,
Jamshedpur, Jabalpur, Jaipur, Jodhpur, Kanpur, Kolkata, Lucknow, Ludhiana, Madurai, Mumbai, Mysore,
All Nagpur,
you need New
to do is:
Delhi, Patna, Panjim, Pune, Surat, Trivandrum, Udaipur, Vijaywada & Vizag.
* Payable at APar
Fill up SECTION in this form and
cheques send
will it tobe
not us accepted.
along with a cancelled cheque (or a photocopy of the same). Simultaneously, SECTION B of the
form needs to be submitted with your bank.
* Charges applicable from the bank (if any) would be borne by the customer.
As soon as the ECS gets activated against your policy, all your premium payments will be debited directly from your bank account.
All you need to do is:
Fill up SECTION A in this form and sendCustomer
it to us along with aHelpline
Service cancelled cheque (or a photocopy of the same).
Simultaneously, SECTION B of the form needs to be submitted with your bank.
Location NumberCustomer Service Helpline Location Number
As soon as the ECS gets activated against your policy, all your premium payments will be debited directly from your
bank Andhra Pradesh
account. 98495-77766 Maharashtra (Mumbai) 98925-77766
Call Centre time : 9.00 A.M. to 9.00 P.M. Monday To Saturday (except on National Holidays)
Assam Location 99540-77766
Number Maharashtra (Rest) Location 98904-47766
Number
Bihar Pradesh
Andhra 99313-77766
9849577766 Orissa
Maharashtra (Mumbai) 99377-77766
9892577766
Chattisgarh
Chattisgarh 98931-27766
9893127766 Punjab
Maharashtra (Rest) 98159-77766
9890447766
Delhi
Delhi 98181-77766
9818177766 Rajasthan
Punjab 98292-77766
9815977766
Goa
Goa 98904-47766
9890447766 Tamil Nadu (Chennai)
Rajasthan 98408-77766
9829277766
Gujarat
Gujarat 98982-77766
9898277766 Tamil NaduNadu
Tamil (Rest)
(Chennai) 98944-77766
9840877766
Haryana (Karnal)
Haryana (Karnal) 98961-77766
9896177766 Uttar Pradesh (Agra, Bareilly, Meerut, Varanasi) 98973-07766
Tamil Nadu (Rest) 9894477766
Haryana (Faridabad) 98181-77766 Uttar Pradesh (Kanpur, Lucknow) 99352-77766
Haryana (Faridabad) 9818177766 Uttar Pradesh (Agra, Bareilly, Meerut, Varanasi) 9897307766
Karnataka 98455-77766 Uttaranchal 98973-07766
Karnataka 9845577766 Uttar Pradesh (Kanpur, Lucknow) 9935277766
Kerala 98954-77766 West Bengal (Kolkatta) 98313-77766
Kerala 9895477766
Madhya Pradesh 98931-27766 WestUttaranchal
Bengal (Rest) 9897307766
99330-77766
Madhya Pradesh 9893127766 West Bengal (Kolkatta) 9831377766
For other cities, kindly call our Customer Service Toll Free Number 1-800-22-2020 from your MTNL or BSNL line
For all other locations
Call Center timings:kindly calltoour
9.00 A.M. 9.00Customer
P.M. MondayService Toll(except
to Saturday Free Number 1-800-22-2020
national holidays)

Reach us.
@
@
Write to us at
Call Our Visit us at Reach us.at
Fax us Our Communication E-mail us at
Customer Service Helpline www.iciciprulife.com 022-67100803/805 Address lifeline@iciciprulife.com

Call Our Visit us at Fax us at Write to us at E-mail us at

Customer Service Helpline www.iciciprulife.com 022-67100803/67100805 Our Corporate Address lifeline@iciciprulife.com

Corporate Address :
Communication Address:
The Customer Service
ICICI Prudential Desk
Life ,ICICI Prudential
Insurance CompanyLife Insurance
Ltd., Company
Vinod Silk Ltd.,ICICI PruLife
Mills Compound, Towers,1089,
Chakravarthy AshokAppaSaheb Marathe
Road, Ashok Nagar, Marg, Prabhadevi,
Kandivali Mumbai
( E ), Mumbai 400–101.
400 025