MANDATE FORM FOR PAYMENT OF SBI LIFE PREMIUMS THROUGH ELECTRONIC MODES ECS/ DIRECT DEBIT
(IN TRIPLICATE)
For Office Use
The Branch Manager
Bank:
Proposal No.
Branch:-
______________________Branch:___________________
Address _______________________________________________
Comments:-
Dear Sir,
Sub: Authorization to pay SBI Life insurance premiums through ECS / DIRECT DEBIT FACILITY
I/We ______________________________________________ hereby inform you that I / We have registered for payment of SBI Life premiums through
ECS (Debit Clearing) / Direct Debit. I/We hereby authorize you to debit my/ our bank account mentioned below towards my/ our premiums due on my
SBI Life insurance policies through their authorized service providers.
Further I authorize the representative (the bearer of this request) to get the above mandate verified. Mandate verification charges if any, may be charged
to my/our above account.
BANK ACCOUNT DETAILS
A/c.Holder’s Name
Jt. A/c Holder's Name
Account Number
Account Type
Savings
Current
MICR code (indicated on the cheque)
Mobile No for SMS alerts
(Mandatory)
IFSC Code
E-mail ID for alert: _____________________@_______________________
POLICY DETAILS
Policy Number
Frequency
Mly/Qly/Hly/Yearly
Mly/Qly/Hly/Yearly
Installment Premium*
Start Date of Mandate
End Date of Mandate
SERVICE ACCEPTANCE
I ______________________the undersigned hereby express my unconditional consent to debit my above mentioned account for the premiums for SBI Life Policies .
A.
B.
C.
D.
E.
F.
G.
I/We hereby authorize SBI Life Insurance Co. Ltd. and their authorized Service Providers to debit my/our Bank Account directly or by ECS/
Direct Debit for collection of premium payments.
I/We also declare that the particulars given above are correct and complete and that I/We have read and accepted the Terms and Conditions
mentioned overleaf.
I/We understand and accept that the transaction will be effected on the due date or the next working day of the bank. If the transaction is
delayed or not effected at all for incomplete or incorrect information or for any other reason I/We shall not hold SBI Life Insurance Co. Ltd. or
its authorized service provider responsible. I agree to discharge the responsibility expected of me as a participant under this scheme.
I/we undertake to inform SBI Life Insurance Co. Ltd. for any changes in my / our bank account.
I/ We hereby authorize SBI life insurance Company to debit the revised premium due to changes in Service Tax or any other tax made
applicable by the government
I/We hereby authorize to recover Rs 150/- per transaction, if the payment is not honored on the due date of premium as per mandate given.
If I/ We wish to revoke the above authorization, I /We undertake to intimate SBI Life Insurance Co. Ltd, at least 30 days in advance in writing.
Policy Holder Name _________________________________________ Policy Holders Sign X_________________________________________
Signature of 1st A/c Holder
Signature of 2nd A/c Holder
Signature of 3rd A/c Holder
Yes, I have attached the photocopy of a blank / cancelled cheque
Note :- 1) Activation of this facility would be done in 30 days from the receipt of the completed form. 2) Premiums due if any during this period will need to
be paid directly.
SBI Life Insurance Co. Ltd,
Corporate Office: "Natraj", M.V Road & Western Express Highway Junction, Andheri (East), Mumbai-400069
Central Processing Center: Kapas Bhavan, Plot No.3A, Sector No.10, CBD Belapur, Navi Mumbai-400614
PS-02/Ver1.3/13.9.2011
Page 1 of 3
Certification by Account Holders Bank
We hereby Certify that the above account is currently operational and the particulars furnished above are correct as per our records
and we have noted the instructions.
BANK STAMP
A
AUTHORISED SIGNATORY
DATE :
______________________________________________________________________________________________________________________________________
ECS
If you are an account holder of any Bank branch in the below mentioned cities you can opt for this mode of payment.
This facility is currently operational in below mentioned locations.
ECS LOCATIONS (87)
Agra
Bhavnagar
Ahmedabad
Allahabad
Amritsar
Anand
Asansol
Aurangabad
Banglore
Baroda
Bhopal
Belgaum
Bhilwara
Bhubanesh
war
Bijapur
Bardhaman
Bikaner
Calicut
Chandigarh
Chennai
Cochin
Coimbatore
Cuttack
Davanagere
Dehradun
Delhi
Dhanbad
Durgapur
Darjeeling
Erode
Gadag
Gorakhpur
Guwahati
Gwalior
Gulbarga
Haldia
Hubli
Hyderabad
Indore
Jabalpur
Jaipur
Jallandhar
Jammu
Jamnagar
Jamshedpur
Jodhpur
Kakinada
Kanpur
Kolhapur
Kolkata
Kota
Lucknow
Ludhiana
Madurai
Mangalore
Mumbai
Mysore
Mandya
Nagpur
Nashik
Nellore
Panjim
Patna
Pondicherry
Pune
Raichur
Raipur
Rajkot
Ranchi
Shimoga
Salem
Shimla
Sholapur
Siliguri
Surat
Tumkur
Thirupur
Tirupati
Tirunelveli
Trichur
Trichy
Trivandrum
Udaipur
Udupi
Varanasi
Vijawada
Vizag
DIRECT DEBIT
If you are an account holder of below mentioned Banks, and your account is core banking account then premiums will be debited to
your account through Direct Debit
BANKS FOR DIRECT DEBIT FACILITY
AXIS BANK
BANK OF BARODA
BANK OF INDIA
CITI BANK
ICICI BANK
INDUSIND BANK
KOTAK BANK
PUNJAB NATIONAL BANK
STATE BANK OF INDIA
UNION BANK OF INDIA
ALLAHABAD BANK
IDBI BANK
FEDERAL BANK
On successful registration, Direct Debit/ ECS instructions will be sent to your bank as per the predetermined schedule depending on the premium due
date , the premiums gets directly debited on the due date or on the next working day of your bank.
SBI Life Insurance Co. Ltd,
Corporate Office: "Natraj", M.V Road & Western Express Highway Junction, Andheri (East), Mumbai-400069
Central Processing Center: Kapas Bhavan, Plot No.3A, Sector No.10, CBD Belapur, Navi Mumbai-400614
PS-02/Ver1.3/13.9.2011
Page 2 of 3
Terms and conditions
1) The DIRECT DEBIT / ECS facility (via a designated bank account) would be made available by SBI Life Insurance Co Ltd. (“company”) through
authorized service providers subject to the following conditions.
2) The applicant should be eligible to avail and should provide true, accurate & current information as required by the Company and keep the same
updated and current at all times.
3) The facility will be available, subject to and upon receipt of confirmation from the bank of the bank account details furnished by the applicant in the
accompanying application.
4) The applicant may be required by the Company (or its authorized representatives) to verify the information furnished /filled –up in the accompanying
application form by way of a call (on mobile or landline number furnished in the accompanying application form).
5) The applicant shall be liable to ensure that there are sufficient clear fund in the designated bank account for effecting the transaction. In case of the
rejection of the transaction by applicant’s bank or the closing/shifting of the accounts, bill amount shall be liable to be paid through normal payment
modes together with interests and other late payment levies as applicable.
6) The Policyholder agrees that it shall be his/ her sole responsibility to schedule the renewal premium payments in a manner that the company receives
the renewal premiums within the due dates as specified in the relevant Policy Contracts(s) and that in the event of a late payment he / she shall be liable
for the late payment charges and other consequences as may be enforced by the company.
7)The ECS/ Auto Debit standing instruction issued by the applicant with respect to the designated bank account shall lapse upon closure of the
designated bank account or upon the bank refusing to honour the standing instruction for any reason’s or upon any moratorium being placed on the
activities of the designated bank accounts.
8) If one or more successive payments/instruction are not received / honoured, Company reserves the right to withdraw the services being provided
pursuant to the policy conditions and the Company reserves the right to withdraw the facility without either of them being liable to provide any notice to
the applicant and to initiate any other action/proceeding as may be deemed appropriate by the Company. In the event the applicant’s payment
instruction is dishonoured by the designated bank for any reason whatsoever, penalty charges of Rs.150 (or such other amount as specified by
Company from time to time) may be levied per instance of dishonoured.
9) The Company reserves the right to reject/withdraw the Facility at any time without assigning any reason and without being liable to provide advance
notice. In addition the Facility shall be withdrawn upon termination of the relationship between the Company and third party vendor(s) providing
equipment / connectivity / integration/ services which are necessary for continued provision of the Facility.
10) Company disclaims all warranties of any kind, whether express or implied including without limitation any representation or warranty, regarding the
use or the results of the Facility in terms of its correctness, accuracy, reliability, usefulness. Completeness, continuity, uninterrupted access, timeliness
or otherwise.
11) Company shall not be responsible and liable for any damages/ compensation for any loss, damages etc incurred by the applicant of use, nonavailability or deficiency in the provisioning of the Facility. The applicant shall bear the entire responsibility for and risk associated with use of the Facility.
12) Company shall not be liable for any direct, indirect, punitive, incidental, special or consequential damages whatsoever, including but not limited to the
damages or losses resulting from: a) The use or performance of inability to use of non-performance of the Facility. b) The provision of failure to provide
the Facility c) The unauthorized access to or alteration of the transmissions or data such transactions that are carried out on your instructions in good
faith. d) Any loss or damage incurred or suffered by applicant due to any defect, error, failure or interruption in the provision of the Facility or any other
matter related to the facility.
13) The Company reserves the right to modify (with prospective to retrospective
liable to provide any reason or notice therefore.
effects). These terms and conditions from time to time without being
14)In the event the applicant dissatisfied with the Facility being made available in any respect or with any of the Terms of Service or alterations thereto,
the applicant’s sole and exclusive remedy is to discontinue the use of the Facility.
15) The Facility shall not be used for any purpose that is unlawful or prohibited under law or the Company. The foregoing terms and condition shall form
an integral part of the CAF. Further the Policy Holder agrees that the laws of India shall govern this agreement and in case of a dispute the matter will be
settled as per the provisions of the Arbitration and Conciliation Act 1996 and within the exclusive jurisdiction of the courts of Mumbai.
16) The customer shall be responsible to pay/ bear any taxes, duties or levies imposed on this form.
17 ) In case of ULIP Policies unitization will be based on the date on which the amount is realized / payment files are received by the company
whichever is later
18) Notwithstanding what is mentioned herein above, it is understood that the company is extending such facilities to make it convenient for and facilitate
the policyholder to pay the renewal premiums and it is further acknowledged that the onus and liability to make such payments within the due dates
specified in the relevant Policy Contract(s) vests solely and absolutely with the policyholder.
Note: If your bank and branch is not covered under Direct Debit facility then premiums will be debited through ECS provided the location of
your branch falls in any of the ECS locations stated given above.
For any clarifications Please Contact us at our Toll Free Number 1800 22 9090 (Toll free), 1800 222 123 OR 1800 425 9010. You can email to us at
ecshelpdesk@sbilife.co.in
SBI Life Insurance Co. Ltd,
Corporate Office: "Natraj", M.V Road & Western Express Highway Junction, Andheri (East), Mumbai-400069
Central Processing Center: Kapas Bhavan, Plot No.3A, Sector No.10, CBD Belapur, Navi Mumbai-400614
PS-02/Ver1.3/13.9.2011
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