Tick the applicable payment option to pay your Initial premium and renewal insurance premium:

Standing Instruction Mandate- Direct Debit/ ECS/ Credit Card/ PNB-Auto Debit / J&K Bank-Auto Debit / KBL-Auto Debit

** Amounts may vary due to taxes (including but not limited to any change in applicable tax rates), counter of fers, revised premiums, additional insurance/ riders. Please Note: Standing Instruction Debit Date will be the Premium Due date or the next banking day, if the due date is a banking holiday

Declaration by the Policy Owner I hereby declare that the particulars given above are correct and complete in all respects. I authorize PNB MetLife India Insurance Company Limited. (the "Company") and/or its authorized service provider/Bank to collect the amounts as may be due on account of payment for life insurance premium(s) payable on and/or pursuant to the life insurance proposal(s)/ policy(ies), and Rider(s) (if any), as issued by the Company, by Debit to my Bank Account/ Credit Card as per details provided above. I understand and agree that premium amount to be debited from my account may vary due to change in tax structure, counter offers, revised premiums, additional insurance/ riders. In the event of my bank being unable to debit my account, for whatsoever reason, I will pay insurance premium directly to the Company. I will also inform the Company for any changes in my Bank Account or Credit Card details.

Mandate Reference Number (To be incorporated by Punjab National Bank / Karnataka Bank, after updating their system)

Mandatory Fields for all options

Please fill the following information if the chosen Standing Instruction option is Direct Debit or ECS or PNB-Auto Debit or J&K Bank-Auto Debit or KBL-Auto Debit

Please Fill in the following information if the chosen Standing Instruction option is Credit Card

Yes, I have attached a copy of the front side of the Credit Card

Name of the Credit Card Holder(s)

(Mr./ Mrs./ Ms./ Dr./ M/s)

Credit Card No.

Name of the Issuing Bank Master VISAAmex Diners

Card Issuing Authority(tick any one)

Credit Card Expiry Date /

This is to state that I have registered for the RBI's Electronic Clearing Service/ Direct Debit / PNB-Auto Debit/ J&K Bank Auto Debit and that my premium payment shall be made from the above mentioned Account/ Credit Card with your bank. I hereby authorize the representative carrying this ECS/Direct Debit/ PNB-Auto Debit/ J&K Bank Auto Debit/ KBL Auto Debit/ Credit Card mandate form to get it verified and /or executed. Account Holder's Signature (As in Bank Record): __________________________________ Account Number : _____________________________

Authorization of the Bank Account/ Credit Card Holder (to be signed by the Account/ Credit card Holder)

Terms and ConditionsThe Proposer/ Policy Owner confirms, understands and agrees that:1. Without prejudice to any rights of the Company/ its authorised service provider/ the Bank the Policy Owner will indemnify and hold the Company / its authorised service provider / the Bank

harmless against any and all liability, costs and expenses that may be incurred by the Company / its authorised service provider / the Bank arising out of any acts of omission or commission or negligence on the part of the Proposer/ Policy Owner.

2. In case the customer intends to cancel the ECS or Direct Debit mandate he/ she may do so by giving 15 days written notice to PNB MetLife prior to the due date of ECS / Direct Debit mandate and the same shall be processed by PNB MetLife at no extra charges.

3. The Company / its authorised service provider / the Bank shall in no way be responsible for non-execution or delay in execution of direct debit instruction either on account of incomplete or inaccurate information or non-availability of sufficient funds in the account or for other reason beyond the Company's control.

4. The Company is authorized to enable the Direct Debit/ ECS/ CC SI/ PNB-Auto / Debit/ KBL Auto Debit facility for the premium payments and in the instance of Direct Debit J&K Bank AutoDebit/ ECS/ CC/ PNB-Auto / Debit/ KBL Auto Debit dishonor, to re-debit the Policy Owner/ Account Holder's account with the mentioned bank to recover the premium Debit J&K Bank Auto payable.

5. The company does not levy any additional charges towards cancellation of the ECS mode/recover such additional charges from the benefits payable under the policy.6. In order to validate Auto Debit Mandate, PNB MetLife is authorized to debit customers' account with Re. 1 which would be refunded back into customer's account.

DECLARATION :The contents of this mandate has been read over and explained to me in vernacular. I have understood the contents completely and have furnished the information and instruction contained herein out of my free will and volition, after fully understanding the contents thereof, I hereby certify the contents hereof as true and correct.

Signature OR Left Thumb Impression of the customer__________________________________________ Date: ____________________________________

Name: __________________________________________________________Place: ___________________________________

Name and Counter Signature of the person who have explained the contents to the customer in vernacular……………………………………………..

If Selected Please Complete The Additional Declaration FormPlease tick ( ) in case of : Vernacular Illiterate

Direct Debit ECS (Electronic Clearing Service) Credit Card-SI

PNB Auto Debit-SI Including Initial Premium PNB Auto Debit-Renewal KBL-Auto DebitJ&K Bank Auto Debit-Including Initial Premium

Payment Frequency Monthly Quarterly Half Yearly Annual

Proposed Holder Name

Policy/Application Number

Email

PAN (Permanent Account No.)

Standing Instruction Start Date : _____/_____/_____ (DD/MM/YY) Standing Instruction End Date : _____/_____/_____ (DD/MM/YY)

(Note - Start and end date for PNB Auto Debit/ J&K Bank Auto Debit/ KBL Auto Debit for first premium will be date of creation of mandate in bank records)

Mobile Number

Amount in “INR” as mentioned in Application form

DC No. (To be incorporated by Jammu and Kashmir Bank, after updating their system)

Bank Account Number:

Yes, I have attached a copy of cancelled bank cheque for Direct Debit/ ECS/ PNB – Auto Debit/ J&K Bank-Auto Debit/ KBL-Auto Debit

BANK SOL ID* (Only for PNB Account)

Others _____________________________________________

Union Bank of India Punjab National BankIDBI Bank

ICICI BankDirect Debit, please tick operated bank name: Citi BankAllahbad Bank Bank of Baroda Bank of India Federal Bank

Karnataka Bank Kotak Mahindra Bank State Bank of India Jammu and Kashmir Bank

Name of the Account Holder as per bank records: (Mr./Mrs./Ms./Dr./M/s.)

Account Type (Please select on) Savings

Salary

Total Freedom

Cash Credit

Overdraft

OthersLoan Account

9 Digit MICR Code

If the chosen option is PNB-Auto Debit, please also fill the below mentioned details. GBPA Code of signature verifying authority : _________________________________________________________________________________

It is certified that the particulars of the Mandate above are correct, and the Signature of the Bank Account Holder, is true, as per our records and that a copy of this form duly completed has been submitted to us.Bank's Stamp : Signature of the Authorized official of the Bank: _____________________________________

Place:_____________________________________________ Date:________________________

Certificate of the Bank Named in the Mandate (to be filled in case of Direct Debit/ ECS/ PNB-Auto Debit/ J&K Bank Auto Debit/ KBL Auto Debit)

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Name and Address of the Bank/Branch

This is to confirm that the declaration has been carefully read, understood & made by me/us.

1. Name as in bank records

Signature of Account holder

2. Name as in bank records

Signature Primary Account holder Signature of Account holder

3. Name as in bank records

an amount of Rupees

with Bank Name of customers bank IFSC or MICR

Bank a/c number

UMRN D D M M Y Y Y YDate

Sponsor Bank Code

I/We hereby authorize SB/CA/CC/SB-NRE / SB-NRO /Otherto debit (tick )

ACH Form (Automated Clearing House)

Note - Please do not mention anything in Reference 2 and Period (From/ To) fields.

Terms and Conditions

The Proposer/ Proposed Owner confirms, understands and agrees that:1. Without prejudice to any rights of the Company/ its authorized service provider/ the Bank the Proposed Owner will indemnify and hold the Company / its authorized service provider / the Bank

harmless against any and all liability, costs and expenses that may be incurred by the Company / its authorized service provider / the Bank arising out of any acts of omission or commission or negligence on the part of the Proposer/ Policy Owner.

2. In case the customer intends to cancel the ACH mandate he/ she may do so by giving 15 days written notice to PNB MetLife prior to the due date of ACH mandate and the same shall be processed by PNB MetLife at no extra charges.

3. The Company / its authorized service provider / the Bank shall in no way be responsible for non-execution or delay in execution of direct debit instruction either on account of incomplete or inaccurate information or non-availability of sufficient funds in the account or for other reason beyond the Company's control.

4. The Company is authorized to enable the ACH facility for the premium payments and in the instance of ACH dishonor, to re-debit the Proposed Owner/ Account Holder's account with the mentioned bank to recover the premium payable.

5. The company does not levy any additional charges towards cancellation of the ACH mode/recover such additional charges from the benefits payable under the policy.

6. There is no need to give cancelled cheque for ACH registration.

T O B E F I L L E D B Y B A N K

Utility Code HDFC00799000009657HDFC0000060

FREQUENCY As & when presented DEBIT TYPE

Phone No.

Email ID

Maximum Amount

Reference 1

Reference 2

PERIOD

From

To

Or Until Cancelled

PNB MetLife India Insurance Company Ltd

Tick ( )

CREATE

MODIFYCANCEL

S. No. Bank Name1. Abhyudaya Co-operative Bank2. Abu Dhabi Commercial Bank3. Ahmednagar Shahar Sahakari Bank Maryadit4. Ambarnath Jai-hind Co-op. Bank Ltd.5. Andhra Bank6. Andhra Pragathi Grameena Bank7. Apna Sahakari Bank Ltd.8. Ashok Sahakari Bank Ltd.9. Axis Bank10. Bank Of America11. Bank Of Bahrain & Kuwait12. Bank Of Baroda13. Bank Of Ceylon14. Bank Of India15. Barclays Bank Plc16. Bassein Catholic Co-op Bank Ltd.17. Bhagini Nivedita Sahakari Bank Ltd.18. BNP Paribas19. Canara Bank20. Capital Local Area Bank 21. Central Bank Of India22. Citibank N A23. Corporation Bank24. Credit Agricole Corporate & Investment Bank25. DCB Bank Ltd.26. Delhi Nagrik Sehkari Bank Ltd. 27. Dena Bank28. Deutsche Bank AG29. Dhanalaxmi Bank30. Dindigul Central Co-operative Bank Ltd.31. DMK Jaoli Bank32. Dombivili Nagari Sahakari Bank Ltd.33. Fingrowth Co-operative Bank Ltd.34. George Town Co-operative Bank Ltd.35. Gopinath Patil Parsik Janata Sahakari Bank36. Guardian Souharda Sahakari Bank Niyamita37. Gurgaon Gramin Bank38. HDFC Bank Ltd.39. ICICI Bank Ltd.40. IDBI Bank41. Indian Bank42. Indraprastha Sehkari Bank Ltd.43. Indusind Bank44. Ing Vysya Bank Ltd45. Jalgaon Janata Sahkari Bank Ltd.46. Jamia Co-operative Bank Ltd47. Janakalyan Sahakari Bank

S. No. Bank Name48. Janaseva Sahakari Bank (Borivli) Ltd.49. Janata Co-op. Bank Ltd. Malegaon50. Janata Sahakari Bank Ltd.51. Kallappanna Awade Ichalkaranji Janatasahakari Bank52. Karnataka Vikas Grameena Bank53. Karur Vysa Bank54. Kotak Mahindra Bank Ltd.55. Kurla Nagarik Sahakari Bank Ltd.56. Maharashtra Gramin Bank57. Mizuho Bank Ltd.58. Mumbai District Central Co-op Bank Ltd.59. Nagpur Nagarik Sahakari Bank Ltd.60. Nagpur Nagarik Sahakari Bank Ltd.61. Navabharat Co-op. Urban Bank Ltd.62. New India Co-op Bank Ltd.63. Nkgsb Co-op. Bank Ltd.64. North Malabar Gramin Bank65. Nutan Nagarik Sahakari Bank Ltd.66. Oriental Bank Of Commerce67. Parshwanath Co-operative Bank Ltd.68. Prathama Bank69. Prime Co-operative Bank Ltd.70. Priyadarshani Nagari Sahakari Bank Ltd., Jalna.71. Pudukottai District Central Cooperative Bank Ltd.72. Punjab & Maharashtra Co-operative Bank73. Punjab & Sind Bank74. Punjab National Bank75. Pusad Urban Co-op Bank Ltd.76. Rajgurunagar Sahakari Bank Ltd.77. Rajkot Nagarik Sahakari Bank Ltd.78. Ratnakar Bank79. Sangli Urban Co-operative Bank Ltd.80. Sant Sopankaka Sahakari Bank Ltd.81. Saraswat Bank82. Shivalik Mercantile Co-op Bank Ltd.83. Shree Mahalaxmi Urban Co-op Credit Bank Ltd.84. Shri Chhatrapati Rajarshi Shahu Urban Co-op Bank 85. Shri Veershaiv Co-op Bank Ltd.86. Sindhudurg District Central Cooperative Bank Ltd.87. Sir M Visvesvaraya Co-operative Bank Ltd.88. South Indian Bank89. Standard Chartered Bank90. State Bank Of India91. State Bank Of Mauritus Ltd.92. Sumitomo Mitsui Banking Corporation93. Suvarnayug Sahakari Bank Ltd.94. Syndicate Bank

S. No. Bank Name95. Tamilnad Mercantile Bank Ltd.96. Tamilnadu State Apex Co-op Bank Ltd.97. Tamluk-ghatal Central Co-operative Bank Ltd.98. Textile Traders Co-operative Bank Limited99. Thane Bharat Sahakari Bank Ltd.100. The Abhinav Sahakari Bank Limited101. The Adarsh Cooperative Urban Bank Limited102. The Agrasen Co-operative Urban Bank Ltd.103. The Ahmedabad Mercantile Co-op Bank Ltd.104. The Annasaheb Savant Co-op Urban Bank Mahad Ltd.105. The Bank Of Nova Scotia106. The Baramati Sahakari Bank Ltd.107. The Bharat Co-operative Bank Ltd.108. The Catholic Syrian Bank109. The Chembur Nagarik Sahakari Bank110. The Chengelpattu Co-op Urban Bank Ltd.111. The Chiplun Urban Cooperative Bank Ltd.112. The Citizen Cooperative Bank Limited113. The Citizens Urban Cooperative Bank Ltd.114. The Cosmos Co-operative Bank Ltd.115. The Delhi State Cooperative Bank Limited116. The Faridkot Central Co-operative Bank Ltd.117. The Fazilka Central Coop. Bank Ltd.118. The Ferozepur Central Coop. Bank Ltd.119. The Gadchiroli District Central Cooperative Bank 120. The Gayatri Cooperative Urban Bank Ltd.121. The Goa State Co-operative Bank Ltd.122. The Goa Urban Co-operative Bank Ltd.123. The Greater Bombay Co-operative Bank Limited124. The Gurdaspur Central Cooperative Bank Ltd.125. The Hasti Co-op. Bank Ltd.126. The Hongkong & Shanghai Banking Corporation Ltd.127. The Jalandhar Central Cooperative Bank Limited 128. The Jalgaon Peoples Co Op Bank Ltd.129. The Kalupur Commercial Co-operative Bank130. The Kalyan Janata Sahakari Bank Ltd.131. The Kangra Central Co-operative Bank Ltd.132. The Kangra Co-operative Bank Ltd.133. The Kapol Co-operative Bank Ltd.134. The Karad Urban Co-op Bank Ltd.135. The Karnataka State Co-operative Apex Bank Ltd.136. The Kottayam District Co-operative Bank Ltd.137. The Lakshmi Vilas Bank Ltd.138. The Ludhiana Central Cooperative Bank Ltd.139. The Madgaum Urban Cooperative Bank Ltd.140. The Mahanagar Co-op. Bank Ltd.141. The Malkapur Urban Co-op Bank Ltd.

S. No. Bank Name142. The Mehsana Urban Co-operative Bank143. The Moga Central Cooperative Bank Ltd.144. The Mugberia Central Co-operative Bank Ltd.145. The Municipal Co-op Bank Ltd.146. The Nasik Merchants Cooperative Bank Ltd.147. The Nav Jeevan Co-op Bank Ltd.148. The Nawanshahr Central Cooperative Bank Ltd.149. The Odisha State Co-operative Bank Ltd.150. The Panchkula Central Co-operative Bank Ltd.151. The Pochampally Cooperative Urban Bank Ltd.152. The Punjab State Cooperative Bank Ltd.153. The Rajasthan State Co-operative Bank Ltd.154. The Ropar Central Cooperative Bank155. The Royal Bank Of Scotland156. The S.a.s Nagar Central Cooperative Bank Ltd.157. The Sahebrao Deshmukh Co-op. Bank Ltd.158. The Sahyadri Sahakari Bank Ltd.159. The Saidapet Co-op Urban Bank Ltd.160. The Salem District Central Co-operative Bank Ltd.161. The Shamrao Vital Co-operative Bank162. The Surat People's Co-op. Bank Ltd.163. The Sutex Co-op.bank Ltd.164. The Thane Dist. Central Co-op. Bank Ltd.165. The Thiruvannamalai District Central Coop Bank Ltd.166. The Tirunelveli District Central Co-op Bank Ltd. 167. The Udaipur Mahila Urban Co-op Bank Ltd.168. The Udaipur Urban Co-op Bank Ltd.169. The Varachha Co-op Bank Ltd.170. The Vellala Co-operative Bank Limited171. The Vellore District Central Co-op Bank Ltd.172. The Vishweshwar Sahakari Bank Ltd. 173. The Wayanad District Co-operative Bank Ltd.174. The West Bengal State Co-op Bank Ltd.175. Thrissur District Cooperative Bank Ltd.176. Tiruvallur Co-operative Urban Bank Limited177. TJSB Sahakari Bank Ltd.178. Tumkur Grain Merchant's Co-operate Bank Ltd. 179. Union Bank of India180. United Bank of India181. Vasai Vikas Sahakari Bank Ltd.182. Vijaya Bank183. Vivekanand Nagrik Sahkari Bank Mydt184. Yavatmal District Central Co-operative Bank Ltd.185. Yes Bank

List updated as on 01‐Oct‐2014

X X X X X X X X X X X X X X X X

Please fill the following mandatory fields – (1) Date (2) Bank a/c number (3) Bank name (4) IFSC/MICR Code (5) Amount (6) Policy No./application No in “Reference 1 column” (7) Account holder signature (8) Account holder name

List of Banks participating in ACH (Auto Clearing House)

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