LIFE INSURANCE CORPORATION OF INDIAPOLICYHOLDERS' MANDATE FORM FOR PAYING PREMIUM THROUGH

ELECTRONIC CLEARANCE SERVICE (DEBIT CLEARING) - ECS Page: 1

NEW APPLICATION I ICHANGE IN BANK DETAILS I ICANCELLATION I

FORM A: ECS Mandate Form.(TO BE SUBMITTED TO LIC BRANCH OFFICE)IMPORTANT: Kindly see the instructions on page-3 before filling theform

(TIck which Is applicable and strike oft'the others)

LIC's User code (Utility Code) for ECS is 40090561. (a) Name of the policyholder/s _

(b) Policy Details :

Sr. New proposal!·No. Policy No.

Name of the Insured Self &/spouse/children Premium Amount

1.

Mode

2.3.45.

(c) Tel. No. Res.: Off.:E-mail ID:

2. Particulars of Bank AlC (from which you want to pay the premia) Bank Nameb) Bank Address

c) Name of the Account Holder/sd) Account Type (Savings Bank Account-lO/Current Alc-ll ore) Account Number (as appearing on the Cheque Book) I I If) 9 Digit MICR CODE NUMBER of the Bank and Branchl I

3. (a) IIWe hereby instruct the bank to debit my/our above AccountRs. as above/as per demand sent by LIC

(b) If in future my/our Bank Account is transferred to a city wherof mode will be necessary which will involve change in premi

(c) IIWe agree that this Mandate will form anintegral part of my/I1we, hereby, declare that the particulars given above are correct and comppolicy/policies express my/our willingness to remit the premium/s referredNational Clearing Cell of Reserve Bank of India and hereby authorize thethe debits on my/our Bank Account towards the said premiumls due referredeffected at all for the reasons of incomplete or incorrect information or non-etc. I would not hold LIC or the user institution responsible. I understand tmay take one month time in getting the process commenced. I also understanof my near relatives as prescribed by the Income- Tax Act, 1961. I1We haveagree to the same.

Place : Date:

Relation of Ale holder to the policy holder (Ist Policy)(in casethe policyholderdiffersfrom that of the Ale holder)

1. We certify that the Bank particulars furnished above are correct as per 0

2. We acknowledge the receipt of the mandate and note to carry out the c

Date: Bank Seal Sign

1

Mobile No.: _

urn) :

Cash/Credit- 13)

e ECS facility is not available, a changeum (in case ofECS (MLY) mode)our proposal (Only for new proposals)lete. I1we being the holder/s of the aboveto above through participation in ECS of

Life Insurance Corporation of India to raiseabove. If any transaction is delayed or not

availability of funds or closure of Accountshat the first transaction after authorization

d that I can pay the premium only on behalfread the terms and conditions and lIwe

Signature/s of the Policyholder/s

Signature of the Alc holder

ur records and the account is active.ustomer' instructions as per mandate given.

ature of the Bank Official

Page: 2

FORM B - Acknowledgement Slip from LIC Branch Office for receipt ofECS mandate(To be given to the policy holder after receiving the ECS Mandate form)

Mandate for premium deduction through ECS received from Mr/Ms on

_______ at (place) with following details:

Polic)' Number Premium Amount Policy Number Premium Amount Policy Number Premium Amount

New Policy; Proposal Number: dated _

Bank Details:1. BankName _

2. Name of the Account Holder/s _

3. Account Type (Savings Bank Account Current Nc or Cash/Credit) _

4. Account Number (as appearing on the Cheque Book) _

5. 9 Digit MICR CODE NUMBER of the Bank and Branch _

Received & verified by Branch Office Date _

(perforation may be provided here)

FORM C - Authorization to Bank(To be retained by the Bank)

The Manager,

Bank Name : ~ .

Bank Address: ......................................................................................................................................

AccountNumber : •..••..............•............••..........•.••...............

Dear Sir,

UWe wish to inform that I/we have registered ECS facility for premium payment to LIC of India, Utility Code4009056 for my/our new / existing policy / policies as mentioned below and the payments are to be madethrough the above mentioned account and be routed to you directly through the RBI's Electronic ClearingServices. UWe authorize you to debit my account to honour all such instructions.

Policy number/s Premium Mode Due Date Premium Ded. DeductionAmount of ECS Start From upto

1. ~ _

2.

3.

4.5. _6. New Policy; Proposal Number: .dated _

Signature/s of the Account holder/s : _Dare: _

Place: _