DIRECT CREDIT AUTHORISATION FORM
Instructions:
1 IRDA of India has mandated all Payouts through National Electronic Funds Transfer (NEFT). Please submit your form today.
2 A Single request form shall apply to all policies where you are Policyholder.
3 Form to be filled by the Assignee in case of Assigned policies.
4 In case of non personalized Cheque, please also provide Bank Pass book/Bank statement.**
5 In case policyholder / Account holder / Assignee is a company, please affix stamp of the company along with signature.#
6 This form shall be ineffective when the Policy is endorsed as Married Women Property Act (MWPA).
Policy Details
Policy Number
Policyholder/Assignee Name Mr/Mrs/M/S.
Address of Policyholder/Assignee
(In case of change - Attach address proof)
Landmark City
State Pin Code
Contact
Numbers STD Residence STD Office Extn Mobile
Email ID
Bank Account Details
Bank Account Number 11 Digit
IFSC code
First Account Holder Name Mr/Mrs/M/S.
(Exactly as per Bank records) Bank
Name
Branch
Account Type Savings Current NRO NRE (For NRE account, payout cheque with NRE letter will be processed)
** Original blank personalized cancelled cheque attached Yes No
Declaration
I/We hereby declare that the information given above are correct and complete and shall inform you for changes if any. Tata AIA Life shall not be responsible for delay in credit, amount not credited,
amount credit to incorrect account, due to incomplete or incorrect information herein. I/we understand that the information provided by me/us may be shared with third parties as per legal or
regulatory requirements.. I/We understand and agree that where NEFT cannot be processed for whatsoever reason, the payout may be processed through cheque.
Signature of Policyholder/Assignee# (As on Signature of 1st Account Holder Signature of 2nd Account Holder Policy
Application) (As per bank records) (As per bank records)
Date - / /
D D / M M / Y Y Y Y Place
CERTIFICATION BY ACCOUNT HOLDER'S BANK: (For Bank Use Only)
We certify that the particulars furnished above are correct as per our records & that this account is currently operational. We confirm that the account details & account holder’s signature(s) above are as
per our records.
/ /
D D / M M / Y Y Y Y
Bank Authorized Signatory with Emplyoee ID Bank Branch stamp Date
Tata AIA Life Insurance Company Ltd. (IRDA of India Regn. No. 110) (CIN - U66010MH2000PLC128403)
Registered & Corporate Office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013. For more Information, contact your advisor or call on our Helpline
No 1-860-266-9966 (local charges apply) or SMS "Service" to 58888 or e-mail us at [email protected] or visit our website www.tataaia.com
Version 5.2 - L&C/Misc/2016/Feb/074
BEWARE OF SPURIOUS PHONE CALLS AND FICTITIOUS/FRAUDULENT OFFERS : IRDA of India clarifies to public that IRDA of India or its officials do not involve in activities like sale of any kind of
insurance or financial products nor invest premiums. IRDA of India does not announce any bonus. Public receiving such phone calls are requested to lodge a police complaint along with details of phone
call, number.
