PSRF330826062098 | Comp/Jun/Int/5062 Customer Acknowledgement Copy - Mandate Deactivation Request Form HDFC Life Insurance Company Limited [Formerly HDFC Standard Life Insurance Company Limited] (HDFC Life). CIN:L65110MH2000PLC128245. IRDAI Registration No.101. Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011. Call 1860-267-9999 (local charges apply). DO NOT prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm | Email – [email protected] | [email protected] (For NRI customers only) Visit – www.hdfclife.com. HDFC Life Insurance Company Limited [Formerly HDFC Standard Life Insurance Company Limited] (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101. Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011. HDFC Life Stamp Policy No.: Interaction ID Nos: ____________________________________ Policyholder’s Name: ____________________________________________________________________________ Customer Relations Officer: ___________________ Date: ____________________Time: ______________________ DD/MM/YYYY Part II - Instructions 1. Request for deactivation needs to be submitted 15 days prior to the debit date. 2. If the request is given within 15 days from the debit date, then the premium will be debited as per the existing mandate on the debit date and the mandate shall be deactivated from the next due date. 3. Mandate Deactivation request stands confirmed only once the request is complete in all aspects and the same is accepted and processed by us. 4. On deactivation of the auto debit facility, any discount on premium (if applicable as per the product feature) will be discontinued. 5. Assignee's details, registered stamp (where applicable) and signature are mandatory in case of assigned policies. For Assigned Policies Signature of Policyholder(s) Signature of Policyholder(s) SIGN HERE Signature of Joint Life Assured SIGN HERE DD/MM/YYYY Date:_________________ Place:_________________ HDFC Life Stamp Assignee’s Stamp and Signature SIGN HERE DD/MM/YYYY Date:_________________ Place:_________________ Name of the Assignee _____________________________________________ Reason for deactivation: __________________________________________________________________________________________________ Policy No. 1: ________________________________________________________________________________________________________ Policy No. 2: ________________________________________________________________________________________________________ Policy No. 3: ________________________________________________________________________________________________________ Mandate Deactivation Request Form For Official Use Only Branch: Received at branch on: Received by: Signature of Third Person SIGN HERE The Policyholder has affixed his/her thumb impression/has signed in vernacular/has not filled the application. I hereby declare that the content of this application form has been explained to the Policyholder in __________________ language and have truthfully recorded the answers provided to me. I further declare that the Policyholder has signed/affixed his/her thumb impression in my presence. With reference to recent regulatory changes, please submit PAN or Form 60 (if you do not have a PAN) with HDFC Life with immediate effect. Pls update via My Account/[email protected]/18602679999/HDFC Life branch. Ignore if submitted. Name of the Declarant: ______________________________________________________________________________ Address: ________________________________________________________________________________ Date: __________________ Place: ________________ DD/MM/YYYY Part III -Declaration made by third person where the Policyholder has affixed his/her thumb impression/has signed in vernacular Type of Deactivation Request: (SI) (ECS) (Credit Card) (Direct Debit) Request Form signed by Policyholder: (Yes/No) Interaction IDs: ___________________________________ Signature verified: Yes No Employee Name: _______________________________________ Employee ID: ________________________ Office Use Only: NOTE Name of the Policyholder: _ _________________________________________________________________________________________________ Contact* No.: (Res) ____________________ / (Office) ____________________ / (Mobile) _______________________________(mobile no. is preferable) Permanent Account Number (PAN): ________________________________ Email ID * : _______________________________________________________________________________________________________________ *Contact details provided herein will be updated for all future communications. The above mentioned contact number will be considered as consent to communicate with you on the contact details provided herein. E- Insurance Account No.: Part I - Personal Details
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![Page 1: 024687020 MANDATE DEACTIVATION REQUEST FORM · 2020. 7. 2. · HDFC Life Insurance Company Limited [Formerly HDFC Standard Life Insurance Company Limited] (HDFC Life). CIN:L65110MH2000PLC128245.](https://reader034.cupdf.com/reader034/viewer/2022051919/600c56a4e4c79a42e3664242/html5/thumbnails/1.jpg)
PSRF330826062098 | Comp/Jun/Int/5062
Customer Acknowledgement Copy - Mandate Deactivation Request Form
HDFC Life Insurance Company Limited [Formerly HDFC Standard Life Insurance Company Limited] (HDFC Life). CIN:L65110MH2000PLC128245. IRDAI Registration No.101.Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011. Call 1860-267-9999 (local charges apply). DO NOT prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm | Email – [email protected] | [email protected] (For NRI customers only) Visit – www.hdfclife.com.
HDFC Life Insurance Company Limited [Formerly HDFC Standard Life Insurance Company Limited] (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
HDFC Life StampPolicy No.: Interaction ID Nos: ____________________________________
Policyholder’s Name: ____________________________________________________________________________
Customer Relations O�cer: ___________________ Date: ____________________Time: ______________________DD/MM/YYYY
Part II - Instructions1. Request for deactivation needs to be submitted 15 days prior to the debit date.2. If the request is given within 15 days from the debit date, then the premium will be debited as per the existing mandate on the debit date and the mandate shall be deactivated from the next due date.3. Mandate Deactivation request stands con�rmed only once the request is complete in all aspects and the same is accepted and processed by us.4. On deactivation of the auto debit facility, any discount on premium (if applicable as per the product feature) will be discontinued.5. Assignee's details, registered stamp (where applicable) and signature are mandatory in case of assigned policies.
For Assigned PoliciesSignature of Policyholder(s)
SIGN HERE
Signature of Policyholder(s)
SIGN HERE
Signature of Joint Life Assured
SIGN HERE
DD/MM/YYYYDate:_________________ Place:_________________
HDFC Life Stamp
Assignee’s Stamp and Signature
SIGN HERE
DD/MM/YYYYDate:_________________ Place:_________________
Name of the Assignee _____________________________________________
Reason for deactivation: __________________________________________________________________________________________________
Policy No. 1: ________________________________________________________________________________________________________
Policy No. 2: ________________________________________________________________________________________________________
Policy No. 3: ________________________________________________________________________________________________________
Mandate Deactivation Request FormFor O�cial Use OnlyBranch: Received at branch on:Received by:
Signature of Third Person
SIGN HERE
The Policyholder has a�xed his/her thumb impression/has signed in vernacular/has not �lled the application. I hereby declare that the content of this application form has been explained to the Policyholder in __________________ language and have truthfully recorded the answers provided to me. I further declare that the Policyholder has signed/a�xed his/her thumb impression in my presence.
With reference to recent regulatory changes, please submit PAN or Form 60 (if you do not have a PAN) with HDFC Life with immediate e�ect. Pls update via My Account/[email protected]/18602679999/HDFC Life branch. Ignore if submitted.
Name of the Declarant: ______________________________________________________________________________
Address: ________________________________________________________________________________
Date: __________________ Place: ________________DD/MM/YYYY
Part III -Declaration made by third person where the Policyholder has a�xed his/her thumb impression/has signed in vernacular
Type of Deactivation Request: (SI) (ECS) (Credit Card) (Direct Debit)
Request Form signed by Policyholder: (Yes/No) Interaction IDs: ___________________________________
Signature veri�ed: Yes No
Employee Name: _______________________________________ Employee ID: ________________________
O�ce Use Only:
NOTE
Name of the Policyholder: _ _________________________________________________________________________________________________
Contact* No.: (Res) ____________________ / (O�ce) ____________________ / (Mobile) _______________________________(mobile no. is preferable)
Permanent Account Number (PAN): ________________________________
Email ID*: _______________________________________________________________________________________________________________*Contact details provided herein will be updated for all future communications. The above mentioned contact number will be considered as consent to communicate with you on the contact details provided herein.
E- Insurance Account No.:
Part I - Personal Details
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