Bank Account Updation Form for Payouts I request Exide Life Insurance Company Limited to update the below bank account details for any future payout of the below mentioned policy/s. A C K N O W L E D G M E N T S L I P Branch Seal DD MM Y Y Y Y Sign: This is to acknowledge the receipt of application for Bank Account Updation for future payouts Date Documents received: Policy No. Original Policy Document Valid Address Proof Identity Proof Bank Account Proof Others______________________________________________________________________________ Please tick (ü) any one Bank Account Type*: Savings Current Account Over Draft / Cash Credit NRO B A N K D E T A I L S Payment Method*: Direct Credit (NEFT/RTGS) A/c Payee Special Crossing Cheque Note: 1) In case the IFSC code is not provided or if the same is not enabled for NEFT, then the payout will be made by A/c payee special crossed cheque. Direct credit is not possible for NRE accounts. 2) Personalised cancelled cheque OR Personalised Bank statement is mandatory 3) If the information provided is incomplete or if there is a mis-match of details with our records, the same will not be updated. 4) Please note that the amoun t would be credited to the bank account numb er p rovided by y ou and the same will be con sidered as final . Bank Name*: Bank Branch*: Account Number*: IFSC Code*: P O S / M P A / V e r s i o n 2 . 1 D E C L A R A T I O N Signature / Thumb Impression of the Policy Owner / Assignee*: Witness Signature*: Date Name & Address of the Witness*: *(Should be someone other than the advisor/agent/employee of the company and who has also explained the contents of this form if signature is in vernacular or a thumb impression.) Y Y Y Y M M DD I take full responsibility for the genuineness and correctness of the details filled herein. All fields with (*) are mandatory Note: Please complete the form in CAPITAL LETTERS. F O R O F F I C E U S E O N L Y Branch Code: Employee No.: DD MM Y Y Y Y Date: Name of the Customer Service Representative: Signature: Address*: City*: State*: PIN*: Landline*: Mobile*: E-mail*: A D D R E S S Policy Number*: Policy Holder’s Name*: P O L I C Y D E T A I L S Additional Policy Nos. : 1. Do you have a PAN card T A X D E D U C T I O N S Yes No If Yes, kindly provide your Permanent Account Number (PAN): along with self-attested photo copy of PAN Card. As per Finance Act 2014 , payments made under Life Insur ance policies which are not exempt und er the Income T ax Act are subject to tax deduction at sou rce @ 2% (Under Section 194DA). In case the payee does not furnish valid PAN details, the rate of tax deduction will be 20%. 2. Are you curren tly a Resi dent of India Yes No If No, please specify country of Residence________________________________________. Note: In case you are not a Resident of India, then tax deductions will be applicable as per beneficial provisions of treaty with the respective Country of Residence. Email : [email protected] Call : 1800 419 8228 (TOLL FREE); +91 80 4134 5444 Visit : exidelife.in (Formerly ING Vysya Life Insurance Company Limited) Registered Office: Exide Life Insurance Company Limited, 3rd Floor, JP Techno Park, No.3/1, Millers Road, Bengaluru - 560 001. IRDAI Registration No. 114 CIN: U66010KA2000PLC028273