Life Insurance Corporation Of India

P & GS UNIT
FORM OF ECS OPTION ( ANNUITY PAYMENT

To,
DIVISIONAL MANAGER(P&GS),
LIC OF INDIA,
PUNE DIVL.OFFICE,
JEEVAN PRAKASH, UNIVERSITY ROAD,
SHIVAJINAGAR, PUNE 411005
DEAR SIR,

1. NAME OF ANNUITANT
(BLOCK LETTERS)

YOGESH KULKARNI

2. ANNUITY NUMBER
3. PARTICULARS OF BANK ACCOUNT
A) BANK NAME
ICICI
A
B)BRANCH NAME & ADDRESS_ICICI Kondhwa Pune
4. 9-DIGIT CODE NO OF THE BABK & BRANCH
APPEARING ON THE MICR CHEQUE ISSUED
BY THE BANK
_________________________________
(PLEASE ATTACH THE XEROX COPY OF A
CHEQUE / A BLANK CANCELLED CHEQUE
ISSUED BY YOUR BANK FOR VERIFYING
THE ACCURACY OF CODE NUMBER______________________________
5.ACCOUNT NUMBER

007401008802

(APPEARING ON THE CHEQUE BOOK)__________________________

6.ACCOUNT TYPE(S.B. / CURRENT A/C, Savings
CASH CREDIT ACCOUNT)
7. RESIDENTIAL ADDRESS WITH PIN CODE Plot 1Survey No 669 Next to Pooja
Park,,Ninad,Sanjwat Hsg Society Bibewadi Pune 411037_
8 CONTACT NUMBER
_9881060287_
I HEREBY DECLARE THAT THE PARTICULARS GIVEN ABOVE ARE CORRECT AND
COMPLETE,IF THE TRANCTION IS DELAYED OR NOT EFFECTED AT ALL FOR
REASONS OF INCOMPLETE OR INCORRECT INFORMATION ,IWOULD NOT HOLD THE
LIC RESPONSIBLE I HAVE READ THE OPTION INVITATION LETTER AND AGREE TO
DISCHARGE THE
RESPONSIBILITY EXPECTED OF ME AS A PARTICIPANT UNDER THE SCHEME.
PLACE:
DATE:

SIGNATURE OF THE ANNUITANT

P.S CONFIRMATION HAVING STARTED PAYMENTS BY THE ECS SYSTEM WILL BE

SENT TO YOU.GIVING DETAILS AT THE TIME OF CREDITING FIRST PAYMENT.