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Bank Account Updation

Form for Payouts


Note: Please complete the form in CAPITAL LETTERS.

All fields with (*) are mandatory

POLICY
DETAILS

I request Exide Life Insurance Company Limited to update the below bank account details for any future payout of the below mentioned policy/s.

Policy Number*:

Policy Holders Name*:

Additional Policy Nos. :

ADDRESS

Address*:

City*:

State*:

PIN*:

Landline*:

Mobile*:

E-mail*:

TAX DEDUCTIONS

BANK DETAILS

Payment Method*:

Direct Credit (NEFT/RTGS)

A/c Payee Special Crossing Cheque

Bank Name*:

Bank Branch*:

Account Number*:

IFSC Code*:

Please tick () any one Bank Account Type*:

Savings

Current Account

Over Draft / Cash Credit

NRO

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 amount would be credited to the bank account number provided by you and the same will be considered as final.
1. Do you have a PAN card

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 Insurance policies which are not exempt under the Income Tax Act are subject to tax deduction at source @ 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 currently a Resident 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.

I take full responsibility for the genuineness and correctness of the details filled herein.
DECLARATION

Signature / Thumb Impression of the Policy Owner / Assignee*:


Date

D D M M

Witness
Signature*:

Y Y Y Y

Name & Address of the Witness*:

ACKNOWLEDGMENT
SLIP

Name of the Customer


Service Representative:
Date:

Branch
Code:

D D M M Y

Y Y Y

Signature:

Employee No.:

Date D

This is to acknowledge the receipt of application for Bank Account Updation for future payouts

Documents received:
Original Policy Document

POS/MPA/Version 2.1

FOR OFFICE
USE ONLY

*(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.)

D M M Y

Y Y Y

Policy No.
Valid Address Proof

Identity Proof

Bank Account Proof

Sign:
Branch
Seal

Others______________________________________________________________________________
Call : 1800 419 8228 (TOLL FREE); +91 80 4134 5444

Email : customer.service@exidelife.in

Visit : exidelife.in

Registered Office: Exide Life Insurance Company Limited, 3rd Floor, JP Techno Park, No.3/1, Millers Road, Bengaluru - 560 001.
(Formerly ING Vysya Life Insurance Company Limited)

IRDAI Registration No. 114

CIN: U66010KA2000PLC028273

Bank Account Updation


Form for Payouts

DOCUMENTS REQUIRED

Note: Please complete the form in CAPITAL LETTERS.

All fields with (*) are mandatory

Please submit any one of the following listed documents along with the mandatory requirements (*).
1) Self-attested valid photo ID proof *

2) Self-attested valid address proof

3) Original Policy Documents

4) Original cancelled cheque with your name and account number pre-printed* OR
5) Self-attested copy of bank statement / pass book copy with bank seal, if personalised cheque is not attached*.
List of valid address proofs: Telephone Bill, Bank letter/ Account Statement, Water Bill, Electricity Bill, Valid Passport, Valid Driving License, Ration Card, ESI Card,
Domicile Certificate, Company Lease Agreement/Rental Agreement, Employer's Certificate. Statement/Receipt/Bill should not be more than six months old from
the request submission date. Please attach self-attested identity proof bearing photo (e.g. Pan card, Voters ID, Passport, Driving License, Aadhar Card)

Call : 1800 419 8228 (TOLL FREE); +91 80 4134 5444

Email : customer.service@exidelife.in

Visit : exidelife.in

Registered Office: Exide Life Insurance Company Limited, 3rd Floor, JP Techno Park, No.3/1, Millers Road, Bengaluru - 560 001.
(Formerly ING Vysya Life Insurance Company Limited)

IRDAI Registration No. 114

CIN: U66010KA2000PLC028273