LIFE INSURANCE CORPORATION OF INDIA

NATIONAL ELECTRONIC FUNDS TRANSFER – MANDATE FORM

To
LIFE INSURANCE CORPORATION OF INDIA
Branch : 71 Service Request Number : 20211107962
Sub : Receipt of policy payment through NEFT

I am giving below the details of my Bank account for receiving policy payment through NEFT.

Policy No: 707342853

(1) Name of policy holder/ claimant S Hari Kumar

(2) Bank Name : Icici Bank Ltd (3) Account Type : Current
(4) Account : 053001504163 (5) IFS Code : ICIC0000276
(6) Mobile : 9080236207 (7) E-Mail Id : mecivil12@gmail.com

(8) Bank Branch Address : 39, Nelson Manickam Road 600029

(9) Are you willing to receive SMS/E-mail, on Yes

matters related to
->if cheque is not having the name of bank holder then
Photo copy of the page of Bank pass book containing
details of Bank accounts number, IFS code

->I authorize LIC of India to make any payments due to

me into this account and such payments made shall be
considered as valid discharge of all the liabilities copy of Pan card
against my policy for the purpose for which payment is
made

-> I declare that the above mentioned policy/ies

has/have not been assigned

I have enclosed the following document to this effect.

A. Cancelled cheque leaf
B. Copy of Pan card

___________________________
Signature of the policyholder Date :

Cancelled Cheque