ELECTRONIC CLEARING SYSTEM (E.C.

S) / DIRECT DEBIT APPLICATION FORM
Section A
Instructions for Premium Payment through ECS Direct Debit (In case no option is selected, the default option will be ECS) To, ICICI Prudential Life Insurance Company Ltd., ICICI PruLife Towers, 1089, AppaSaheb Marathe Marg, Prabhadevi, Mumbai – 400 025. Dear Sir, Re : Authorisation to pay Insurance Premium amount through Electronic / Debit Clearing System. I, the undersigned hold a valid Policy bearing No. Or Application bearing No.
Date: D D M M Y Y Y Y

I, wish to avail of the direct debit facility and hereby express my unconditional consent to debit premium payment of my policy referred to above through participation in the Electronic Clearing System (ECS) / Direct Debit. I understand and agree that the premium amount to be debited from my account may vary due to taxes and other statutory levies as may be applicable from time to time. I, hereby declare that the particulars given are correct and complete. I understand and accept that the transaction will be effected on the policy due date (provided the day is a working day). If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I shall not hold the user institution (company) responsible. I agree to discharge the responsibility expected of me as a participant under the scheme.

*Primary Account Holder’s Signature (* Only if Primary Account Holder differs from Policyholder)

Joint Account Holder’s Signature 1 Joint Account Holder’s Signature 2 (Signature of all account holders is mandatory)

Policyholder’s Signature

I hereby authorise ICICI Prudential to enable direct debit facility for my premium payments. The details of my Bank Account are mentioned below Particulars of Bank Account (to be filled in CAPITAL letters) a. Name of the Primary Account Holder (as in the bank account) : b. Bank Name : c. 9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank* (*In case of ECS, kindly ensure that the first three digits of the MICR code that you fill in are all not zero.) d. Account Type: e. Account Number : Savings Account Current Account Cash Credit (As appearing on your cheque book)

Yes, I have attached a photocopy of a blank cheque or a blank cancelled cheque Certified that the particulars furnished above are correct and as per our records.

Bank Stamp:

Signature of Authorised Bank Official

The ECS / Direct Debit facility will be activated in your next billing cycle.

Section B
To be retained by your Bank To, The Manager Bank Name premium dues on my ICICI Prudential Life Insurance Company Policy/ Policies. Mandate verification charges (if any) may be charged to my/ our account. I further request you to inform ICICI Prudential Life Insurance Company of any change in the status of my account. Incase I wish to revoke the above authorisation for any reasons whatsoever, I undertake to inform ICICI Prudential Life Insurance Company after giving an advance notice of two months in writing.

Branch Address

No.

towards my

Joint Account Holder’s Signature 1 Joint Account Holder’s Signature 2 (Signature of all account holders is mandatory)

Please refer to the reverse for information on ECS / Direct Debit facility.

1

Aug 2007

Dear Sir/Madam, I, the undersigned hold a valid Policy number and wish to avail of the Electronic Clearing System / Direct Debit facility towards settlement of my Monthly / Halfyearly / Yearly Policy Premium payments in favour of ICICI Prudential Life Insurance Company. I hereby authorise you to debit my Account

* Primary Account Holder’s Signature (* Only if Primary Account Holder differs from Policyholder)

Policyholder’s Signature

• Payable at Par currently available in 26 cities namely Ahmedabad. IndusInd Bank. Fill Payable at A in this form and send it to us accepted.M. Gwalior. Kanpur. All Nagpur. Allahabad. all your premium payments will be debited directly from your Andhra Pradesh 98495-77766 98925-77766 bank account. Baroda. Nasik. in which case your account would be debited on the next working day Electronic Clearing date falls (ECS) facility enables hassle-free premium and top-up payments.your schedule. Gorakhpur.1089. Panjim. premium due date for ECS and within 13 days for Direct Debit.ICICI Prudential Life Insurance Company Ltd. Hyderabad. Ahmedabad. Jaipur. Indore. Nagpur. Ludhiana. Mangalore. Jamshedpur. AppaSaheb Marathe Marg. Chennai. Hubli. Depending on your respective premium due date. New is: you need to do Delhi.. Premium Payment requests through ECS / Direct Debit are sent to your bank as per the pre-determined schedule. the premium gets directly debited on your premium due date for ECS and Directamount. Ludhiana. Mumbai. in following conditions 1) ECS locations under Non-rolling settlement category • The Direct Debit facility is available for all account holders of ICICI Bank.00 P . Ashok Nagar. Vizag. Jabalpur. cancelled cheque (or a photocopy of the same). Bhopal. Udaipur. Simultaneously. to 9.ICICI PruLife Towers. Charges Chandigarh. Kolkata. Madurai. Meerut. Prabhadevi. kindly call our Customer Service Toll Free Number 1-800-22-2020 from your MTNL or BSNL line For all other locations kindly call our Customer Service Toll(except national holidays) Call Center timings: 9. Lucknow) 98954-77766 West Bengal (Kolkatta) 9895477766 Uttaranchal 98931-27766 West Bengal (Rest) Reach us. Amritsar.com E-mail us at lifeline@iciciprulife. the premium gets directly debited on Hyderabad. Mumbai – 400 025 ICICI Prudential Life Insurance Company Ltd. • • • Premiums in the following conditions may 2 days after the the premium due date: • Top-up NAV applicable will be post not be debited on Renewal NAV.iciciprulife. pre-determined Baroda. • The renewal amount will be collected as and when due after adjusting for any balance lying in the contract. applicable fromChennai. Lucknow. Kolhapur) • The2) If the premium due System on a holiday. Calicut. Monday To Saturday (except on National Holidays) Assam Bihar Andhra Pradesh Chattisgarh Chattisgarh Delhi Delhi Goa Goa Gujarat Gujarat Haryana (Karnal) Haryana (Karnal) Location 99540-77766 Number Maharashtra (Rest) 99313-77766 9849577766 Orissa Maharashtra (Mumbai) 98931-27766 Punjab 9893127766 Maharashtra (Rest) 98181-77766 9818177766 Rajasthan Punjab 98904-47766 Tamil Nadu (Chennai) 9890447766 Rajasthan Location 98904-47766 Number 99377-77766 9892577766 98159-77766 9890447766 98292-77766 9815977766 98408-77766 9829277766 98944-77766 9840877766 98973-07766 9894477766 99352-77766 9897307766 98973-07766 9935277766 98313-77766 9897307766 99330-77766 Haryana (Faridabad) Haryana (Faridabad) Karnataka Karnataka Kerala Kerala Madhya Pradesh Madhya Pradesh 9893127766 West Bengal (Kolkatta) 9831377766 For other cities. Aurangabad. 2 . Jalandhar. Cochin. Surat. Trivandrum. Coimbatore. it to us along with Helpline Simultaneously. depending on your respective premium due date. Varanasi) 98455-77766 Uttaranchal 9845577766 Uttar Pradesh (Kanpur. Bill Junction is our authorized service provider for ECS and we offer you this service free of charge.M. Jabalpur. would not be debited on the premium due date: Udaipur. Jammu.00 A. Varanasi) Tamil Nadu (Rest) 98181-77766 Uttar Pradesh (Kanpur. Jammu. 1) ECS locations charge for Top-up • There will be a 1%under non-rolling settlement category (Nasik. Trichur. Mysore. Trivandrum. Vijaywada & Vizag.iciciprulife. Location Number Location Number Customer Service Helpline As soon as the ECS gets activated against your policy. Surat. Vijaywada. Jodhpur. Bhubaneshwar. The amount mentioned in this mandate is applicable for Top-up Debit. Mumbai. The Renewal amount will be collected as to enable the payment adjusting for any balance lying in the contract. SECTION B of the form needs to be submitted with your bank. Delhi.com @ @ Write to us at E-mail us at Our Corporate Address lifeline@iciciprulife. Reach us at Fax us. Hence.M. Chakravarthy Ashok Road. Aurangabad. Meerut. Kotak Mahindra Bank 2) If premium due date falls on Holidays then your account would be debited on next working day. Coimbatore. Lucknow. Kindly note that the Direct Debit application would have to be successfully registered with your bank and when due after to be debited from your account. Guwahati. Patna. Chandigarh. Madurai.Jodhpur. Trichy. (if any) would be borne by the customer.00 A. Bhubaneshwar. • This facility ischeques will not be accepted for ECS payment mode. Madurai. bank As soon as the ECS gets activated against your policy. Premiums Varanasi. Jamshedpur. Centre time : 9. UTI Bank. Kanpur.M. Kolkata. Mysore. Mumbai 400 101. Rajkot. Bareilly.com Visit us at www. • ECS works in a very simplified manner: • This ECS facility is currently Top-up amount requests through ECS are sent to your bank as per the Bangalore. Pune. Indore.. the bank Coimbatore.com Corporate Address : Communication Address: The Customer Service Desk . Hubli. Vinod Silk Mills Compound. Kandivali ( E ). Jaipur. Panjim. to 9. 022-67100803/805 Fax us at 022-67100803/67100805 Write to us at Our Communication Address Call Our Customer Service Helpline Call Our Customer Service Helpline Visit us at www. (all branches) and Punjab National Bank (select locations). All you need to do is: Fill up SECTION A in this form and sendCustomer Service a cancelled cheque (or a photocopy of the same).• ECS / Direct Debit works in a very simplified manner: The Electronic Clearing System (ECS) / Direct Debit facility enables hassle-free premium payments. Patna. IDBI Bank. Bangalore. Trichy. • Calicut. Monday to Saturday Free Number 1-800-22-2020 98982-77766 9898277766 Tamil Nadu (Rest) Tamil Nadu (Chennai) 98961-77766 9896177766 Uttar Pradesh (Agra. Bareilly.(if any) would be borne by theGuwahati. Pune. all your premium payments will be debited directly from your bank account. Premium Payment and available in 51 cities namely Agra.00 P Maharashtra (Mumbai) Call . Lucknow) 9818177766 Uttar Pradesh (Agra. SECTION B of the up SECTION Par cheques will not be along with a * form needs to be submitted with your * Charges applicable from thebank. customer. Kolhapur. Bhopal. Gorakhpur. Raipur.

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