REQUEST FOR ELECTRONIC POLICY PAYOUT

Policy Number OP3 0 2 7 2 4 0

Name of AD A MRA J U V EN KA T E SH WAR RA J U
Policy holder M r.
Mr./Ms./Mrs. First Name Surname

E-Mail ID avraju9963@gmail.com Mobile number 97 9 1 0 1 2 8 71 PAN BMT PA 2 5 65 A

Trustee Details (Required to be filled, only in case it is an MWPA Policy)

Trustee Name
Mr./Ms./Mrs. First Name Surname
Trustee PAN

Your bank account details to receive policy benefits

Name of Customer/Trustee* ADAMRAJU VENKATESHWAR RAJU

(as mentioned in the bank account and printed on your cheque)
*In case it is an MWPA Policy, Trustee Bank account details are required to be filled.

Name of Bank HDFC BANK

Branch Address Ascendas International Tech Park, Csir Road ,Taramani, Chennai ,Tamil Nadu -600112

Account Type Current Account Savings/ NRO Account NRE Account*

*Proof of premium payment, i.e bank statement required for NRE bank account.
CBS
PERSONAL BANKING : SAVING ACCOUNT DATE ....................
Bank Account No. 5 0 1 0 0 0 6 2 3 6 0 7 5 2 PAY ................................................................................................................................................
................................................................................................................................................... OR BEARER
Bank account number as printed on your cheque RUPEES ...................................................................................................
Rs.
..................................................................................................................
ANWB
SBGEN A/c No.
IFSC Code of Bank HD F C 0 0 0 2 4 0 6 005070123756

ICICI Bank Limited

Prabhadevi Branch
Ground Floor, Kala Academy, Ravindra Natya Mandir Amit Wadekar
MICR Code of Bank 60 0 2 4 0 0 8 7 Prabhadevi Mumbai - 400 028
RTGS / NEFT IFSC Code : ICIC0000057

9 digit code as appearing on the Cheque copy issued by bank. || 338894|| 400229013|: 000000|| 31

Branch Address MICR Code IFSC Code Name

Bank Account Number

Signature of Policyholder Signature of Trustee Place:

Bangalore Date: 08/12/2022
DD/MM/YYYY

SUBMIT THIS FORM WITH THE FOLLOWING DOCUMENTS:

Cancelled cheque of your bank account. Your bank account number and name should be printed on the cheque.
Signed copy of PAN card.
Proof of premium payment, i.e bank statement, if receiving amount in NRE bank account.

YOU CAN SUBMIT THIS FORM AND DOCUMENTS THROUGH ANY OF THESE OPTIONS:

@ Email:
Email the scanned copy of the documents to lifeline@iciciprulife.com with your policy number

Branch:
Submit the documents at any of our branches. To locate the nearest branch, visit www.iciciprulife.com/branchlocator.

Courier: Courier the documents to

#Payout Department#, ICICI Prudential Life Insurance Co. Ltd., Unit No. 1A & 2A, Raheja Tipco Plaza, Rani Sati Marg,
Malad (East), Mumbai- 400 097.

ACKNOWLEDGEMENT SLIP
This is to acknowledge the receipt of application for electronic policy payout

Policy Number : Date : D D M M Y Y Y Y

Signed Cancelled Cheque STAMP

Documents Submitted : Self Attested Photo ID
&
TIME
Received By

Registered Address:- ICICI Prudential Life Insurance Co. Ltd.,1089, Appasaheb Marathe Marg, Prabhadevi, Mumbai-400025. IRDAI Regn No. 105. CIN: L66010MH2000PLC127837.
Insurance is the subject matter of the solicitation. COMP/DOC/Mar/2019/143/2183.