MANDATE INSTRUCTION FORM FOR NACH/ DIRECT DEBIT

D D M M Y Y Y Y

I C I C 0 0 2 6 1 0 0 0 0 0 1 9 9 2
ICIC0TREA00 Bajaj Allianz Life Insurance Company Limited

- -

Application No. Policy No.

D D M M Y Y Y Y Maximum period validity of this mandate is 40 years only

0 1 0 1 2 0 6 4 Signature of primary account holder Signature of account holder Signature of account holder
Maximum period validity of this mandate is 40 years only

Name as in bank records Name as in bank records Name as in bank records

1 2 3

MANDATE INSTRUCTION FORM FOR NACH/ DIRECT DEBIT

D D M M Y Y Y Y

I C I C 0 0 2 6 1 0 0 0 0 0 1 9 9 2
ICIC0TREA00 Bajaj Allianz Life Insurance Company Limited

- -

Application No. Policy No.

D D M M Y Y Y Y Maximum period validity of this mandate is 40 years only

D D M M Y Y Y Y
Signature of primary account holder Signature of account holder Signature of account holder
Maximum period validity of this mandate is 40 years only

Name as in bank records Name as in bank records Name as in bank records

1 2 3

MANDATE INSTRUCTION FORM FOR NACH/ DIRECT DEBIT

D D M M Y Y Y Y

I C I C 0 0 2 6 1 0 0 0 0 0 1 9 9 2
ICIC0TREA00 Bajaj Allianz Life Insurance Company Limited

- -

Application No. Policy No.

D D M M Y Y Y Y Maximum period validity of this mandate is 40 years only

D D M M Y Y Y Y
Signature of primary account holder Signature of account holder Signature of account holder
Maximum period validity of this mandate is 40 years only

Name as in bank records Name as in bank records Name as in bank records

1 2 3