Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims) (Page 5 of 6) in pdf

Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims) Page 5

Electronic Funds Transfer (EFT) Mandate Form

(Direct Transfer of funds to your bank account)

Account Holder Name: ________________________________________________________________________

(as mentioned in Bank Account)

Bank name: _________________________________________________________________________________

Type of Bank Account: ________________________________________________________________________

Bank Account Number:

____________________________________________________________________________________________

Branch Address: ______________________________________________________________________________

_____________________________________________________________________________________________

MICR code: __________________________________________________________________________________

(9 digit code as appearing on the cheque copy issued by bank)

IFSC code (Indian Financial Security code): _______________________________________________________

Note:

In case of beneficiary who is a minor, kindly provide with the account details held by the minor

Please attach Pre Printed Cancelled Cheque bearing the above mentioned Account Number and IFSC Code along

with this form. In case of non availability of Pre Printed Cheque, BSLI requires a bank statement or a Printed

Bankers Authorization in original containing aforesaid details duly seal and signed by Bank Branch Manager

Submission of this form should not be construed as acceptance of claim by the company.

In case of submission of incomplete / incorrect form Company will not transfer the Claim Proceeds Electronically

and provide an account payee cheque mentioning account number and bank name if provided in the mandate or

else company will draw an account payee cheque in case of admissibility of claim.

Declaration–

I / We hereby

Declare that the details provided as above are correct and complete.

Authorize BSLI to process the proceeds under the death claim of the aforesaid policy/s through EFT to the

above mentioned account details

Agree to not hold Birla Sun Life Insurance Company Limited or its associate / agent responsible in case of

any non credit to my bank account or if the transaction is delayed or not effected at all for reasons of error/

misrepresentation/incomplete/incorrect information furnished by me in this EFT mandate

Date:

Claimant’s Signature(s): ______________________________________________________________________

Birla Sun Life Insurance Company Limited Claimant'S Statement Form (Death Claims) Page 5