Authority Letter For Cash Deposit
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1PSNL408623041507
Comp/June/Int/4514
Authority Letter for Cash Deposit
To,
Date:
DD/MM/YYYY
The Manager,
HDFC Standard Life Insurance Company Limited
Branch Address
Dear Sir/Madam,
I, Mr/Ms/Mrs. __________________________________________________________________________________hereby authorise
Mr/Ms/Mrs. ___________________________________________________________________________to deposit an amount of INR
___________________________by cash on my behalf at HDFC Life branch towards the proposal / Policy number
___________________________ taken by me. I am unable to visit the branch personally because______________________________
________________________________________________________(Reason)___________________________________________.
Details of cash deposit
Payment for:
Denomination
Amount (INR)
New Application
Rate Up
Bounce
Renewal
1000 X
Bima Bachat
Revival/Reinstatement
Top-up
500 X
100 X
Short payment
50 X
Agent Licensing:
20 X
Application Fees
Exam Fees
License Fees
10 X
5 X
Franking Fees
Training fees
Coins
PAN No: ______________________________________
Total
INR in words_________________________________________________________________________________________________
Depositor’s contact no.: _________________________________________ Email ID: _______________________________________
Address: ___________________________________________________________________________________________________
If the depositor is an employee/FC, then please mention the employee/FC code ____________________________________________
SIGN HERE
SIGN HERE
(Signature of the proposed Policyholder /Policyholder)
(Signature of the Depositor)
Declaration to be made by Third party where, the Policyholder has affixed his/her thumb impression/has signed invernacular /has not
filled the application:
I hereby declare that I have explained the contents of this application form to the Policyholder in_____________________________
language and have truthfully recorded the answers provided to me. I further declare that the Policyholder has signed /affixed his/her
thumb impression in my presence.
Name : _____________________________________________________________________________________________________
Address : ___________________________________________________________________________________________________
DD/MM/YYYY
Signature: _____________________________________ Date: ________________ Place: ___________________________________
IRDAI Registration No. 101.
HDFC Standard Life Insurance Company Limited. In partnership with Standard Life Plc. CIN:U99999MH2000PLC128245.
th
Regd. Off: Lodha Excelus, 13
Floor, Apollo Mills Compound, N. M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, Call 1860-267-9999 (local charges apply). DO NOT prefix any country code e.g. +91 or 00. Available all days from 9am to 9pm | Email – |
NRI (For NRI customers only) Visit –
For Office use only
Branch Name: _______________________________________ FC/SDM/BDM Name: ____________________________________________________
Client ID: _______________________________________ Received Date: ___________________ Receipt No: ________________________________
Receiver’s Name: _____________________________________________________ Receiver’s Signature: ___________________________________
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