NACHOC 01/09/21 1.

0 CANA | CVT: 05/09/22

SI/ECS/NACH Mandate-Other Channels / Other Banks / IDFC First Bank

SI/ECS/NACH Mandate ( Below details to be filled only if SI/ECS is opted for)

UMRN F O R O F F I C E U S E O N L Y Date
D D M M Y Y Y Y

Tick ( ) Sponsor Bank Code Utility Code

CREATE
MODIFY I/We hereby authorize HDFC LIFE to debit (tick P) SB/CA/CC/SB-NRE/SB-NRO/OTHER
CANCEL
Bank a/c number

with bank Name of customers bank IFSC or MICR

`
an amount of Rupees

FREQUENCY MONTHLY Qtly H. Yrly Yrly
As
&
when
presented
DEBIT TYPE Fixed Amount Maximum Amount

Reference No. 1 Application No. Mobile No.

Reference No. 2 FOR OFFICE USE ONLy Email ID

I agree for the debit of mandate processing charges by the bank whom I am authorizing to debit my account as per latest schedule of charges of the bank.
PERIOD
D D M M Y Y Y Y Signature Primary Account holder Signature Primary Account holder Signature Primary Account holder
From
x x x x x x x x
To
1. Name as in bank records 2. Name as in bank records 3. Name as in bank records
Or P Until
Cancelled

This is to confirm that the declaration/terms has been carefully read, understood and made by me/us. I am authorizing the User entity /corporate to debit my account.
I have understood that I am authorized to cancel/amend this mandate by appropriately communicating the cancellation/ammendement request to the User entity/corporate of the bank where I have authorized the debit

Renewal Payment has been made from account / Debit Card / Credit Card that belongs to:
Self Spouse Parent Children Sibling Grandparent Partnership Company
HUF Trust Others ________________________
please specify

DECLARATION:
1. I/ We hereby declare that the particulars given above are correct and complete. 2. I/We hereby declare that in case of a third party account holder, a KYC form of the
account holder shall be submitted. 3. I/ We undertake to keep sufficient funds in the account mentioned in the mandate as on the date of execution of debit. 4. I/ We
hereby authorise the Bank / Tech Process Solutions Ltd / Bill desk / any other intermediaries to communicate my / our funding account number and any other account
details (as may be necessary) to HDFC Life Insurance Company Limited (HDFC Life) for the specific purpose of recovering my/ our HDFC Life premium/EMI payments
through a debit instruction to my/ our account. 5. I/ We hereby authorise HDFC Life, in the instance of the ECS/SI/DD/NACH failing for any reason, to authorise the
Bank/ Tech Process Solutions Ltd /Bill desk to recover the premium/EMI payable through a direct debit to my/our account with the mentioned bank. 6. If the
transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I will not hold HDFC Life, the Bank or the other Intermediaries
responsible. 7. I/ We agree that for changing the premium/EMI amount as per my requirement, I/ We will furnish a fresh mandate for such change in the premium/EMI
amount, which will supersede all other mandates previously given. 8. I/ We agree that in the event of any violation by me/ us of any undertaking confirmed in the
agreement herein, shall amount to an event of default in the terms of the Insurance Policy and HDFC Life shall be entitled to invoke the remedies available to it in terms
of the Policy agreement. 9. I/ We agree that in the event of the Bank being unable to debit my account for want of sufficient funds or for any other reason, HDFC Life
shall be entitled to deal with my Policy in the manner as described in the Policy provisions, unless the payment is received by any alternate mode on or before the
specified date. 10. I/ We hereby authorise my/ our Bank to debit my/ our account with the amount of taxes and other levies as maybe stipulated by the Government,
from time to time, on the premium/EMI stated above and for this purpose, no further or revised authority is required by my/ our Bank. 11. I/We hereby authorise that
in the instance of a transaction failure towards an ECS request, HDFC life can represent twice the transaction to my /our account for realising this premium/EMI. 12. I/
We wish to avail the ECS/SI/DD/NACH facility and hereby express my unconditional consent to debit premium/EMI of my Policy to above through participation in
Electronic Clearing System (ECS)/ Direct Debit. I/ We understand and agree that premium/EMI amount to be debited from my account may vary due to taxes and other
statutory levies as may be applicable from time to time. 13. I/ We understand and accept that the transaction will be effected on the Policy on the due date (provided
the day is a working day). I/ We agree to discharge the responsibility expected of me/ us as participants under the scheme. I take full responsibility of correctness of the
details filled herein. 14. I/ We authorise the above mentioned bank to debit my bank account if my/our ECS mandate is active and until I give a written request for
cancellation of ECS/SI/DD/NACH. 15. In the future, if I/We opted out of ECS/Direct Debit mode there may be an increase in premium/EMI amount. 16. I/ We
understand and agree that the submission of this form does not mean that the request will be processed. I/ We understand that any payout under the Policy shall be
strictly in accordance with the Policy terms and conditions. Also, any payment shall be subject to realisation of the last renewal premium/EMI payment. 17. I/ We also
understand and agree that the Company reserves the right to use any payout option. 18. For SI with HDFC Bank/RBL Bank, premium will be debited from your account
on debit date. However, in case of failure, we will debit your account anytime again upto 180 days from date of debit. 19. I/ We authorise the above mentioned bank to
debit the amount from my bank account if my ECS/SI/DD/NACH is active, until I give a written request for cancellation of the Mandate. 20. I authorise the Company to
deduct all the outstanding premium along with interest (in case of non Unit Linked Products) for the purpose of revival. I am aware that in case of Conventional
products, company may deduct the Mortality and the other charges for the period while the policy was in lapsed stage. I understand that the Company reserves the
right to refuse revival of the policy. 21. In case a preferred day of debit is selected, the debit attempt will done on the Preferred Billing Date instead of the premium due
date. 22. In case of EMI collection for Loan-Against-Policy, the Company may process debit attempts post the EMI due date to recover pending payments.
Important Note:
1. Any cancellation, correction, alteration etc. should be countersigned by the Account Holder. 2. For SI cases (HDFC Bank/RBL Bank), the NAV allotted will be the date
on which the bank gives a confirmation of the debit. 3. For ECS, NAV would be allocated on the basis of the debit date. 4. Direct debit facility (non ECS location) is
offered by ICICI Bank, Citibank, Union Bank of India, Bank of Baroda, State Bank of India, Axis Bank, Punjab National Bank and J&K Bank only. 5. For Direct Debit, NAV will
be provided for the day when the payment is received in the HDFC Life account. 6. Request for de-activation of Auto debit facility has to be submitted at least 12 days
prior to the next premium/EMI due date. 7. The premium/EMI will be debited starting from the premium/EMI due date which occurs after the date of this mandate. Till
the last premium/EMI due date unless the mandate is revoked. 8. In case of any increase or decrease in premium/EMI amount due to changes in payment frequency or
any Policy related changes including reduction in premium/EMI*, the existing debit instruction will be de-activated. Hence, a fresh Auto Debit Mandate is required to
be submitted at any HDFC Life branch at least 30 days prior to the next premium/EMI due date. 9. In case of PBD option the NAV will be allocated as per preferred billing
date and not premium/EMI due date. 10. Grace period in case of PBD will start from premium/EMI due date only and not from Preferred billing date.
* Reduction in premium/EMI is a product-specific alteration.

HDFC Life Insurance Company Limited (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off: Lodha Excelus, 13th Floor, Apollo Mills Compound, N. M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, call us on 1860 267 9999 (Local charges apply) | 022-68446530 (STD Charges apply)
DO NOT prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm |
Email - [email protected] | [email protected] (For NRI customers only) | Visit -www.hdfclife.com