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Tata Life shall not be responsible for delay in credit amount not credited amount credit to incorrect account due to incomplete or incorrect information herein. I/we understand that the information provided by me/us may be shared with third parties as per legal or regulatory requirements. I/We understand and agree that where NEFT cannot be processed for whatsoever reason the payout may be processed through cheque. DIRECT CREDIT AUTHORISATION FORM Instructions IRDA Has mandated all Payouts through National Electronic Funds Transfer NEFT. Please submit your form today. A Single request form shall apply to all policies where you are Policyholder. Form to be filled by the Assignee in case of Assigned policies. In case of non personalized Cheque please also provide Bank attestation/Bank Pass book/Bank statement. In case policyholder / Account holder / Assignee is a company please affix stamp of the company along with signature. This form shall be ineffective when the Policy is endorsed as Married Women Property Act MWPA. Policy Details Policy Number Policyholder/Assignee Name Mr/Mrs/M/S* Address of Policyholder/Assignee In case of change - Attach address proof Landmark City State Contact Numbers Pin Code STD Residence Office Extn Mobile Email ID Bank Account Details Bank Account Number 11 Digit IFSC code First Account Holder Name Exactly as per Bank records Bank Name Branch Account Type Savings Current NRO Original blank personalized cancelled cheque NRE For NRE account payout cheque with NRE letter will be processed Yes No Declaration I/We hereby declare that the information given above are correct and complete and shall inform you for changes if any. Tata Life shall not be responsible for delay in credit amount not credited amount credit to incorrect account due to incomplete or incorrect information herein* I/we understand that the information provided by me/us may be shared with third parties as per legal or regulatory requirements. I/We understand and agree that where NEFT cannot be processed for whatsoever reason the payout may be processed through cheque. Signature of Policyholder/Assignee As on Policy Application Date D D Signature of 1st Account Holder As per bank records / / M M Signature of 2nd Account Holder / Y Y Y Y Place CERTIFICATION BY ACCOUNT HOLDER S BANK For Bank Use Only We certify that the particulars furnished above are correct as per our records that this account is currently operational* We confirm that the account details account holder s signature s above are as per our records. D Bank Authorized Signatory with Emplyoee ID -. Bank Branch stamp -. / 0 2/ 3. / M M / Y Date / 0. DIRECT CREDIT AUTHORISATION FORM Instructions IRDA Has mandated all Payouts through National Electronic Funds Transfer NEFT. Please submit your form today. A Single request form shall apply to all policies where you are Policyholder. Please submit your form today. A Single request form shall apply to all policies where you are Policyholder. Form to be filled by the Assignee in case of Assigned policies. In case of non personalized Cheque please also provide Bank attestation/Bank Pass book/Bank statement.

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