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Policy No:: If NEFT Details Not Provided, Please State Reason

This document is a request form for a policyholder to receive a payout or reissuance of a cheque from an insurance company. It requests information such as the type of payout, reason for reissuance, bank account details for direct deposit, policy owner details, and signatures.

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kavenindia
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88 views2 pages

Policy No:: If NEFT Details Not Provided, Please State Reason

This document is a request form for a policyholder to receive a payout or reissuance of a cheque from an insurance company. It requests information such as the type of payout, reason for reissuance, bank account details for direct deposit, policy owner details, and signatures.

Uploaded by

kavenindia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Policy No:

Please tick the payout nature for the cheque:


Surrender Freelook Cancellation Partial Withdrawal Policy Loan

Coupon Dividend Excess Refund Annuity Maturity

Request Category
Please tick one of the below:
I have not received/misplaced the cheque. (Please fill NEFT section on reverse so that amount can be credited to your
account directly)
OR

Please reissue the attached cheque (original cheque attached): (Please fill NEFT section on reverse so that amount can be
credited to your account directly)
Tick the appropriate reason for reissue:
Cheque out dated
Incorrect Payee name: Correct Payee name _____________________________________________________________
(Please fill in block letters and attach ID proof with correct payee name)

National Electronic Fund Transfer (NEFT)


If NEFT details not provided, please state reason ________________________________________________________
Name of Account Holder ____________________________________ Bank Account No ______________________________
Bank Name _____________________________________________________________________________________________
Branch Name ___________________________________________________
Account Type: Current Savings NRO NRE (For NRE account refund cheque with NRE letter will be processed)

IFSC CODE:
(Please refer to your cheque book)
MICR CODE:
Original personalized cancelled cheque is mandatory along with this form. If personalized cheque is not available attach bank
statement. Bank attestation is necessary in case original cancelled cheque is not attached.

CERTIFICATION/ATTESTATION BY ACCOUNT HOLDER’S BANK:- (Bank Use Only)


We hereby certify that the particulars furnished above are correct as per our records and that this account is currently operational.
We hereby confirm that the below signature(s) are as per our records.

__________________________________________________ ___________________________________________________
st
Signature of the 1 Account Holder Signature of the Joint Account Holder
Bank Authorized Signatory with Date Bank Branch Bank Stamp

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Personal Details
My correspondence address is (Please fill in BLOCK Letters)* :

House No & Street :

Town & District :

State : Zip Code :

Landline No:
STD code

Mobile No:

E-mail ID

* Please provide valid address proof in case above address is different from our records.

Declaration :
I/We authorize Tata AIA Life Insurance Company to transfer all policy proceeds to the above bank account. I/we understand that
the information provided by me/us may be shared with third parties for compliance with any legal or regulatory requirements.
I/We hereby declare that the particulars given above are correct and complete. If the transaction is delayed or not effected at all
for the reasons of incomplete or incorrect information provided above then the user institution i.e Tata AIA Life Insurance
Company would not be held responsible. I/We shall intimate Tata AIA Life about any change in the above details as and when
the change occurs.

_________________________________________________________________
(Signature of the Policy Owner)

For Official use: To be filled by receiving branch


1. Cheque No./s i) ________________ for Rs. __________________ not received by customer
ii) ________________ for Rs. __________________
2. Address Checked (please tick one below):
Address matches with system Address requires change, address proof attached
3. Cheque to be dispatched to
Customer’s registered Address
Branch : Branch Code : ___________
Reason for requesting cheque at branch : ____________________________________________

____________________________ ________________ ___________________________ _________________


Signature Verified By (Name) Employee Code Employee Signature Date
I have enclosed the following :
Cheque for revalidation / reissuance
Original/ Copy of cancelled cheque/Bank statement (For NEFT cases)
Address proof (In case of change in address)
* Policy Owner signature is not required if the request is received over the phone

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