Kotak Mahindra Bank

Channel Access Request Form (Individual and Non-Individual)

Date Siebel ID

For Bank Use:

Wealth Privy NR Resident Individual Resident Non-Individual

For Individual Customers

CRN PAN

Name

CASA Primary Account Number #

Meal Account Number #

(applicable only for the existing Meal account customers)
Demat Client ID
Investment A/C Investment A/c no.

For Non-Individual Customer

Corporate CRN Name of Organization

PAN Primary Account Number#

Easypay Account Number#
(applicable only for the existing Easy pay customers)
Authorized Signatory 1 (Auth 1)

Name

CRN

Authorized Signatory 2 (Auth 2)

Name

CRN
# Required for Debit card facility. Charges if any will be recovered from this account
While all accounts maintained by the organization to which the above is/ are authorised signatory / ies can be viewed or can be accessed through the card on all Kotak
Mahindra Bank ATMs, this is the account that will be available on any VISA ATMs or merchant establishments. In case no account is specified, the first account opened with
the Bank will be treated as the primary account.
Channel Access Request
Please ✓ on the appropriate option below:
Deposit Account
Channels Individual Auth 1 Auth 2 Channel Access Maintenance
Phone Banking Password Reissuance Blocking Unblocking Deactivation

Net Banking-Transaction Rights* Password Reissuance Blocking Unblocking Deactivation

$
Physical E-Mail

Password Reissuance
Net Banking-View Rights* Blocking Unblocking Deactivation
$
Physical E-Mail

Mobile Banking Blocking Unblocking

Deactivation Activation
Deregistration Resending of activation key
Registration

*Payment Gateway (PG) and Tax Payment rights will be activated by default for customers registered for Net Banking with unconditional rights.
This option is applicable only if valid E-mail Id I Mobile Number is updated in the Bank records There are no charges for this service

Associate Enquiry Card

Individual Non Individual

Name as Desired : (20 Character only)

Declaration for Associate Enquiry Card

This is to confirm that I/we have read and understood the terms and conditions relating to the Associate Enquiry Card and the cardholder will be
permitted to use the Associate Enquiry Card as per the terms and conditions applicable to the Associate Enquiry Card, including as may be amended
from time to time by the Bank. I/We acknowledge that all the charges as applicable to the Associate Enquiry Card will be recovered from my/our
primary account. I/We agree that any action taken by any person authorized by me to use the Associate Enquiry Card shall be the sole responsibility
of the primary account holder and I/we shall not hold the Bank responsible for any actions/omissions committed by the cardholder in relation to the
Associate Enquiry Card.
 Debit Cards
Please ✓ on the appropriate option below (You can also process these service requests through Net Banking / Mobile Banking instantly. Also explore other exciting features there):
PIN Re-issuance1 Replacement of Card2 Permanant Blocking of Card Priority Pass3 Unblocking of Card
1
Generate your Kotak Debit Card PIN instantly Visit Kotak corn > Explore Products > Generate PIN for Debit Cards or Visit www bit ly/CardPIN
2
For waiver of charges, damaged card needs to be submitted at the branch.
3
Priority Pass can be issued to customers holding Platinum, Business Platinum, Signature and Infinite Debit Card.Add on Debit Card holders are not
eligible for priority pass.
I want to apply for new debit card As per Account Classification Platinum Debit Card (applicable to Edge equivalent account)
PVR DEBIT CARD REQUEST
Yes, I wish to apply for PVR DEBIT CARD

I hereby authorize Kotak Mahindra Bank Ltd. (KMBL), to share my NAME, MOBILE NUMBER, EMAIL ID, MASKED DEBIT CARD NUMBER, D.O.B,
GENDER and SPENDS DETAILS (AMOUNT, DATE OF TRANSACTIONS, and MERCHANT NAME) ON KOTAK PVR Debit Card to PVR CINEMAS. I hereby
give my voluntary consent to the sharing of this information which will be used by PVR CINEMAS to reward for Debit card spends and also to send
communication via different channels like SMS/Email or Push Notifications.
Please Note: In case you are an existing mobile PVR PRIVILEGE customer, kindly provide the mobile number which is registered with PVR CINEMAS. This
is required, so as to upgrade your existing points and voucher, if any, with PVR PRIVILEGE PROGRAM TO PVR PRIVILEGE PLUS program. A different
mobile number provided here, will result in 2 separate profile creation on PVR system and merging of profiles will not be allowed at later stage.

CARD ANNUAL FEE - RS. 499 + TAXES

Debit Card Channel Selection*
#Default Debit card will be EMV Chip and PIN enabled.

Card Channel POS / ECOM/Online Contactyless Tokeniza

ATM *Services selected in the check box will be enabled in your Debit Card. If you wish to
In-store payment payment^ tion^^ activate/de-activate the services, please log in to Kotak Net / Mobile Banking. If no option is
selected, then by default Debit Card will be enabled for domestic usage at ATM and POS / In-
store.
Domestic # #
^Contactless Payment is Tap & Pay facility in your Debit Card. Available at selected stores.

^^ Tokenization means registering debit card in third party app installed in mobile phone and
International make payment via mobile phone.

Mylmage Debit Card request For CPC Use

Yes, I wish to personalize my Debit Card with an image* Image Code
(To be filled by Branch, If applied for Image Card)

Customer Classification Special Debit card Platinum Card Features Annual Fee
Kotak Edge Platinum - EDP Higher daily ATM withdrawal and purchase limits of up to Rs 3 lakhs each INR 750 + taxes
Personal Accident Death cover upto Rs 50 lakhs
Permanent Partial/Total Disability Cover upto Rs. 30 lacs
Education benefit upto Rs. 1 lac to one dependent child
Enjoy Fuel Surcharge waiver up to Rs 750 in a calendar month
Unlimited ATM withdrawals at all ATMs in India
Enjoy Fuel Surcharge waiver up to Rs 750 in a calendar month
#Note :
1. in case special card type is not mentioned, default card as per customer's classification will be issued. Please refer General Schedule of Features and Charges (GSFC) for applicable charges.
2. *Applicable charges for Image card. Please ask the branch representative for our Image gallery. You may also visit HYPERLINK "http://www.kotak.com/myimagecard
www.kotak.com/myimagecard for exploring our Image gallery of 70+ images covering various exciting themes for you. Image card is available only for retail customers (Currently Image
card functionality is not available for Wealth and current account customers)
3. Access India Debit Card is issued to customer having NRO account and will be chip debit card enabled for domestic usage only.
4. Rupay Debit card will be Chip Debit Card enable for domestic usage only.

Add on Debit Card - Individual

Add On Debit Card Applicant Details
Name
Date of Birth
Mother's Maiden Name
Address

City Pin Code

State Country
Telephone Mobile
E-mail Address
Primary Account
Declaration for Add on Debit Card - Individual
This is confirm that I have read and understood the terms and conditions relating to the Debit Card and that the Add On Debit Cardholder will be
permitted to use the Add On Debit Card as per the said Terms and Conditions I also confirm that the Add On Debit Cardholder may avail all the
facilities and will be entitled to carry out all transactions under the said facilities and also receive all information relating to the Add On Debit Card I
understand that by default, the Add On Debit Cardholder will have access to all the accounts linked to my card, unless I del ink the accounts which I do
not want Add on Debit cardholder to access.
I accept that the usage of the Add On Debit Card constitutes the acceptance of the said terms and conditions relating to the Debit Card, including as
may be amended from time to time by the Bank I acknowledge that all charges as applicable or charges incurred by the Add On Debit Card will be
deemed charges incurred by me and will be recovered from my primary account and I will be fully liable for discharge of all obligations in respect of all
the transactions performed by the Add On Debit Cardholder I agree to pay the Bank damages and compensation including direct and indirect
damage, cost expenses that may be caused, incurred by the Bank arising out of any actions/omissions on the part of the Add On Debit Card Holder.
Notes :
1. This application for Add-on Debit Card is for Individual Customers only. For Non Individual customers, separate form needs to be filled.
2. Add On Debit Card can be issued only to an Adult Resident Indian.
3. You may apply for more than one Add on Debit Card by filling a separate form.
4. While the address of the Add On Debit Cardholder is being obtained for the purpose of identifying the Add On applicant, for security reasons the
Add On Debit Card will be sent to customer's mailing address as registered with the Bank.
Declaration for Priority Pass
I hereby authorize the bank to debit my account for charges as applicable towards issuance of Priority Pass. I hereby declare and confirm that the
Priority Pass will be used exclusively by me.
I understand that the usage of Priority Pass for lounge access(facility) offered by Priority Pass Ltd (Company) shall be subject to conditions of use
specified at www.prioritypass.com, and charges as specified at www.kotak.com and that the charges will be debited from my account. I have read,
understood, accept and agree to be bound by the Terms and Conditions relating to Priority Pass, including as may be amended from time to time
available at www.prioritypass.com and www.kotak.com.

Please note:
1) Charges, wherever applicable, will be levied as per General Schedule of Features & Charges (GSFC) of the Bank available at www.kotak.com. I/we hereby authorize
the Bank to debit my/our Deposit Account(s) towards Service Charges (as per GSFC) + Service Tax, as shall be applicable from time to time.
2) Your Mobile Number and E-mail Address registered with the Bank will be used for all alerts sent by the Bank Please ensure to update correct Mobile Number in Bank
records in order to receive Account Transaction and Maintenance related Alerts In case of non-updation of correct Mobile Phone Number, Bank will not be
responsible for non-receipt of Account Transaction and Maintenance related alert in case of a fraudulent transaction in your account Further Bank will be constrained
to restrict electronic transactions (e g NB, MB, E-Commerce, POS) in your account and allow only ATM Cash withdrawals in case of non- availability of Mobile Number
If you wish to update this information, kindly fill ModificationForm for the same available at bank branch The bank will also use these details for sending out
information and updates about products & services In case you do not want to receive these information / updates, you can register yourself for Do Not Contact by
logging in to NetBanking at www kotak corn
3) Mobile banking will be available by default for all customers registered for net banking or having debit/ credit card.
4) Customers having Deposit Account(s) with joint mode of operation will get only view or enquiry rights on Net Banking, Mobile Banking and Phone Banking and will
not get Payment Gateway facility.
5) All existing account(s) or to be opened in future will be linked to the Debit Card/Payment Gateway. Specific written instructions are required for delinking any
account(s).
6) This form should be accompanied with the Resolution of the Board / Managing Committee in case of Limited Companies, Trusts, Societies, Associations and Clubs. In
case of partnerships, declaration letter duly signed by all the partners/ Distinct Board / Managing Committee Resolution and Partnership Letter is to be provided for
each Deposit Account, as applicable.
7) In case of Partnerships, Limited Companies, Trusts, Societies, Associations, and Clubs, person(s) with conditional mode of operation / authority will get only non-
financial transactions on Net Banking / Mobile Banking and Phone Banking and will not get Payment Gateway access.
8) In case of Authorized Signatories, all signatures should be accompanied by proper seal of the organization, as applicable.
9) In case of Partnerships, Limited Companies, Trusts, Societies, Associations, and Clubs, Debit Cards will be issued only to person(s) with unconditional mode of
operation / authority.
10) Proprietor of a Proprietorship concern and Karta of an HUF will get both financial and non-financial transactions on Net Banking / Mobile Banking and Phone
Banking. They are also eligible for Debit Cards and Payment Gateway access.
11) Payment Gateway facility is provided as per the terms and conditions of the Bank and regulatory guidelines as applicable from time to time.
12) The customer reiterates that he shall be governed by the applicable terms and conditions of the Bank.
13) Bank reserves the right to modify these offerings with/ without prior notice.

Signature(s)

KMBL/Nov-2021/V1.04
1st Account Holder* 2nd Account Holder* 3rd Account Holder*

* For Non-Individual - (Sign, Name and Designation with Stamp of Organization).

For Bank Use only

Date and Sol ID
time of acceptance Service Request Number

Signature verified by Sign & Emp Code Receiver's stamp

Authorized by

Acknowledgement Slip

We acknowledge the receipt of Channel Access instruction from Mr. / Mrs. / Ms

relating to customer relationship number under service request number

Bank Official
For Kotak Mahindra Bank Ltd.,
(Sign and stamp)
Date:

Kotak Mahindra Bank Ltd. CIN: L65110MH1985PLC038137,

Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra (E), Mumbai 400051, www.kotak.com