TATA AIA

AUTHORISATION FORM
DIRECT CREDIT

hstructons: Payouts though

Natonel Eectrone
Funde Trhenefor (NEFT).
Plense mbm your form today
AStho ed a Piloyholber.
t bm ehl apply to a pololee where you ere
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om otb»non
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bytheAabnee noaneof Asn BarkPaonbookBark
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sigri* with
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he compeny
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Th r i Aooount an Med Women Property Act (MWPA

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Bnk Account Detas

LLLLLLL LLLLLLLU
Bark Aaoourt Number
HIDIEICIO9101015125S
11 DigtIFSC oode
UL LL L U
Rrst Acoourt Holder Name h. ET HA MADIAUIRL KIA
(Ectyas per Berk records)

Bart Neme

BICIHIMDIIDI IRIOIA DL 1BEINIGALURU be proceesed)

(ForNRE accourt, payout chequswth
NRE
Brunch NRE
Carent NRO
Savings
Accourt Typ
Yee N
canceled cheque attached
Onghl bank personelzed

Decleration for delay In credi, amount

not
Tata AlA Life shall not be responsible
and shal Inlom you for changes f any. may be shared wn thd peras
as

he iniomadon gven above are corect and complete that the iniommaton provided by mats cheque.
We hereby declere fhat
incompleta or incoTect ntoaiion heralin. we understand
for whatsoover reason, the payout
may be processed throuph
cedi b hoorec accouni due D NEFT Cannot be processed
ced hed, amaurt
or regutaton requlremernts.
We understand and agree
that where
per lega

Synature of 2nd Account Holder

Sionatureof 1s1 Account Holder (As per benk records)
Sigrere of PaloyholderAsslgneef (As on (As per bank records)
Polcy Applicadion)

Date- o712 202

DD MM 7Y
Pace

Benk Use Only)

cERTIRCATION BY ACCOUNT HOLDERS BANK:(Forreoorde &that the account ls aurenly operatlonel. We contm thet the aocournd detals a aocount
holders sreure

tmhed above are corectas per our

We certhyhe
the perlcuen
above ere as per our reoorda

DD MM Y YY

Bunk Brench stamp

Bar Auhotzd SyraorywihEmgyoee1D
of Indla Regn. Na 110) (CIN U66010MH2000PLC1
28403)
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