Gy ssoos02ssae [Sworn drartionatite sem = {Bots service wo 50677 jeevan surakano kn imisnuciese on - ‘maya nazariya, warddress your query Payout Request Form | Pease ed all nsuctns tlre ging the fom i + tint a eta LOCK LETTERS ony + Alcommunleatn vibe ent he dees recoded with ws * Thespolestan ay whol news oe stm slong with requste domes as martordn he frm j . Moser Pot Holer Pay Theda tame pater sea fol ulmi tisloTalat/¢ 6524) . i Name of Member lalla a fa a ee Fea) Panay epee Tothone Tae Tae : 4 NameotMenbe: — (WIETTLFLRLAl [ I MII (coapteanty Thon Tata ae | Nenvctsineer = TT Tritt [ele aia TT LO | ld et acl he ply re ok ered wuld hf continue the snes oe tou am cing nn entInuanco of cove snot value n cae of jt ites covared® sna to suende pote kar sure aot | . IL “abe i: ola lalalsicTelstelok | ' po | Talal Adol. Tal TTT TT TTT TT) ne sen name/ Bun sateen Coy of Pasbct® oe | by ig i 3 | Internal Page 1 of 3 atwo CS Pputs wold ont be made vide NEFT. Payout would be In accordance and subject to the terms and cont ame of he Bank Aeron tee ish AiMal TTT TTT TTT TTT TTT ttt wore: BIE TOO gale lolo wscester: ETE Ing loa EBE] setters (cltlaieTel Tela Tolel KINA CET TTT TTT r) Bonk Acorn nunber: ET 1 CurentAecount Decdione (SoT=IULA Te IIA el Tale la oo Tralee Tal 1-7 BleiGlalIulelol Tela Aarlaleal TTT TTIITL) (clolak b) li NICR code ofthe brand ranch appearing onthe cheque sued bythe bark. Submit bark cancel hesue slang withthe form. canes ‘cheques non personaled please bmi tet Dan sttemert/pat book copy *ForFreelokcancsitin payout woul be reed tthe master poy eters account ieee [DECLARATION IW EASE THs PAYOUT FORM Is FILLED YA PERSON OTHER THAN THE POLICYHOLDER OR SIGNED IN VERNACULAR LANGUAGE: Decatin by Poker. nrc dectare hatte contents inthe em have been Inferatlon previa. Thunb mre Siete the Poleyoier + _Decaraton by perso lg he frm: Inne esate conta fh oe othe Frain lnguge and Rave eel recone te ans prided oe Murer dcr thatthe Poll has sete hha tur Wes In my presence, Peete | EEEEEE ELLE eee prsoentereoree EET TT TT TTT TTT ti tii tit titi) EO ty explained ome a de ate ts GEEEEECE Decorantssteatre: Date PERETTI TT Pace “epee nance apr roan annette IV We do herety author, conto, declare Bhar AKA Lf Insurance (the Company) to make a Poly relsedpeyment trough electronic wane tthe Bank Account as spcfied above caf that ll ner the Company abot any change'n thank Aceoun deals as mononed sb) om te time and understand and agree thatthe change willbe effective enya he Company ontming he execiton of tha change nthe ete, hereby declare tat | wou not hold the Company response in cate of noncretof pment to my bank account crf the transaction f dsaye or not eee canara ae ree Ce « [GATED] es ‘Signature ber Insured olaly 2 tie EE fea oe PID) ‘Spare of Meibw reed ‘Bus AXA Life Insurance Company Li ‘Rega. oftes: Unk No-1904 49: Foor, Paine resenz, Block, and Kurla Compe, KC Rood Sand MCA Ground Bande East, Mural ~ 400081. Mahaaehira ‘Serce ol Assess: Spectrom owe, Flot, Malad ink road, Mala (nest) Mumbal 400064, Manarestva sooamaue SMS SERVICE 56677 we enengaeeniensnimerroy tances Internal Page 3 0f3