Electronic Clearing System Case Study

Only available on StudyMode
  • Topic: Uttar Pradesh, Banking, Madhya Pradesh
  • Pages : 6 (1603 words )
  • Download(s) : 346
  • Published : September 14, 2011
Open Document
Text Preview
ELECTRONIC CLEARING SYSTEM (E.C.S) / DIRECT DEBIT APPLICATION FORM Section A
Instructions for Premium Payment through ECS Direct Debit (In case no option is selected, the default option will be ECS) To, ICICI Prudential Life Insurance Company Ltd., ICICI PruLife Towers, 1089, AppaSaheb Marathe Marg, Prabhadevi, Mumbai – 400 025. Dear Sir, Re : Authorisation to pay Insurance Premium amount through Electronic / Debit Clearing System. I, the undersigned hold a valid Policy bearing No. Or Application bearing No. Date: D D M M Y Y Y Y

I, wish to avail of the direct debit facility and hereby express my unconditional consent to debit premium payment of my policy referred to above through participation in the Electronic Clearing System (ECS) / Direct Debit. I understand and agree that the premium amount to be debited from my account may vary due to taxes and other statutory levies as may be applicable from time to time. I, hereby declare that the particulars given are correct and complete. I understand and accept that the transaction will be effected on the policy due date (provided the day is a working day). If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I shall not hold the user institution (company) responsible. I agree to discharge the responsibility expected of me as a participant under the scheme.

*Primary Account Holder’s Signature (* Only if Primary Account Holder differs from Policyholder)

Joint Account Holder’s Signature 1 Joint Account Holder’s Signature 2 (Signature of all account holders is mandatory)

Policyholder’s Signature

I hereby authorise ICICI Prudential to enable direct debit facility for my premium payments. The details of my Bank Account are mentioned below Particulars of Bank Account (to be filled in CAPITAL letters) a. Name of the Primary Account Holder (as in the bank account) : b. Bank Name : c. 9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank* (*In case of ECS, kindly ensure that the first three digits of the MICR code that you fill in are all not zero.) d. Account Type: e. Account Number : Savings Account Current Account Cash Credit (As appearing on your cheque book)

Yes, I have attached a photocopy of a blank cheque or a blank cancelled cheque Certified that the particulars furnished above are correct and as per our records.

Bank Stamp:

Signature of Authorised Bank Official

The ECS / Direct Debit facility will be activated in your next billing cycle.

Section B
To be retained by your Bank To, The Manager Bank Name premium dues on my ICICI Prudential Life Insurance Company Policy/ Policies. Mandate verification charges (if any) may be charged to my/ our account. I further request you to inform ICICI Prudential Life Insurance Company of any change in the status of my account. Incase I wish to revoke the above authorisation for any reasons whatsoever, I undertake to inform ICICI Prudential Life Insurance Company after giving an advance notice of two months in writing.

Branch Address

No.

towards my

Joint Account Holder’s Signature 1 Joint Account Holder’s Signature 2 (Signature of all account holders is mandatory)

Please refer to the reverse for information on ECS / Direct Debit facility.

1

Aug 2007

Dear Sir/Madam, I, the undersigned hold a valid Policy number and wish to avail of the Electronic Clearing System / Direct Debit facility towards settlement of my Monthly / Halfyearly / Yearly Policy Premium payments in favour of ICICI Prudential Life Insurance Company. I hereby authorise you to debit my Account

* Primary Account Holder’s Signature (* Only if Primary Account Holder differs from Policyholder)

Policyholder’s Signature

• ECS / Direct Debit works in a very simplified manner: The Electronic Clearing System (ECS) / Direct Debit facility enables hassle-free premium payments. Premium Payment requests through ECS / Direct Debit are sent to...
tracking img