7/29/2019 SI Mandate New
1/1
SIM000101Bank Name : ____________________________________Branch
Name : ____________________________________Address :
____________________________________
____________________________________
Copy to - Canara HSBC Oriental Bank of Commerce LifeInsurance
Co. Ltd
Address: Unitech Trade Centre, 2nd Floor, Sushant Lok,
Phase-1,Sector - 43, Gurgaon, Haryana 122002, India.
Ph: 1800-103-0003 / 1800-180-0003 (BSNL/MTNL)
Standing Instructions for Life Policy / Application Number
Dear Sir/MadamThis is to inform you that I/We have registered
for availing the Electronic Premium Payment facility of Canara HSBC
Oriental Bank ofCommerce Life Insurance Company Limited. I/We
hereby authorize you to periodically debit my account for making
payments to CanaraHSBC Oriental Bank of Commerce Life Insurance
Company Limited through ECS (debit clearing ) / Direct Debit
(strike off whichever isnot applicable) only on request from the
Insurance Company, as per details mentioned below. I/We also
authorize Canara HSBC OrientalBank of Commerce Life Insurance
Company Limited, or its representative for carrying this mandate
form in duplicate to get it verified andexecuted from your branch.
The Second copy of Mandate form after it has been duly verified and
authenticated be handed over to therepresentative of the Insurance
Company for their records. Mandate verification charges (if any)
maybe charged to my/our account.
Mandate Start Date (DD/MM/YYYY) Mandate End Date
(DD/MM/YYYY)
Name of the 1st/Sole Account Holder:
Name of the Joint Account Holder:
9 Digit MICR Code:
(MICR code number of the bank and branch appearing on the cheque
issued by the bank. If it starts from 000, please obtain correct
code from your Bank Branch)
Account Number:
(As appearing on the cheque book)
Account Type: Savings Current
I/We hereby declare that the particulars given above are correct
and complete to the best of my/our knowledge. I/We have read and
agreeto the terms and conditions mentioned overleaf.
Signature of the 1st/Sole Account Holder
________________________________ Date:
Signature of the Joint Account Holder
________________________________ Place:
__________________________
Important : 1. In case the account is being held in capacity as
a Sole Proprietor, Partner and Director (Company A/c) then the
appropriate
company stamp is also required on the Mandate form along with
the signatures of the account holder. 2 Please attached a self
cancelledcheque of the account on which the Standing Instruction is
being issued (in case cancelled blank cheques does not bear account
holder'sname, photocopy of the bank statement containing the
account details or photocopy of the front page of passbook is
required to beattached.)
POLICY RELATED INFORMATION
Name of the Policy Holder
Premium Frequency
Premium Amount*E Mail ID:
____________________________________
Mobile Number: _______________________________
CERTIFICATION BY THE BANK
We hereby certify that the account number mentioned above is
currently operational and the account details mentioned are correct
as perour records. We also hereby attest the signature of the
account holder affixed on the SI mandate above. These signatures
match with theone in our bank records.Date
____________________________________________________________________
Signature of the Authorised Bank Official with the BANK STAMP
and PA/Emp. Code
Mandate Terms and ConditionsThe Electronic Premium payment
facility (facility) offered by Canara HSBC Life Insurance Company
Ltd., (*the Company*) is subject to the following terms and
conditions.
1. These terms and conditions form an unconditional agreement
between the Policy Holder and the Company and/or the Service
provider. By exercising the option to avail the facility, the
Policy Holder acknowledges havingunderstood and accepted these
terms and conditions.
2. The ECS facility is available in select cities only.
3. The Direct Debit facility is available for HSBC and Oriental
Bank of Commerce account holders only.
4. It will be the Proposer/Policy Holder's responsibility to
ensure that the Company receives credit for the payments due
towards premium(s) when payable and/or on or before the respective
due dates. The Company will notbe responsible for making any
follow-up in relation to the receipt or non-receipt of
premium(s).
5. Premium will be debited from the Proposer/Policy Holder's
bank account up-to 7 days before or after the policy premium due
date.
6. The Proposer/Policy Holder shall at all times maintain
sufficient credit balance in the Bank Account specified in the
Mandate so that the Mandate is honoured and credit for the premium
due is received in the first instanceby the Company within the time
specified thereon.
7. In the event of dishonour of Direct Debit/ECS on account of
Insufficient Funds, the payor's bank may levy return charges at the
rates applicable from time to time which may be deducted from the
payor's accountmaintained with such bank.
8. Without prejudice to any right of the Company, the
Proposer/Policy Holder will indemnify and hold the company harmless
against any and all liabilities, cost and expenses that may be
incurred by the Company arising outof any acts of omission or
commission or negligence on the part of the Proposer/Policy
Holder.
9. It is understood that the Company is extending such facility
of ECS/Direct Debit to make it convenient for and facilitate the
Proposer/Policy Holder to pay the premiums, this facility may be
withdrawn by the Company at anytime, and in such a scenario,
subsequent premium payments due will have to be made in any other
manner acceptable to or stipulated by the Insurance Company.
10. In case of decline of a said transaction for any due the
Proposer/Policy Holder would make payment for the policy due
through an alternate mode. The policy would not be removed from the
standing instruction mode andsubsequent premiums would be debited
as per the mandate instructions. The company reserves the right to
remove the policy f rom standing instruction mode in case of three
consecutive decline transactions.
11. You have a right to opt for, by way written notice to the
company of not less than 30 days, any other mode of premium payment
as may be allowed by the Insurance Company, and shall have a right
to revoke this mandateby giving a notice of not less than 30 days
in writing, simultaneously to the Company and to the Bank.
12. The Company in no way shall be responsible for non-execution
or delay in execution of direct debit instructions either on
account of incomplete or inaccurate or non-availability of
sufficient funds in my account or for anyother reason beyond the
Company's control.
13. The Proposer/Policy Holder agrees that in the event he/she
is dissatisfied with any portion of the f acility or with any of
the terms and conditions or alterations thereto, his/her sole and
exclusive remedy is to discontinue theuse of the facility.
Monthly Quarterly Half-Yearly Annual
(*Important: In case indexation has been opted for, this mandate
for Standing Instructions shallbe deemed to be on Indexed premium
from time to time. Premium amount would increase at a
fixed rate of 5 % on each policy anniversary on the then
existing Premium.)
ECS Debit clearing/Direct Debit Mandate
