Wore oy be AGH MANDATE NBTRUGTION a Fe FAP oma 07204 Ta ‘ponte Bank Code | } my coe Cate. ia ]_Weherby manne Wore LIFE Jodie“) | \SBicAccise.NRE/SEAROOTIER | soscnnee IROM6IV PB izle! 1111 TTT ti 1 PEELULEL woven STATE BANK OF INDIA weolS|B)ZWI0\0 [0/2192 5 wmcn sm emanttinen|THENTY 3IX THOUSAND ONE HUNDRED TWENTY FIVE ¢26/257~ FREQUENCY, Bawownny cE} tty [IAs 8 when presented DeniT TYPE “Fomedt Amon 7 Mame Amount pevwwoenno | OCT ROS FIRS ee Wo Ls peer Renown nt [oS c : <7 we aren torte debt of mandate processing charges by the bark whom | ane oe ators ode my/our acount as per aes ached of charges of he bank J TT)|- Dhavestwoun Sorenalct © COT) ayanesnnan ae + Tanto corto fat nn cncrton hs bee carey en und & dey ma anv ae sere he Ue eit ae nyu ou 1 fh hksinmenmea tas anny nueaves i cecanon hemo yspponiny ener acesvanerer ein whe oat DECLARATION: 1Luwehereby dare thatthe partic given above ae corect and complete. 2. Ve hereby care that incase of thd party account okie, 9 KYEformof the count hoger sabe submitted 3. undertake to ep suticent ands te acount mentioned nthe mandates onthe Jatt erection of debit 4, Ue vey uth ‘he Bonk Word nel dean ther ntrmearis a communicate my/our funding accunt etal as maybe nessa) To HOFC Lite sur Compary and forthe Specie purpose of ecovering my/our OFC if prem poyientsthougha debt insrution a my/our aceaun. 5. Uwe heed) autho IDrc Lite, theinstance ofthe ELSrs/SOPNAGS fling for any reason, to author the Bank/WordLine Gok to recver the premium payable through a dect debi to my/our acount wth the Imertoned bok 6 Ifthe transaction delayed not effected al for eaions of Incomplete a nett formation wil ot held HOF ite the Banko the other Intermediates tespnsble-7 Vie agte that for cuanging te premiunvEM amour spt mou requrement. ve wl fuish a fresh mandate fer uch change the ‘premium mount whic wil supersede al ther mangates previously ven 8 We age that nthe event of vation by me/us of any undertaking confemed in te Soreement hrc sal amount tan event ofthe tess of he insurance Ply and HOF Lie sha been to invoke therernedies nauabl of ters af he poly ‘preement 9 we are thatin the evento the Ban being unable to eit myer acount for want of sunt ands er any oe reson HOFC Life shade ented to ea with my poicyinmenne’ as Gescrbedin the poy provisions, ules the payment recived any alteratve hede an or before he specified a. 10, rey ‘Ssthonse myles Bank te dest my/our account with the amount of sence tax an the eves 9s may be stiplated by the Govern rm tine 10 te, on the premiun/Eh stated above and forts purpose, no further or resed autho req by my/our Cank 1. /We hereby authorise that mde tance ofa ansacton Titre tomas an ECS request HOFC fe on reresen tice the waneaton tomo account fr easing this rami 12 Vie ws to ou he ECSSUDQINACH city and hereby express my unconditional cansent to debt prern/EM of my pay to above hugh pata on Electric lang 5st (5) Dect Det Ve Uinetsand and epee that pre mion/Mramount tobe debited rommy/ou aout ay at eto tes ad thr statutory eves sry be oppaefrom neo ine 13'vweundestextandacept thatthe tansacton be effected nthe polcyanthedue de revided the dy sa waking da VWe ates a dehage te espensbty ‘Spectedotme/usasportpant(s} under te scheme, ve fateful responsi ofthe corectnessof he detailed heres. Ve autbrse te abovementionedbank ‘2eetat ny bank ues ffmyrour Es mandates sctve and url Ue give aweten request or cancelation of ECS/S/ODINACH 15. the future Ate ope out of EeSrbeect Debt nove. heremay be anncease npremun/EMancont. 16. Wieundetsandané agree atte subssionof ts form doesnot mean that the request il Expressed Vc unde'stond tat any payout under te polcy sal be siti aeardance wit the ply fers ad cndtons. Aso. payne sal be subject 0 epee ofthe lst renewal remnvéMpayent 17 WWe sto uncarstand and gre thatthe Conga ess the ght use any yout option. For Stith HOFC Gakbmaester Sane, pcasanvolbe Geta trem your account an the dei dae However case are, we vill Jeb your acout aytine am upto 10 days rom fhecateof debt 13 lauthorse the Company to deduct tthe oustanding premium ng withnerest fo case af nent inked rod} fo the purpose of rea Mrertnatin cas of onwetinlpreduts cmpany may deduct he Horta) anlthe the carges ft the period whe th poy wasiniaysed tage understand hat he Coit vebanes te right toretuperesval ofthe poy £0 incase prefered of debits selected, the Gbitattenpt wil ane onthe retiring Datelsteodot the eran sO incase of caecton fo Lonr-Agenst-Pokcy the Compary may pocess debit attempt post the EMiGuedatet recover pending payments Amportent Nowe: caacrcinain, econ arate, ee shoud te cuersred bye Aas Held 2. Fe Sica (OFC Banka Oa) th NAV ae wi ee dl on wn Bak Te cacti soo 3 Fer ECS NAV wos cnc ant brat Gat te 4 Deco ay fon ES ol) feed y IC Bar Crk, Unen ark ta Fe edt iabe hex ana sn Pros National ark ety Tor Brot Deb NAV wl bx Foe fle Gay we payer eavedin he HOF Ue cco 6, a a ea headlong et 7 wast pats te peu ele. Te pana wl be end stg ante em a ert cit otis mat ti tel poms Suds ss We mana evan Incase fy eteuse decane UMM act ew chogesn are re oy eux eed Gages Feng asta h emus he eg eb ntuton wb Ge acted Herc, aes Ale Ort Mande egret be re aan co 30 says porto remus nts casa of POD open NAV wi ead essa ira dl rd ret rene a OE cis PD Sn on prema dota ot on Pere ing ae, art amount enaed 15% tod rena ane a ee eno scams my seas n prema uo crungee rei web eat oP: ul pete hans Foy aya Bot ao rg ts monary vd Pao OFAN a etatan) Peat wae va My AzurvceG hoe con OHAN OFC Ue anh pret emits ‘asus npromanliewosstpecc tn, ee af Duy cient Tam ol yur tre as vag TO) Prefered Bg Dl opin avaiaie ECEO, Gmicayeoonenn senior Pomy yc Ltetmrane Company Unt ori. LstowlngeAc 2215 IRDA Region No, 10 aoe a Era Ao is Compe NM Jo Ma ios, ai 1001 sci ay ach uavoATEWSTROETIN eleanor oe Nabe ee ICE vee ane Ca Ratt apm preety eel ITary "here eaegotnaimtman timansan actions aaa tn em ac olAetatonship wit Potter ease ek) [I spmiee Pawn [ting CloranparnisClenpoyer tr Enpoye conga bra Over Pst Dew Cratsaney SC) rears Paar Te Kaa Furs Sos ane ow (ZlebyPisi4 a WIZIF! | Clow noe had ett 8 de apt, Prey ce ‘ta hv ened tn arnt ae open oe eo be seared Ign we Ne Wu eae hs rae pond Fu Testa dora alin eo sonreias ore ny psa Gove Ye 1 glgjelssleleje|y/elsle Peter Bling Ble pion vale or ECSOOS. renamed at customer RaansName: Mr. Ohaneshwar Soren S/D/#/o —: BALESHWAR MANJHT CIF under : 241812411 Account No. 42069932192 Alc Type REGULAR SAVINGS BANK ACCOUNT Address —: 8/0: Baleshwar Manjhi, QTR.NO-H/V-44, PA SCHIM PoLLY, VILL-CHANDRAPURA Chandarpura Phone No. Enail:ebi .02925asbi .co. in Phone No LFSC: SB1N0002925 Buss. Hrs:10:00:00-16:00:00 MICR: 827002504 MOP: “SINGLE A/c Opening Ot: 10/07/2023 Nom Reg Customers PaN: LOHPS4347F. Date of Issue: 11/07/202 ‘) ‘S FIRST f oe