APPLICATION FORM FOR RE-KYC UPDATION THROUGH VIDEO KYC (V-KYC)

(For resident Individual Savings Account & individual Current Account)

Customer & Account details

VREKYC1162 05-05-2022
Tracking ID:_________________________________ Date:_________________________________

Customer ID: 5 2 2 3 5 5 1 6 5 Account No: 0 6 0 5 0 1 5 0 5 3 8 8

Customer ID: Account No:

Customer ID: Account No:

Customer ID: Account No:

Account No:

Account No:

Account No:

All the above mentioned Account Numbers shall be hereinafter referred to as Account(s).

Personal details
SIDDHARTH DAS 1984-06-19 M
Customer Name: ___________________________________________________ Date of Birth (DOB): _________________________ Gender: _________________
9337774334 [email protected] ALWPD0670J
Mobile no.:_________________________________ Email ID: _________________________________________ PAN: _______________________________

Customer Instruction

✔ Permanent Address (Permanent address shall be the same as the address detail updated in the Aadhaar)
PLOT NO-328/2885
Address ________________________________________________________________________________________________________________________________

CHANDRASEKHARPUR BACK SIDE OF OMFED PLANT BHUBANESWAR, Mancheswar Railway Colony

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

Khorda Odisha India 751017

City: ________________________________ State: ____________________________Country: __________________________Pincode: _______________________

Do you want to change your communication address?

✔ Yes No
Is your new communication address same as the address in the Aadhaar Card? (if selected yes for above question)
✔ Yes No
✔ Communication Address (As per selected by Customer)

PLOT NO-328/2885
Address ________________________________________________________________________________________________________________________________

CHANDRASEKHARPUR BACK SIDE OF OMFED PLANT BHUBANESWAR, Mancheswar Railway Colony

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

Khorda Odisha India 751017

City: ________________________________ State: ____________________________Country: __________________________Pincode: _______________________

✔ Self-Declaration for communication Address (Applicable in any of the situations for communication address)
I hereby declare that information provided herein is correct & further authorize ICICI Bank to update my address details in above linked Accounts.

FATCA/CRS Declaration
Resident Indian India
Current Residential Status: __________________________________________________________ Country of Birth:______________________________________
India India
Country of Citizenship: __________________________________Country of current Residence: ______________________________________________________
India No
Country of Residence for Tax Purposes:_____________________________ Are you a US citizen (Yes/No):___________________________________________
✔ Self-declaration for FATCA/CRS: I understand that ICICI Bank is relying on this information for determining my status in FATCA / CRS
compliance and understand that the Bank is not able to offer any tax advice or FATCA/CRS status or its impact. I agree to submit a new form
within 30 days, if any certification or information in the FATCA/CRS becomes incorrect.

eSigned using Aadhaar

(Leegality.com - DK0CEa7)
SIDDHARTH DAS
Date: Thu May 05 10:58:26 IST
2022
 3. I/We hereby, agree that the Bank shall be entitled to send Profile Details to all account holder(s) listed above for linking under the CASA Family I
communication
informing them if they do not wish to link their account(s), they shall opt out. I/We understand that the Bank shall not be liable to anyone in this rega
Salaried
(i) Occupation:__________________________________________ Private Ltd
(ii) Sub-Occupation: ______________________________________________
if any family member denies to link the account to the SA Family ID.The account holder(s) reserves the right to decline upgrade to the CASA Fami
through
(iii) Education: acceptable electronic or physical modes.
Post Graduate
___________________________________________ (iv) Gross Annual Income: 10 lakh to 15 lakh
__________________________________________
4. I/We hereby agree if the family members account(s) being linked in the CASA Family ID holds a higher account variant than the proposed fam
(v) Income source: Salary
___________________________________________
variant, then such family members account(s) will not be linked under CASA Family ID.
5. I/We agree that benefits and features refers to any of the facilities, discounts, services or arrangements offered to the account holder(s) as a result
being a part of the CASA Family. The benefits and features Aadhaar mayConsent
be introduced/amended from time-to-time at the sole discretion of ICICI Bank a
may vary by CASA Family type. Features may also vary within the same CASA Family, depending on whether the account holder(s) continues
I hereby affirm thatthe
satisfy I have been provided
prevailing various
criteria for that options by ICICI
CASA Family Bank for
variant. I/weestablishing
understandmy identity/address
and agree that all theproof for the and
benefits purpose of conducting
features a Re-KYC
may be subject to applica
process for terms
my ICICIand Bank Account
conditions and
and byI have voluntarily
availing the same,submitted
I/we agree mytoAadhaar
be bounddetails
by theto applicable
ICICI Bank terms
for conducting the Re-KYC process for my Account
and conditions.
held with
6. ICICI
The Bank and may
features hereby be give my consent
extended to such toaccount
ICICI Bank: i) to establish
holder(s)’s my identity/
(‘Primary Group ID’s)address proofand/or
business through Aadhaar
family based authentication
relationship(s) system
to form a Family/Busines
or verify the‘Group’
genuineness of the Aadhaar
at the discretion through
of the Bank andQuick
basedResponse
on consent (QR) code orapproved
(through through such otheror
electronic manner,
physical asmeans)
set outreceived
by UIDAI or any
from bothother law from
the Primary Membe
time to time;andii) share my Aadhaar
the prospective details
linked with holder(s).
account UIDAI, NPCI, concerned regulatory or statutory authorities, as may be required under applicable laws; iii)
also upon
7. authentication,
I/We agree that UIDAI
If themay
QABshare withas
required ICICI
perBank
CASAinformation in the nature
Family requirement and of my demographic
eligibility information,
are not maintained for including
a quarterphotograph, which ICICI
or three consecutive months(
Bank may use any as an reason
other identityas / address
deemedproof,
fit by forthe the above
Bank), the mentioned
Bank reserves purpose. I also
the right to agree
withdrawthat the
I have been informed
prevailing CASA Family that (a) my Aadhaar
features details
and dissolve/close
(including myCASA Family ID with
demographic or without
information) prior intimation.
shared by UIDAI will In case of such
not be usedwithdrawal of prevailing
for any purpose CASAthe
other than Family
purposeentitlement,
mentioned all the existing
above, or asCASA
per Fam
requirements features
of law;(e.g. discounts,
I hereby services
declare that etc.) willabove
all the be withdrawn/delinked
information voluntarily and account
furnishedholder(s)previous
by me, is true,account
correct variant will be reinstated
and complete with the
in all respects andminimu
I
understandbalance
that ICICIrequirements
Bank shall be as relying
applicable,
uponfeesthe & charges will
information be applicable
received as per
from UIDAI forthe standalone
completing theproduct
Re-KYC/ account
process variant/s held by the account holder
for my account.
The Bank shall not be responsible / liable in any manner whatsoever for any costs, losses, damages or expenses, or other consequences, caused b
reason of such instance/ migration/downgrade. Declarations and Terms & condition
8. A CASA Family Banking ID (“Family ID”) can be formed with a minimum of two (One Current account and one Savings Account) and maximum
1. I hereby understand,
nine accounts agree
with aand confirm that:
combination of current and savings account.
I have read, understood and accept the Terms and Conditions applicable for the Re-KYC process
9. I/We hereby, agree and confirm that in case any family member wishes to opt out of the family linking request, the Bank shall not process my reque
2. I hereby fordeclare
CASA that, theIDinformation/documents
Family creation. provided by me, during the Re-KYC process, through VKYC are up to date and correct and further
authorise ICICI Bank to update the information provided herein, in my Account
10. I/We agree that the CASA Family ID will be closed and deleted if there is only 1 member left in the CASA Family ID.
3. I agree that this request for KYC update is subject to verification and ICICI Bank reserves the right to reject my application, without providing any
11. ICICI Bank reserves the right to discontinue the services/benefits/offers provide under the family banking facility at any time without prior notice to m
reason and may choose not to return the documents provided herewith. If an incomplete or inaccurate information is given, ICICI Bank reserves the
or the linked members.
right to ask for additional documents at its sole discretion before processing this KYC update request.
12. I/We confirm that the above mentioned details are true and accurate.
13. I/We understand that the de-linking request byGeneral Terms
any family and
member conditions:
will be processed without my consent or consent of any other member.
14. I/We hereby agree and undertake to hold ICICI Bank, its Directors, employees harmless if any claims are raised by any family members/third partie
1. The above
theirdetails entered/selected
representatives/heirs by methe
against willBank,
be updated in to
pursuant mytheAccount(s)
CASA Family ID creation, linkingrequest by me, any subsequent de-linking/closure/mig
tion/downgrade by the Bank.
2. I hereby authorise ICICI Bank to contact me on the registered mobile number for verification, callback or checks, to confirm the veracity of any
15. I, the Karta
transaction, hereby
as deemed fitdeclare
by ICICIon behalf of the members of the Joint Hindu Family (HUF) under the name and style mentioned hereinabove, I am autho
Bank
rized to link the HUF account under the CASA Family ID and have taken prior consent and permission from all the members in the HUF and I, sh
3. I authorise
hold ICICI
ICICI Bank
Bank to send all correspondence
indemnified with
againstany claims regards
that to the
are raised byAccount
any HUFon the communication
member/third parties, address, as updated in thisagainst
their representatives/heirs application and pursu
the Bank,
shall indemnify ICICI Bank for any loss/damage/liability due to updation of the communication address provided by me
to my request for CASA Family ID creation/linking and any subsequent de-linking/closure/migration/downgrade by the Bank. in this application and for
sending correspondence at the communication address updated herein

4. I have understood the information requirement of this application form (read along with the FATCA/CRS Instruction and Terms & Conditions) and
hereby confirm that the information provided by me is true, correct and complete

5. I hereby authorise ICICI Bank to send SMS alerts and e-mails to the registered mobile number and e-mail ID

6. I have authorised NSDL e-Governance Infrastructure Ltd. (“NSDL e-gov”) to use my Aadhaar details (as applicable) for execution of this application
form, through Aadhaar based electronic signature

7. I have authorised the NSDL e-gov to provide my Permanent Account Number (“PAN”) details to ICICI Bank, for verification purposes

8. Under e-KYC Authentication, my permanent address will be stored as the address mentioned in Aadhaar mandatorily

9. If any request for deliverables, such as ATM/ Debit Card or ATM PIN is made, immediately after placing the address change request, the deliverables
will be delivered to the existing address available in the ICICI Bank Account records. I understand that in order to receive the deliverables at the new
address, I will have to place the request for deliverables after the address change request has been successfully completed

10. ICICI Bank does not take any responsibility for any incorrect/incomplete details provided by me and I shall hold ICICI Bank harmless, in case of any
disputes/claims arising out of the same.

Terms and Conditions for Video KYC:

These Terms and Conditions for Video KYC process (“Terms”) apply to and regulate the operation of the Video-KYC process offered by ICICI Bank
Limited (“ICICI Bank/Bank”) in India and govern the general relationship between the Customer (defined below) and ICICI Bank, having its registered
office at: ICICI Bank Tower, Near Chakli Circle, Old Padra Road, Vadodara 390007, India. These terms shall be in addition to any other terms as
stipulated by ICICI Bank from time to time on its website (defined below), whether pertaining to the Product/Facility (defined below) or in relation to other
services or offers provided by ICICI Bank.
Further, in case of inconsistency between the Terms and any specific Term and Condition pertaining to a specific Product/Facility, the specific Term and
Condition of that particular Product/Facility shall prevail.

eSigned using Aadhaar

(Leegality.com - DK0CEa7)
SIDDHARTH DAS
Date: Thu May 05 10:58:26 IST
2022
1. Definitions:
1.1 In these Terms applicable to the Video based KYC process, the following words and phrases shall have the meaning stated hereunder, unless
indicated otherwise:
i. Customer” shall mean a resident Indian individual applicant who applies for any Product/Facility (defined below) with ICICI Bank, subject to
such Product/Facility specific Terms and Conditions, as may be specified by ICICI Bank from time to time
ii. “KYC” shall mean the ‘Know Your Customer’ process to be completed by ICICI Bank, as per extant regulations
iii. “Product”/”Facility” shall mean any ICICI Bank Product or Facility that the Customer has applied/requested for and with respect to which the
Customer has consented to complete the KYC through the Video KYC process
iv. “Video KYC process” shall mean the process of KYC verification conducted through a video call feature, supported by ICICI Bank, in line with
extant regulations and ICICI Bank policy
v. “Primary Terms and Conditions” shall mean the terms applicable to the Product/Facility being availed by the Customer
vi. “Website” shall mean ICICI Bank’s website www.icicibank.com.
2. Interpretation:
i. All references to singular include plural & vice versa and the word "includes" should be construed as "without limitation"
ii. Words importing any gender include the other gender
iii. Reference to any statute, ordinance or other law, includes all regulations and other instruments and all consolidations, amendments, re-enact
ments or replacements for the time being in force
iv. All headings, bold typing and italics (if any) have been inserted for convenience of reference only and do not define limit or affect the meaning
or interpretation of these Terms and Conditions
v. Reference to any “law or legislation, regulation, rule” shall mean, applicable, constitution, statute, law, rule, regulation, ordinance, judgement,
order, decree, authorisation, or any published directive, guideline, notice, requirement or governmental restriction, having the force of law in any
jurisdiction and include laws as amended from time to time.
3. Applicability of the Terms:
3.1. These Terms and primary Terms and Conditions, form the express contract between the Customer and ICICI Bank. The Customer shall apply to
ICICI Bank in the prescribed form for the Product / Facility. By applying, the Customer acknowledges that he has read, understood and accepted
these Terms and the primary Terms and Conditions, as applicable.
4. General Terms for Video KYC process:
4.1. Requirements for availing of Video KYC feature:
i. Video KYC process is available only for Customers who are physically present in India and if the same can be confirmed through their live
location through geo-tagging and shall be accessible only during the working hours, defined by ICICI Bank
ii. Video KYC process shall not be available during Bank holidays and National holidays
iii. Video KYC process shall work only in good network/internet conditions and
iv. Customer should possess the requisite documents and materials, as informed on the journey page, at the time of the Video KYC process, to
avoid any inconvenience.
4.2 On opting for the Video KYC process, a two-way video call will be initiated between the Customer and an ICICI Bank official, to start the Video KYC
process. The Customer hereby consents to complete his KYC through the Video KYC process and further understands that pursuant to RBI
regulations on the Video KYC Process, it is necessary to track and ascertain the Customer’s location for which purpose the Customer
herebyauthorises and consents to ICICI Bank tracking and ascertaining the Customer’s location through its IP address or any other manner, as
determined by ICICI Bank.
4.3 As a part of the Video KYC process, the Customer shall be required to verify their identity by answering certain questions asked by ICICI Bank
officials, through a video call. By proceeding with the video call, the Customer accepts the Terms herein
4.4 The Customer shall be required to cooperate with ICICI Bank officials in every manner and provide all such relevant information/data/documents,
including but not limited to, allowing ICICI Bank officials to capture their photographs, photographs/screenshots of various documents (including
but not limited to Officially Valid Documents (“OVD”), PAN, etc.), by the Customer during the Video KYC process, as and when requested by the
ICICI Bank officials. The Customer agrees and consents to co-operate and provide all such relevant data/documents, etc. for the purpose of Video
KYC process.
4.5 The Customer authorises ICICI Bank to collect/store/verify any and all information/details received through the Video KYC process, including but
not limited to the video call itself, information received from documents/information captured/shared through the video call
4.6 In case the documents shown and verified by ICICI Bank officials over a video call do not comply with the ICICI Bank policy and/or relevant guide
lines due to any reason whatsoever, the application request shall be rejected and the Customer shall need to visit an ICICI Bank Branch to complete
the KYC verification
4.7 Customers who have opted for a Video KYC process to update the KYC request is subject to verification and may be rejected by the Bank for
various reasons including, but not limited to:
i. Call drop due to network/internet issues at the Customer’s or ICICI Bank’s end; or
ii. Documents matching criteria is not fulfilled or
iii. Bank official is unable to capture the screenshot of the Customer’s photo or any document or
iv. Customer is not ready to cooperate with Bank officials or
v. Location outside India, face mismatch, poor quality uploaded documents or
vi. For any other reason at the discretion of ICICI Bank.
In case of such rejection, Customers need to visit the ICICI Bank Branch to complete their KYC verification.
4.8 The Customer understands that the Video KYC process is subject to the availability of ICICI Bank officials to conduct such Video KYC and technical
stipulations, including but not limited to those arising due to any delay, interruption, suspension, resolution or error of ICICI Bank in receiving and
processing the request and in formulating and returning responses or any failure, delay, interruption, suspension, restriction, or error in the
transmission of any information or request to and from the telecommunication equipment of the Customer and the network of any internet service

eSigned using Aadhaar

(Leegality.com - DK0CEa7)
SIDDHARTH DAS
Date: Thu May 05 10:58:26 IST
2022
 provider and ICICI Bank's system or any breakdown, interruption, suspension or failure of the telecommunication equipment of the Customer, or
ICICI Bank's system or the network of any internet service provider and/or any third party who provides such services, as is necessary to provide
the Video KYC process.
5. Acceptance of Terms and Conditions:
5.1 By accepting these Terms and Conditions in the digital journey of the Video KYC process, the Customer shall be deemed to have accorded his
approval/consent to (i) complete the KYC verification for the Product/Facility application through Video KYC process (ii) the consents,
authorisations, declarations and undertakings, etc. mentioned therein.
6. Miscellaneous:
6.1 Customer agrees that all costs incurred at the Customer’s end (technical/data plan related or otherwise) for completing the Video KYC process,
shall be borne by the Customer, solely
6.2 The Customer agrees that ICICI Bank shall not be liable for any connectivity/signal/data related issues leading to incomplete information /
application being provided by the Customer
6.3 In case the Video based KYC process is not completed/submitted for any reason whatsoever, Customers need to visit an ICICI Bank Branch, to
complete their KYC verification
6.4 Customer hereby agrees to indemnify, defend and hold harmless ICICI Bank from and against any and all liability, loss that may occur, arise from
reliance by ICICI Bank on the information, declarations, documents, images and undertakings, etc. provided by the customer (on account of them
being fake/incorrect/erroneous), the usage of online/offline mode for the Product/Facility application, including the details provided basis this Video
KYC process or breach, non-performance or inadequate performance by the Customer of any of these Terms, Primary Terms and Conditions or the
acts, errors, representations, misrepresentations, misconduct or negligence of the Customer in performance of its obligations
6.5 In case of any inconsistency/inaccuracy/non-completion of any formalities in the Video KYC process or for any other reason whatsoever, ICICI Bank
may contact the Customer for offline completion of KYC. The Customer agrees and confirms that ICICI Bank shall, at its sole discretion reject the
Product/Facility application for any reason whatsoever, including but not limited to reasons attributable to erroneous, incomplete, misleading
information or non-adherence with the relevant norms/non submission of KYC documents to ICICI Bank or upon any notice/directions received from
any other regulatory body
6.6 The Bank reserves the right, at any time and from time to time, with or without notice, to cancel, withdraw, suspend, vary, change, add to or supple
ment the Video KYC process and facilities offered to Customers hereunder.
7. Change of Terms:
7.1 ICICI Bank shall have the absolute discretion to amend or supplement any of these Terms, at any time. ICICI Bank may communicate the amended
Terms by hosting the same on their website or in any other manner as decided by ICICI Bank.
8. Limitation of Liability:
8.1 Neither ICICI Bank nor its employees shall be responsible or liable in any way for any direct or consequential loss suffered by the Customer or any
third party or towards any claims that may arise due to the rejections of the KYC update request, due to the Video KYC process availed by the
Customer
8.2 ICICI Bank shall not be liable for any failure to perform any obligation contained in these Terms, or for any loss or damage whatsoever suffered or
incurred by the Customer or a third party howsoever caused and whether such loss or damage is attributable (directly or indirectly) to any
disputeor any other matter or circumstances whatsoever
8.3 Under no circumstances shall ICICI Bank be liable to the Customer or a third party for any indirect, incidental, consequential, special or exemplary
loss or damages in connection with the Video KYC process.
9. Force Majeure:
9.1 ICICI Bank shall not be liable for any losses caused by its inability or delay in providing the Video KYC process or fulfilling any of ICICI Bank’
bligations hereunder, either wholly or in part, caused by or in connection with any force majeure events including, but not limited to, restrictions on
convertibility, transferability, requisitions, hacking, involuntary transfers, riot, disturbance, strikes, lock-outs, bandhs, war, civil strife, burglary, theft,
dacoit, accident, hacking, technical fault, including problems related to computers, accessories, software, printers, fax machines, internet,
telephone system and such related hardware and software beyond the control of ICICI Bank, breach of trust by any authorised persons, flood,
epidemic/pan demic, fire, earthquake, act of god, act of any government, change in regulation or law and other allied acts of regulatory or statutory
nature or if the performance of such obligation or provision of such service would result in the breach of any law, regulation or other requirement
of any govern mental or other authority or on account of any other restriction or requisition or other circumstances or events whatsoever beyond
the control of ICICI Bank and the Bank shall not be obliged to provide any service or facility or perform any of its obligations hereunder, during the
period, while the Bank’s performance is affected by force majeure conditions. The Bank shall not be responsible for any loss or damage caused
to the Customer by reason of any failure to comply with the Customer’s instructions, when such failure is caused due to reasons beyond the control
of the Bank, the opinion of the Bank being final in this regard.
10. Governing Law:
10.1 The laws of India shall govern these Terms. The Customer hereby agrees that any legal action or proceedings arising out of the Terms shall be
brought in the courts or tribunals at Mumbai in India and irrevocably submit themselves to the jurisdiction of such courts and tribunals. ICICI Bank
may, however, in its absolute discretion, commence any legal action or proceedings arising out of the Terms in any other court, tribunal or other
appropriate forum, and the Customer hereby consents to that jurisdiction.

I have read and understood the declarations, consents and terms governing this application form/request and hereby accept the same.

eSigned using Aadhaar

(Leegality.com - DK0CEa7)
SIDDHARTH DAS
Date: Thu May 05 10:58:26 IST
2022