Registration Cum Mandate Form for Auto Debit Policy No.

Date D D M M Y Y Y Y
through Credit Card
Important Note

Please read the terms & conditions before completing this form
Please attach photo copy of Credit Card (both sides)
Please ensure that this mandate form reaches the company before 10 days from the next premium due date

CUSTOMER DETAILS

Customer Name (as per company records) F I R S T L A S T

Client No.

In case of Regular Pension Plan and Regular Top Ups, please give the following details

Policy Number Amount to be deducted Start Date (*) Frequency

*Should be after 10 days from the date of mandate

In case of other plans, please give the following details

Policy Number Start Date (*) Frequency (optional)

CREDIT CARD DETAILS

I hereby authorize Reliance Nippon Life Insurance Company/their authorized service provider to debit my following Credit Card towards Premium and other dues

Name of Credit Card Holder (as appearing on the Credit Card) F I R S T L A S T

Credit Card No. Credit Card Type Master Visa Diners Club

Expiry Month & Year M M Y Y Issuing Bank

Signature of the Credit Card Holder

(as appearing on the credit card)

DECLARATION AND SIGNATURE

I hereby declare that the particulars above are correct and express my willingness to make payments referred above through my/our Credit Card. If the transaction is delayed or
not effected at all for reasons of incomplete or incorrect information, I would not hold Reliance Nippon Life Insurance Company Limited or their appointed service providers or
representatives responsible. I have read and agreed to the terms and conditions.
I hereby agree to follow the terms and conditions of the Credit Card Mandate as mentioned overleaf.
Mktg/CC Mandate/Version 1.5/Mar2018

Signature of the Customer (Policyholder)

Date D D M M Y Y Y Y Place

Name F I R S T L A S T

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TERMS & CONDITIONS

01. By opting for the Credit Card facility/facilities, the Policyholder elects to make the payment of Premium (other than First Premium) to RNLIC from the Credit Card Holder's Bank Account
through any authorized service provider that the Company may tie up with from time to time.
02. The Policyholder agrees to abide by the terms & conditions of the Credit Card facility of Credit Card Issuer.
03. Payment by Credit Card shall not be effected for First premium and one time Top-up Premium.
04. On the Policyholder electing the option/mode to pay the Premium (other than First Premium), the same, unless revoked and/or modified by him/her subsequently by a minimum 10 days
prior written notice to RNLIC shall be valid and binding on the Policyholder.
05. The Policyholder agrees that he/she shall remain liable for all the instructions and transactions that have been submitted by him/her or processed under his/her account prior to the date
of Policyholder obtaining RNLIC's acknowledgment to the said Notice.
06. Any Outstanding amount prior to 10 days from the date of providing information relating to the particulars of the Credit Card to the Company by the Policyholder should of collection
(Cash/Cheque/DD). In case of Regular Pension Plan, Credit Card deduction will be effected based on mandate irrespective of outstanding amounts are paid or not.
07. The Credit Card Account shall be debited on Premium Due date (excluding grace period) or next day (if the day happens to be holiday, next working day).
08. Modification/Cancellation of Credit Card facility: A written request shall be given to the company for any modification/cancellation of Credit Card facility and the receipt of the request. The
Company will not be responsible for any delays in effecting this, which are beyond its control.
09. The policyholder can opt for Frequency change (eg., half yearly to quarterly). At present, monthly mode option not available for any product except Connect 2 Life. Regular Pension Plan
and Regular Top Ups.
10. Only Annual Premium Paid Certificate will be issued instead of individual receipts for all premiums paid through Credit Card.
11. No reminder notices shall be sent during the term of Credit Card.
12. The records of RNLIC and/or its authorized Service Provider, on the Premium (other than First Premium) payments, maintained through computer systems or otherwise, shall purposes and
shall be conclusive proof of the genuineness and accuracy of the same and binding for all purposes and can be used as evidence in any proceedings.
13. The Policyholder acknowledges that he/she is eligible to avail the facilities and agrees to provide true, accurate, correct and complete information as required by RNLIC and to keep the
same updated Incorrect, incomplete, ambiguous forms will not be accepted and will be returned to the policyholder within 30 days.
14. The Policyholder agrees that the facilities will be available to him/her, subject to and upon receipt of confirmation by RNLIC and/or its authorized Service Provider from the Credit Card
Issuer of the details furnished by him/her in this application.
15. The Policyholder agrees that it shall solely be his/her responsibility to schedule his/her Premium (other than First Premium) payments in a manner that the Company receives the First
Premium within the due dates as specified in the relevant Policy Contract(s) and that in the event of a late payment he/she shall be liable for the late payment charges and other
consequences as may be enforced by RNLIC.
16. The Policyholder expressly understands and agrees that if any one payment/instruction are not received/honored, RNLIC reserves the right to automatically cancel/withdraw the facilities
forthwith without notice.
17. The Policyholder further agrees that RNLIC and/or its authorized Service Provider shall not be responsible or liable if it is unable to effect any of his/her payment instructions owing to (a)
incomplete, inaccurate, invalid or delayed submission of details by Policyholder (b) insufficient funds to cover Policyholder's transactions (c) encumbrance or charge on Policyholder's
account or (d) events beyond the control of RNLIC and/or authorized Service Provider
18. The Policyholder expressly understands and unconditionally agrees that he/she will not hold RNLIC and/or its authorized Service provider liable for any direct, indirect, punitive, incidental,
special or consequential damages whatsoever, including but not limited to damages or losses resulting from (a) the use or performance or inability to use or non- performance of the
facilities (b) the provision of failure to provide the facilities (c) the unauthorised access to or alteration of the transmission or data (d) such transactions that are carried out on the
Policyholder's instructions in good faith (e) any loss or damage incurred or suffered by the Policyholder due to any defect, error, failure or interruption in the provision of the facilities or (f)
any other matter related to the facilities.
19. The Policyholder agrees that the RNLIC and/or its authorized Service Provider may from time to time make alterations, additions or deletions to these terms and conditions take effect from
such date as may be intimated by RNLIC and/or authorized Service Provider. The Policyholder further agrees that he/she shall be deemed to have agreed, accepted and be bound by such
altered terms and conditions.
20. The Policyholder agrees that in event he/she is dissatisfied with any portion of the facilities or with any of the terms and conditions or alterations thereto, his/her sole and exclusive
remedy is to discontinue the use of the facilities.
21. The Policyholder agrees that the laws of India shall govern this Agreement and in case of a dispute the matter will be settled as per the provisions of The Arbitration and Conciliation Act,
1996 and within the exclusive jurisdiction of the courts of Mumbai.
22. It is agreed by the policyholder that the onus and liability to make all premium payments within the due dates specified in the relevant Policy Contract(s) vests solely and absolutely with
the Policyholder.
23. This facility is available to Master, VISA and Diners Club cards issued in India.
24. Mandate should reach the company 10 days before the next premium due date. Any dues after 10 days from mandate date will only be considered for this facility. Any Outstanding
amount prior to 10 days from mandate date should be paid by the customer through the normal mode of collection (Cash/Chq/DD).
25. When a Policyholder, who has chosen monthly payment mode opts to leaves this facility for any reason , the person should opt for a change in premium payment frequency such as
quarterly, half-yearly or yearly payment of premiums. In such a case, the installment premium payable under the contract will be revised based on the new frequency of payment chosen,
and, an endorsement to this effect is placed on the contract stating the revised premium, due dates, and date of payment of last premium.
A change in frequency is possible only in such a manner that a premium falls due on the policy anniversary date. Hence, it may become necessary for the contract owner to pay a lump
sum representing the monthly installments required to make the new frequency coincide with the policy anniversary. For example, if a policy commences on February 15th in any year, and
the policy was removed from the monthly mode sometime in October of an year, say before payment of the October premium, then since the next policy anniversary is only in February of
the following year, we will collect the monthly due for October, and a quarterly premium due November, to enable us to alter the mode to quarterly frequency. If the Life Assured had opted
for half yearly mode, then we will collect monthly premiums due October, November, December and January to alter the frequency to half yearly mode. An endorsement slip will be sent
to the Contract owner to keep in the policy document file.
26. No extra cost will be charged to the Policyholder for this facility.
Mktg/CC Mandate/Version 1.5/Mar2018

Reliance Nippon Life Insurance Company Limited (formerly known as Reliance Life Insurance Company Limited). IRDAI Registration No: 121. Registered Office: H Block, 1st Floor,
Dhirubhai Ambani Knowledge City, Navi Mumbai, Maharashtra 400710. For more information or any grievance, 1. Call us between 9am to 6pm, Monday to Saturday on our Toll Free
Number 1800 102 1010 or 2. Visit us at www.reliancenipponlife.com or 3. Email us at: rnlife.customerservice@relianceada.com. Trade logo displayed above belongs to Anil Dhirubhai
Ambani Ventures Private Limited & Nippon Life Insurance Company and used by Reliance Nippon Life Insurance Company Limited under license.
Beware of spurious phone calls and fictitious/fraudulent offers IRDAI clarifies to public that 1. IRDAI or its officials do not involve in activities like sale of any kind of insurance or
financial products nor invest premiums. 2. IRDAI does not announce any bonus. Public receiving such phone calls are requested to lodge a police complaint along with details of phone
call, number.
Page 2 of 2 CIN: U66010MH2001PLC167089