050050021 KYCThird Party Payor V5

MSCNF123403101863 | Comp/Oct/Int/4906
Know Yor Customer - Addendum

(For Third Party Payment)
Instructions
1. Details required to be provided are of the Payor paying the premium on behalf of the Policyholder.
2. All points are mandatory. Affix recent
3. Any cancellation or overwriting needs to be countersigned by the said person. photograph of
payor
Application/Policy No.: ______________________________________________________
1. Details Photograph to be
Name of the payor: ____________________________________________________________ signed across by
the payor
Payor Category Individual* Company Partnership HUF Trust
Others (Please specify)
Name of the Authorised person in case of Company/Partnership/HUF(Karta)/Trust:
* Acceptable relations who can be payors are spouse, parents, children, siblings and grandparents
Communication/Registered Address of the Payor:
City: State: Pin Code:
Mobile No.: - Email:
Payment Details
Cheque/DD Fund Transfer Direct Debit NetBanking Debit/Credit Card
Cheque No.: Cheque Date: Amount: INR

This is to certify that I am paying this premium on behalf of <PH First Name> <PH Last Name> related to me as my
<Reason>
<mention relation> due to ______________________________________________________________________________________________________
______________________________________________________________________________________________________
Proof of Identity
Document submitted for Identity Proof:
Proof of Residence
Document submitted for Residence Proof:
If the residential proof provided is other than that of Self, Spouse or Father, then please state -
A. Name of the owner of the residence:
B. Relationship of the Payor with the owner of the residence:
Permanent Account Number (PAN) details (Please tick mark)
PAN: (If No, please tick relevant option)

Form 60 NRI declaration
Current gross total income from all sources is INR ______________ per annum.
NPO Declaration
Is the payor a Non-Profit Organisation? : Yes No

(NPO stands for Non Profit Organisation. It can be in different form, depending upon the jurisdiction and legal system. In India, NPOs
can be registered as 1) Trust 2) Society 3) Section 25 companies forms under Company Act, 1956)
Are you a Non Resident Indian (NRI)? Yes No
If ‘Yes’, Please state the current country of residence _______________________________________________________
Are you a “Politically Exposed Person”? Yes No
Definition of a “Politically Exposed Person”:

A "Politically Exposed Person" is a person who performs important functions for the state. This would include individuals who have or
have had positions of public trust such as government officials, senior executives of government corporations, politicians, important
political party officials, member of parliament, member of legislative assembly, etc. and their families and close associates.
Declarations
I hereby declare that,
1. The first premium has been paid out of legally declared and assessed sources of income and the subsequent premiums if any, will
continue to be paid out of legally declared and assessed sources of income. 2. I will provide information as and when required by the
company, acting on its own or under any order or instruction received from Statutory Authorities, with regard to sources of funds or
utilizations or withdrawals. 3. I agree to the Company providing any information related to me as available to the Company at any time, to
any Statutory Authority in relation to the laws governing prevention of money laundering, applicable in the country. 4. I understand
that the Company classifies its customers under various categories of risk for the purposes of complying with the laws governing
prevention of money laundering and I confirm that I do not have any objections to the same. 5. I understand that the Company has the
right to peruse my financial profile and also agree that the Company has right to cancel the Insurance contract in case I have been found
guilty of any of the provisions of any Law, directly or indirectly, having relation to the laws governing prevention of money laundering in
the country, by any competent court of law. 6. I am aware that the benefits under this policy are payable in accordance with the policy
terms and conditions. 7. I am aware that the premiums paid under this policy will get tax benefit, under section 80C of the Income-tax
Act, 1961 ('the Act'), only if paid towards the life of self (individual), spouse and any child of such individual or any member of an HUF, or
under section 80D of the Act if paid towards health insurance for self (individual), spouse, dependent children and parents of an
individual or any member of an HUF. These tax benefits are subject to the terms and conditions stated under the Income-tax Act, 1961.
SIGN HERE
Date: DD/MM/YYYY
Place:
Payor Seal, if applicable Signature of
Payor / Authorised Signatory
Know Your Customer – Addendum (to be filled by the Proposer/Policyholder)

I, <PH First Name> <PH Last Name> hereby confirm that <Payor First Name> <Payor Last Name> is paying on my behalf for the above
mentioned application.
Name of the Proposer/Policyholder: <PH First Name> <PH Last Name>

SIGN HERE
Date: DD/MM/YYYY
Place:
Signature of Proposer/Policyholder
The policyholder/Payor has affixed his/her thumb impression or has signed in vernacular or has not filled the application.
I hereby declare that I have explained the contents of this application form to the Proposer/Policyholder/Payor in _____________
language and have truthfully recorded the answers provided to me. I further declare that the Proposer/Policyholder/Payor has signed
or affixed his/her thumb impression in my presence.
Name: SIGN HERE
Address:
Date : Place: Signature of Third Person
HDFC Life Insurance Company Limited (HDFC Life). CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, call us on 1860-267-9999 (Local charges apply) | 022-68446530 (STD charges apply). Available Mon-Sat from 10 am to 7 pm.
DO NOT prefix any country code e.g. +91 or 00. | Email - service@hdfclife.com | nriservice@hdfclife.com (For NRI customers only) | Visit - www.hdfclife.com

050050021 KYCThird Party Payor V5

Uploaded by

Copyright:

Available Formats

050050021 KYCThird Party Payor V5

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

050050021 KYCThird Party Payor V5

Uploaded by

Copyright:

Available Formats

MSCNF123403101863 | Comp/Oct/Int/4906

Know Yor Customer - Addendum

Communication/Registered Address of the Payor:

City: State: Pin Code:

Mobile No.: - Email:

Cheque No.: Cheque Date: Amount: INR

Document submitted for Identity Proof:

Document submitted for Residence Proof:

Permanent Account Number (PAN) details (Please tick mark)

PAN: (If No, please tick relevant option)

Is the payor a Non-Proﬁt Organisation? : Yes No

If ‘Yes’, Please state the current country of residence _______________________________________________________

Are you a “Politically Exposed Person”? Yes No

Deﬁnition of a “Politically Exposed Person”:

Know Your Customer – Addendum (to be ﬁlled by the Proposer/Policyholder)

Name of the Proposer/Policyholder: <PH First Name> <PH Last Name>

Name: SIGN HERE

Date : Place: Signature of Third Person

You might also like