{"id":1907,"title":"NACH/ECS/DIRECT DEBIT MANDATE INSTRUCTION FORM","purpose":"service","insurer":{"slug":"star-union-dai-ichi-life-insurance","name":"Star Union Dai-Ichi Life Insurance Company Limited"},"source_pdf":"https://dxwkpt4djlxwl.cloudfront.net/NACH_Direct_Debit_Mandate_Form_Ver_04_d45629c21a_420f142559.pdf","sha256":"2e4ac20cd642470492cc107f55f56efdddd8b4e1b22ffffd5cfb1bf9474aa771","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is used by policyholders to authorize Star Union Dai-ichi Life Insurance Co. Ltd. to debit their bank account for premium payments via NACH/Direct Debit.","notes":["UMRN, Sponsor Bank Code, and Utility Code fields must be left blank.","Date must be in DD/MM/YYYY format.","Bank account details and signatures must match bank records.","For cancelling or modifying the mandate, use the same NACH Mandate form with appropriate option selected.","Auto Debit Mandate request will be accepted only if the bank is listed in the NACH banks list.","This form must be filled compulsorily with every application when premium payment frequency is monthly.","Preferred draw date for auto debit is within the same due month.","5th, 10th, and 15th debit date options are not applicable for monthly mode."],"title":"NACH/ECS/DIRECT DEBIT MANDATE INSTRUCTION FORM","submit":{"to":"","how":"","address":""},"purpose":"service","sections":[{"title":"Customer and Bank Details","fields":[{"help":"Enter the name of your bank","type":"text","label":"Name of customer bank","options":[],"required":true,"pdf_field":""},{"help":"Enter your bank account number as per CBS records","type":"text","label":"Bank a/c number","options":[],"required":true,"pdf_field":""},{"help":"Enter the destination bank name","type":"text","label":"Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter the IFSC or MICR code of your bank branch","type":"text","label":"IFSC or MICR","options":[],"required":true,"pdf_field":""},{"help":"Tick the relevant account type","type":"choice","label":"Bank A/c Type","options":["SB","CA","CC","SB-NRE","SB-NRO","Other"],"required":true,"pdf_field":""},{"help":"Enter account holder name as per bank record","type":"text","label":"A/c Holder Name","options":[],"required":true,"pdf_field":""},{"help":"Enter joint account holder name if applicable","type":"text","label":"Joint A/c Holder Name","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Mandate Details","fields":[{"help":"Leave blank","type":"text","label":"UMRN","options":[],"required":false,"pdf_field":""},{"help":"Leave blank","type":"text","label":"Sponsor Bank Code","options":[],"required":false,"pdf_field":""},{"help":"Leave blank","type":"text","label":"Utility Code","options":[],"required":false,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter start date of mandate in DD/MM/YYYY format","type":"date","label":"Period From","options":[],"required":true,"pdf_field":""},{"help":"Write the amount to be debited in words","type":"text","label":"Amount in words","options":[],"required":true,"pdf_field":""},{"help":"Enter the amount in numbers","type":"amount","label":"an amount of Rupees","options":[],"required":true,"pdf_field":""},{"help":"Select how often the premium is to be debited","type":"choice","label":"FREQUENCY","options":["Monthly","Quarterly","Half Yearly","Yearly","As & when presented"],"required":true,"pdf_field":""},{"help":"Select the debit type","type":"choice","label":"DEBIT TYPE","options":["Fixed Amount","Maximum Amount"],"required":true,"pdf_field":""},{"help":"Enter your Star Union Dai-ichi Life policy number","type":"text","label":"Reference 1 (SUD Policy No.)","options":[],"required":true,"pdf_field":""},{"help":"Enter your application number if applicable","type":"text","label":"Reference 2 (SUD Application No.)","options":[],"required":false,"pdf_field":""},{"help":"Select preferred debit date; 5th, 10th, 15th not applicable for monthly mode","type":"choice","label":"ACCOUNT DEBIT DATE","options":["5th","10th","15th","Due Date"],"required":false,"pdf_field":""},{"help":"Enter your phone number","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"Enter your email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Signatures","fields":[{"help":"Sign as per bank records","type":"signature","label":"Policy Holder Signature","options":[],"required":true,"pdf_field":""},{"help":"Sign as per bank records","type":"signature","label":"A/c Holder Signature","options":[],"required":true,"pdf_field":""},{"help":"Sign if joint account holder","type":"signature","label":"Joint A/c Holder Signature","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":["Maximum period of validity of this mandate is 40 years only"],"applies_to":"NACH/Direct Debit premium payment mandates for Star Union Dai-ichi Life Insurance policies","attachments":[],"declarations":["I/We authorize the bank to debit my account as per instructions agreed and signed by me/us.","I/We agree for the debit of mandate processing charges by the bank as per latest schedule of charges.","I/We understand the transaction will be effected on the account debit date or next working day and the premium allocation is based on realization date.","I/We agree to any increase in premium deductions due to regulatory or frequency changes.","I/We authorize Star Union Dai-ichi Life Insurance Co. Ltd. to enable ACH/Direct Debit and to redebit in case of dishonour.","I/We declare that the particulars given on this mandate are correct and complete.","I/We have read and understood the terms and conditions."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/star-union-dai-ichi-life-insurance/1907-nach-ecs-direct-debit-mandate-instruction-form"}