…………………………
…………………………

Date: …………………..

To
The Manager,
…………………….Bank
…………………..Branch
…………………………

Dear Sir,
I hereby request you to pay from my Savings Bank Account No …………………………
maintained with you, the premiums on the policy of Insurance No……………for Rs .
……………………with the Life Insurance Corporation of India ……………………Branch.
(i) Branch to which premium is to be paid:
(ii) Amount of premium:
(iii) Date of payment of premium:

Yours faithfully,