Bill Pay Request Form (New)
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Transcript of Bill Pay Request Form (New)
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8/3/2019 Bill Pay Request Form (New)
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To, Date:
The Branch Manager,
Branch
KOTAK BILLPAY REQUEST FORM
Dear Sir / Madam,
I / We having
Customer Relationship Number (CRN) hereby request you to process the BillPay request as mentioned below.
Biller Type Pay Bill AutoPay Delete
Electricity
Amount Entire Bill Biller
(Rs.) Or
*Biller Short name Pay Limit (Rs.) AutoPay
Consumer No.Process Cycle No. Scheduled
Billing Unit No. Payment
BillPay Requests
Location : (City / State)
Name of the Company
D D M M Y Y Y Y
# Debit Account Number
Telephone
Amount Entire Bill Biller
(Rs.) Or
*Biller Short name Pay Limit (Rs.) AutoPay
Telephone No.
Account No. Scheduled Payment
Name of the Company
MobileAmount Entire Bill Biller
(Rs.) Or
*Biller Short name Pay Limit (Rs.) AutoPay
Mobile No.
Account No. Scheduled
Customer Name Payment
Name of the Company
Insurance
Amount Entire Bill Biller
(Rs.) Or
*Biller Short name Pay Limit (Rs.) AutoPay
Policy ID
Client ID Scheduled
Premium Amt. Payment
Name of the Company
Gas
Amount Entire Bill Biller
(Rs.) Or
*Biller Short name Pay Limit (Rs.) AutoPay
Consumer Reference No.
Bill Group No. Scheduled
Billing Unit No. Payment
Name of the Company
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8/3/2019 Bill Pay Request Form (New)
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ACKNOWLEDGEMENT
Branch Date:
Transaction Reference No. (For Pay Bill only)
ADD BILLER DELETE BILLER PAY BILL VISA CREDIT CARD PAYMENT
ENABLE AUTOPAY DELETE AUTOPAY DELETE SCHEDULED PAYMENT RECHARGE
Customer Name CRN
Account No.
Authorized Signatory Branch Stamp
Visa Credit Card Payment Frequency Biller
Visa Credit Card Amount Monthly Quarterly Half Yearly Yearly AutoPay
*Biller Short name (Rs.) Amount (Rs.)
Visa Card No. Start Date Scheduled
Beneficiary Name
End Date Payment
Senders Name
D D M M Y Y Y Y
D D M M Y Y Y Y
Declaration
I have read and understood the Terms and Conditions relating to Kotak BillPay on www.kotak.com. I accept and agree to be bound by the said Terms and Conditions.
I understand that the Bank may at its absolute discretion, discontinue any of the services completely or partially without any notice to me. I agree that in case of Payment of Bill
and AutoPay the account number mentioned in this form will be debited automatically. Instructions provided in this form will automatically add the specified biller if it is not anexisting biller. Any instruction provided in this form for modification of information pertaining to existing billers will update the existing information of the said biller.
For PAYBILL / AUTOPAY / RECHARGE PLEASE SIGN AS PER MODE OF OPERATION
First Account Holder Second Account Holder Third Account Holder
Biller Type Pay Bill AutoPay Delete
For Branch Use only
Applicants Signature Verified: Yes No
Employee Name:
Employee Code:
Sign:
* Biller short name should be unique for each biller and should not be more than 6 characters
# This Account will be debited incase of Pay Bill / AutoPay / Recharge
** Mobile No. Field is mandatory incase of DTH, alert will be sent on the mobile no. mentioned.
Others
Amount Entire Bill Biller
(Rs.) Or
*Biller Short name Pay Limit (Rs.) AutoPay
Biller Identifier 1
Biller Identifier 2 Scheduled
Biller Identifier 3 Payment
Name of the Company
RECHARGE
Prepaid Mobile Direct - To - Home (DTH)
Operator Name
** Mobile No:
Subscriber No: (For DTH Recharge)
Amount : (Rs.)