INDUS BILLPAY APPLICATION FORM

CUSTOMER INFORMATION
Name:______________________________________________________________________________________
Address: ____________________________________________________________________________________
___________________________________________________________________________________________
City : ________________________Pin Code :____________________ Date of Birth : DD / MM / YY
Tel (Off) :__________________ __________Tel (Res)_____________________Mobile:_____________________
E-Mail address_______________________________________________________________________________
*This is also your Login Id for using the “Online Pay” bill payment facility available at www.indusind.com

BILLER INFORMATION

Telephone Insurance
Name of Company:……………………………………………….. Name of Company:…………………………………….
Customer Name:……………………………………………….…. Name:……………………………………….
Customer Account No:…………………………………………… Premium Amount :…………………………………
Telephone No:………………………………………….…………. Policy No:………………………………………….
Auto pay, * Autopay Limit (Rs)……………………..………… Auto pay, * Autopay Limit (Rs)……………………

Electricity Gas
Name of Company:……………………………………. Name of Company:…………………………………….
Consumer Name:………………………………………. Consumer Ref No :……………………………………….
Process Cycle No:………………………………… ………………………….…………………………………
Billing Unitt No:…………………………………………. Bill Group:………………………………………….
Auto pay, * Autopay Limit (Rs)…………………… Auto pay, * Autopay Limit (Rs)……………………

Mobile ……………………
Name of Company:……………………………………. Name of Company:…………………………………….
Customer Name:………………………………………. Customer Name:……………………………………….
Account No:………………………………… Customer Account No:…………………………………
Mobile No:…………………………………………. …………………………………………………………….
SMSPay Auto pay, * Autopay Limit Auto pay, * Autopay Limit (Rs)……………………
(Rs)……………………

Credit Card ………………………

Name of Company:……………………………………. Name of Company:…………………………………….
Cardholder’s Name:………………………………………. Customer Name:……………………………………….
……………………………………………………………… Customer Account No:…………………………………
Online Pay ID:…………………………………………. …………………:………………………………………….
Auto pay, * Autopay Limit (Rs)…………………… Auto pay, * Autopay Limit (Rs)……………………

Please provide a copy of any previous bill for each biller added to enable us to verify the customer account details For additional billers,
please provide the above details on a separate sheet, sign it and attach with the form
For AutoPay instructions, the debit to customer account may take place upto five working days prior to due date, to ensure payment to
the biller by due date. Please ensure that your bank has sufficient funds to cover the bill amount
 BANK ACCOUNT DETAILS
First/sole Account Holder ___________________________________________________________
Second Account holder _____________________________________________________________
Third Account Holder _______________________________________________________________
IndusInd Bank Branch:____________________________________City: ________________________________
Account No MICR CODE
Account Type: Savings Current A/C Operation Single Joint E or S

DECLARATION & ACCEPTANCE

I/We hereby declare that the particulars given in this form are correct and complete. I/We hereby authorize the Service* to debit
my/our Bank account as detailed above and I/We undertake to keep my/our account funded sufficiently to meet the obligations.
The mandate is applicable for recovery of payment of bills /other payments made through use of the service. If transactions are
delayed or not effected at all for reasons of incomplete or incorrect information, I/We will not hold the Bank/Service responsible.
The authority shall continue to be inforce with immediate effect until I/We revoke it by instructions delivered to the Bank/Service
in writing.
I/We hereby declare that the above information is correct and complete and request that a Service account be opened in the
name listed at the beginning of this application. I/We acknowledge that I/We have read , understood and agree to be bound by
the Terms & Conditions of the Service (www.billdesk.com/ terms.htm) that are currently in effect and as may be amended from
time to time.

_______________________ ________________________ ___________________________

Fisrt Account Holder Second Account Holder Third Account Holder

________________________ ___________________________
DATE PLACE
*Please affix a rubber stamp in case of companies, proprietorships, partnerships, etc
•Service provided and managed by BillDesk, the Bill Payment Services of M/s IndiaIdeas.com Ltd., on behalf of IndusInd Bank

CERTIFICATION BY BRANCH
Certified that the particulars furnished above are correct as per our records and we have noted the instruction

MICR AUTHORISED SIGNATORY _______________________

DATE BANK’S STAMP _________________________________

Your account will be activated from the next billing cycle

or 14 days whichever is later. However, for the first bill
received by you after registration, please call the Indus
BillPay Customer Service Desk and confirm activation of
your account.

Ensure form is complete Ensure documents are attached Submit form to the branch