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Mandate Form For Electronic Clearance System: Declaration

This document is a mandate form for an electronic clearance system. It requests information such as policy numbers, claim numbers, names of policy holders and bank account holders, bank branch details, email addresses, account numbers, and a signed declaration agreeing to the terms. A cancelled cheque sample is also provided for verification of bank account details. The declaration states that any false information provided will forfeit the right to claim reimbursement, and the insurer will not be responsible for delays or non-receipt of payments once instructions have been issued.

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452 views1 page

Mandate Form For Electronic Clearance System: Declaration

This document is a mandate form for an electronic clearance system. It requests information such as policy numbers, claim numbers, names of policy holders and bank account holders, bank branch details, email addresses, account numbers, and a signed declaration agreeing to the terms. A cancelled cheque sample is also provided for verification of bank account details. The declaration states that any false information provided will forfeit the right to claim reimbursement, and the insurer will not be responsible for delays or non-receipt of payments once instructions have been issued.

Uploaded by

rhvenkat
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Mandate Form for Electronic Clearance System

Policy Number MDID / EMP Number Claim Number Policy Holder Name Telephone Number Name of Account Holder Name of Bank Branch Name Branch Address Email ID

Type of Account: Account Number MICR Code IFSC Code Cancelled Cheque Y N

Declaration:1. I hereby declare that the information furnished in this ECS Form is true & correct to the best of my knowledge & belief. If I have made any false or untrue statement, suppression or concealment of any material fact, my right to claim reimbursement shall be forfeited. I agree that I shall not hold TPA/Insurance Company responsible for delay or non-receipt of the payment for any reason whatsoever after issue of the instructions for payment by Insurer/TPA based on the above.

2.

3. As per the revised RBI guidelines, Canceled cheque should have pre-printed name of account holder. Date: Place: Signature of the Policy Holder

----------------------------------------------------------------SAMPLE CHEQUE FORMAT --------------------------------------------------------------Note: Claims Number / Policy number / MDID number to be mentioned on cancel cheque and Please enclose the cancelled cheque of your bank account for our record; your banker should be a participant of NEFT/RTGS Facility.

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