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Mandate Form For Electronic Clearance System

This document is a mandate form for an electronic clearance system. It collects information from a policy holder such as their name, address, contact details, bank account information including account number, bank name, branch, and MICR/IFSC codes. The policy holder must declare that the information provided is true and correct, and agrees not to hold the third party administrator or insurance company responsible for any delays or non-receipt of payments initiated through this process.

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Pravin Patil
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261 views1 page

Mandate Form For Electronic Clearance System

This document is a mandate form for an electronic clearance system. It collects information from a policy holder such as their name, address, contact details, bank account information including account number, bank name, branch, and MICR/IFSC codes. The policy holder must declare that the information provided is true and correct, and agrees not to hold the third party administrator or insurance company responsible for any delays or non-receipt of payments initiated through this process.

Uploaded by

Pravin Patil
Copyright
© © All Rights Reserved
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 No/Certif No

Policy Holder`s Name

Address

Telephone No Email ID

MDID No

Claim NO

Name of Account Holder

Name of Bank

Branch Name

Branch Address

Type of
Account:SB/CD

Account No

MICR Code IFSC Code

Cancelled Cheque Y N

1) Please enclose the cancelled cheque of your bank account for our record, Your banker should be a participant of NEFT/RTGS Facility.
2) 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.
3) 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.

Date : Siagnature of the Policy Holder

Place:

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