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Claim Form Part - C

This document is an electronic clearing service mandate form for payment of an insurance claim. It requests the claimant's contact information, TTK ID number, bank account details including name, branch, address, MICR and account numbers, and date of effect for electronic funds transfer. The claimant authorizes the insurance company to settle the claim through direct payment via ECS/RTGS/NEFT to the provided bank account, and confirms the details are correct.

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Rahul Rathod
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676 views1 page

Claim Form Part - C

This document is an electronic clearing service mandate form for payment of an insurance claim. It requests the claimant's contact information, TTK ID number, bank account details including name, branch, address, MICR and account numbers, and date of effect for electronic funds transfer. The claimant authorizes the insurance company to settle the claim through direct payment via ECS/RTGS/NEFT to the provided bank account, and confirms the details are correct.

Uploaded by

Rahul Rathod
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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ELECTRONIC CLEARING SERVICE (CREDIT CLEARING) MANDATE FORM

For Claim under Policy No ___________________________________________


1.

(B) ADDRESS

(C) TELEPHONE / MOBILE No:

(D) E-MAIL ID:

2. TTK ID No

3. PARTICULARS OF BANK ACCOUNT


A. BANK NAME

B. BRANCH NAME

C. ADDRESS

D. 9 DIGIT CODE NUMBER OF THE BANK & BRANCH APPEARING ON THE MICR CHEQUE ISSUED BY THE BANK

E. ACCOUNT TYPE (SAVINGS ACCOUNT/ CURRENT ACCOUNT)

F. ACCOUNT NUMBER (AS APPEARING ON THE CHEQUE BOOK)

G. BANK ACCOUNT HOLDER NAME

4. DATE OF EFFECT:

INFORMATION FOR PAYMENT THROUGH RTGS OR NEFT


5. IFSC CODE (INDIAN FINANCIAL SYSTEM CODE)

6. NEFT CODE (NATIONAL ELECTRONIC FUNDS TRANSFER CODE)

By submission of the above, I authorise M/s Vidal Health TPA Private Ltd (formerly known as TTK Healthcare TPA Pvt
Ltd) / the Insurance Company to settle the claim under reference through direct payment by ECS. I hereby declare &
confirm that the particulars given above are correct and complete. I agree that I shall not hold the TPA/ Insurance
Company responsible for delay or non-receipt of payment for any reason whatsoever after issue of instructions for
transfer of payment by Insurer/ TPA based on the above.

Date:
Place: Signature of the Insured

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