Health Insurance Claim Form (Page 3 of 4) in pdf

Health Insurance Claim Form Page 3

Mandate Form for Electronic Transfer of Claim Payments

Office Code & Name :

To, Bajaj Allianz General Insurance Company Ltd

I‐track Number:

Partner ID

(To be filled by Office)

Full Name:

Shri / Smt / Kum / M/s _______________________________________

(As appears in your bank account)

Full Address:

__________________________________________________________ __

_____________________________________________________________

PIN Code: ________________

Contact / Mobile No:

__________ ___Email ID:________________________________________

Particulars of bank:

Bank Name:

Branch Name & Address:

Branch Telephone No & Contact No:

Branch MICR Code

Branch IFSC Code for NEFT

Branch IFSC Code for RTGS

Name of the Account Holder :

(As per Bank Account)

Account Type

Savings

Current

Cash Credit

Account No.

(as appearing in the cheque book)

I/we have read the declarations / conditions mentioned overleaf.

Place: ____________

Date: _____________ _______________________

(Beneficiary’s Signature)

(Please attach copy of a cancelled blank cheque of your bank for ensuring accuracy of name of the bank, branch name, Account

number and IFSC code. If name of the payee is not printed on the cheque leaf please attach copy of the first page of the bank

passbook also )

Health Insurance Claim Form Page 3