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

DECLARATION

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I / We hereby declare that the particulars given above are correct and complete and no blanks have been left.

If the transaction is delayed or not effected at all for reason of incomplete or incorrect information I / we

would not hold Bajaj Allianz General Insurance Company Limited responsible.

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I / We undertake to revoke the instruction for NEFT in the event of the business relationship expiring and or

being ‘terminated’ and further hereby specifically authorize Bajaj Allianz General Insurance Company Limited,

to do so, for me and on my behalf, in case the revocation communication is not received from me within

seven days of expiry and or being termination of relationship.

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I / We further undertake to refund, at any time, any excess amount whether demanded by Bajaj Allianz

General Insurance Company Limited or not, which has been credited to my account [due to any reason] by

Bajaj Allianz General Insurance Company Limited, in excess of (i) the amount due to me, or (ii) in excess of

amount for which I gave mandate, and or (iii) agreed rent/license fees/compensation/refundable security

deposit/Commission/Claim/Refund/ Any other payment.

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I / We agree that the payment will be endeavoured to be credited starting from the date of next payment

cycle and unless the Mandate is revoked by me/us issuance of relevant credit instruction for electronic

payment from Bajaj Allianz General Insurance Company Limited into the aforesaid account will be valid

discharge to Bajaj Allianz General Insurance Company Limited for having paid (i) the amount due to me, or (ii)

in excess of amount for which I gave mandate, and or (iii) agreed rent/license fees/compensation/refundable

security deposit/ Commission/Claim/Refund/ Any other payment.

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I / We further confirm that we understand this mode as a method of payment introduced by Reserve Bank of

India, which provides us an option to receive the amount and or to collect our payments by electronic

payment mode directly through my/our bank accounts.

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I / We further confirm that I/we understand, Bajaj Allianz General Insurance Company Limited, shall make

electronic payment to my account by issuing the Payment instruction electronically through its banker to the

Clearing Authority and the Clearing Authority would ensure credit to my/our specified bank account provided

hereinabove.

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I / We further undertake to inform Bajaj Allianz General Insurance Company Limited with an advance notice

of 6 weeks, to withdraw from this mode of electronic payment.

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I / We further confirm that Bajaj Allianz General Insurance Company Limited will have, at its sole discretion,

the right to return back to the option of paying to me/us by way of cheque if there are more than 2

consecutive failures in remittances for no fault on the side of Bajaj Allianz General Insurance Company

Limited.

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After Bajaj Allianz General Insurance Company Limited issuing the Payment instruction electronically through

its banker, for whatever reasons, if I/we do not get the credit to my/our account, then same shall neither

constitute the default in (i) Payment of amount requested by me, or (ii) Payment of amount due to me/us, or

(iii) Payment of agreed rent/license fees/compensation/refundable security deposit/ commission/claim/

Refund/Any other payment by Bajaj Allianz General Insurance Company Limited nor constitute default of any

terms and conditions of any agreement/MOU/ Claim/Refund/Other contract and or Lease agreement/Leave

and license agreement with me/us.

Health Insurance Claim Form Page 4

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