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Mandate Form for Electronic Clearance System Policy Number MDID / EMP Number Claim Number Policy Holder Name Telephone Number Email ID Name of Account Holder Name of Bank Branch Name Branch Address Type of Account Account Number MICR Code Cancelled Cheque Y N IFSC Code 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. 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. 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. Mandate Form for Electronic Clearance System Policy Number MDID / EMP Number Claim Number Policy Holder Name Telephone Number Email ID Name of Account Holder Name of Bank Branch Name Branch Address Type of Account Account Number MICR Code Cancelled Cheque Y N IFSC Code 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. 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. 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. 3. As per the revised RBI guidelines Canceled cheque should have pre-printed name of account holder.