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    Electronic Funds Transfer (Neft/ RTGS) For Claim Payments: Beneficiary Details

    Uploaded by

    Abhineet Garg
    The document contains a form for beneficiaries to provide their bank account details for electronic funds transfer payments of claims by an insurance company. The beneficiary must provide identification information, bank account information, and sign declaring the accuracy of the information and consenting to electronic payments. A cancelled cheque must also be attached to ensure accuracy of bank account details.

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    © All Rights Reserved
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    Electronic Funds Transfer (Neft/ RTGS) For Claim Payments: Beneficiary Details

    Uploaded by

    Abhineet Garg
    89 views2 pages
    The document contains a form for beneficiaries to provide their bank account details for electronic funds transfer payments of claims by an insurance company. The beneficiary must provide identification information, bank account information, and sign declaring the accuracy of the information and consenting to electronic payments. A cancelled cheque must also be attached to ensure accuracy of bank account details.

    Original Title

    NEFT_Form

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    The document contains a form for beneficiaries to provide their bank account details for electronic funds transfer payments of claims by an insurance company. The beneficiary must provide identification information, bank account information, and sign declaring the accuracy of the information and consenting to electronic payments. A cancelled cheque must also be attached to ensure accuracy of bank account details.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    89 views2 pages

    Electronic Funds Transfer (Neft/ RTGS) For Claim Payments: Beneficiary Details

    Uploaded by

    Abhineet Garg
    The document contains a form for beneficiaries to provide their bank account details for electronic funds transfer payments of claims by an insurance company. The beneficiary must provide identification information, bank account information, and sign declaring the accuracy of the information and consenting to electronic payments. A cancelled cheque must also be attached to ensure accuracy of bank account details.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    ELECTRONIC FUNDS TRANSFER (NEFT/ RTGS)

    FOR CLAIM PAYMENTS


    (TO BE FILLED IN BY THE BENEFICIARY)
    (To be filled in Block Letters)
    Beneficiary Details
    Beneficiary Name
    [As per Bank Account]

    Full Address

    Pin Code
    Contact No Mobile No

    Email ID
    Beneficiary Bank Details
    Bank Name
    Branch Name

    Branch Address

    Branch Contact No

    Email ID

    Branch IFSC Code

    Account Type Savings A/C Current A/C Cash Credit

    Account No.
    [as appearing in the cheque book]

    Beneficiary PAN & Alert Details


    Name as per PAN Card

    PAN Number
    Payments Details Alerts Required

    SMS YES NO If Yes Mobile No.

    Auto Mailer YES NO If Yes E-Mail ID

    Place: ____________________ Date: ________________

    Authorized Signatory & Stamp(If applicable):

    MANDATORY REQUIREMENT
    Cancelled blank Cheque of your bank for ensuring accuracy of name of the bank, branch name, Account number and IFSC code. If NAME OR IFSC code of the payee
    is not printed on the cheque leaf, please attach copy of the first page of the bank passbook also.
    Please attach your cancelled cheque here.
    Declaration

    i) I / We hereby undertake to refund, at any time, any excess amount whether demanded by Universal Sompo General Insurance Company Limited or not, which has
    been credited to my account [due to any reason] by Universal Sompo 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.

    ii) I / We agree that the payment will be endeavored 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 Universal Sompo General Insurance Company Limited into the aforesaid account will be valid discharge to
    Universal Sompo 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.

    iii) 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 Universal Sompo General Insurance Company Limited responsible.

    iv) 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 Universal Sompo 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.

    v) I / We further confirm that Universal Sompo 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 two consecutive failures in remittances for no fault on the side of Universal Sompo General Insurance Company Limited.

    vi) After Universal Sompo 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 Universal Sompo 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.

    vii) 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.

    viii) I / We further confirm that I/we understand, Universal Sompo 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.

    ix) I / We further undertake to inform Universal Sompo General Insurance Company Limited with an advance notice of six weeks, to withdraw from this mode of
    electronic payment.

    I/ We have read the declarations/ conditions mentioned above.

    Place: ____________________ Date: _______________

    Authorized Signatory & Stamp(if applicable):

    Registered Office: Universal Sompo General Insurance Co Ltd,Unit 401,4th floor,Sangam Complex,127,Andheri Kurla Road, Andheri East, Mumbai - 400059
    Health Claims Management: Universal Sompo General Insurance Co Ltd, Assotech One, 5th Floor, C-20/1A, C –Block, Sector-62, Noida -201309
    Toll Free Fax No: 1800 200 9134; Toll Free Helpline No: 1800 200 5142; Email ID: healthserve@universalsompo.com
    Website: www.universalsompo.com; CIN# U66010MH2007PLC166770

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