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    NEFT Mandate Form

    Uploaded by

    sanoj kaushik

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    NEFT Mandate Form

    Uploaded by

    sanoj kaushik
    60 views1 page

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    60 views1 page

    NEFT Mandate Form

    Uploaded by

    sanoj kaushik

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    Universal Sompo General Insurance Co. Ltd.

    (A joint venture between Allahabad Bank, Sompo Japan Insurance Inc., Indian Overseas Bank, Karnataka Bank and Dabur Investments)
    Regd. Office : Unit No. 401, 4th Floor, Sangam Complex, 127 Andheri Kurla Road, Andheri (East), Mumbai-400059

    Bank Account Mandate for Direct Credit


    (This form to be used for one time Customer payment only)
    For legibility, please use BLOCK LETTERS in blank ink.

    Universal Sompo Location: __________________ Claim no: _________________ Date: ______________

    Beneficiary Details (TO BE FILLED IN - BLOCK LETTERS ONLY) all fields are mandatory
    Beneficiary Name : __________________________________________________________________________________________
    (Should be same as in Bank) First Name Middle Name Last Name
    Address : __________________________________________________________________________________________
    (As per the policy)
    : __________________________________________________________________________________________

    City : __________________________________________________________ Pin Code: ________________________

    PAN No : ____________________________________________________ Date of Birth: ____/_____/_______DD MM YYYY

    Service Tax Reg No: _______________________________________ E Mail: ____________________________________________

    Phone No.(with STD code): _______________________________________ Mobile Number :______________________________

    Bank Account Details (TO BE FILLED IN - BLOCK LETTERS ONLY) all fields are mandatory as per
    bank records

    Bank Account Number : _______________________________________________ Account Type: _____________(Savings /Current/Other etc)

    Name of the Bank : ________________________________________________________________________________________________

    Bank Branch Name : ___________________________________________________ Bank Branch Code: ____________________________

    IFSC Code : _____________________________________________________________MICR Code: _________________________

    (The above details are available on the face of the cheque as per CTS-2010/06.2013. If not, please speak to your branch and get the details /
    submit the copy of bank pass book where all the above details are available)
    * I /we DO NOT wish to receive direct credits, but wish to receive payment by cheque. (Please  )

    I hereby understand and confirm that:


    1) The details given above are true and I have no objection for directly credits in the bank account mentioned above.
    2) If the electronic credit is not effected, delayed or credited to a wrong account on account of incorrect or incomplete information provided, USGIC
    shall not be held liable now or in future for such losses.
    3) In the event the credit is not effected by your Banker for any reason, USGIC reserves the right to make the payment through cheque. USGIC shall
    not make any payout either partially or wholly in the form of cash.
    4) Enclosed copy of PAN OR certificate of Service Tax registration (if applicable for institutions).
    5) Enclosed cancelled cheque as per CTS-2010 of the bank account mentioned above.
    6) If wise to receive payments by cheque instead of direct credit, have appropriately ticked the check –box provided for this purpose.

    Place: ________________ __________________________


    Date: D D M M Y Y Y Y Signature of Customer

    Documents to be attached:
     Self attested copy of PAN Card OR Service Tax Regn certificate (if applicable for Institutions)
     Original cancelled Cheque (CTS- 2010) duly signed by insured Inward stamp
    with date
    Verified by Company :YES / NO
    Signature of Verifying Person: _________________________________ Date: D D M M Y Y Y Y

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