Declaration / Mandate for Electronic Transfer of Claims Payment

To,

Bharti AXA General Insurance Company Limited

The First Floor, The Ferns Icon, Survey No.28, Next to Akme Ballet,

Doddanekundi, Off Outer Ring Road, Bangalore - 560 037

Full Name of the Customer______

(As appears in your bank Account)

Full Address:______

______PIN Code:______

Mobile Number / Contact Number______Email______

Bank Name
Account Number
(as appearing in the cheque book)
Branch Name & Address
Branch Contact Details
Branch IFSC Code for NEFT
Branch MICR Code
Account Type / Savings / Current / Cash Credit / (Please √ One )

Declarations / Conditions:

  • I / We, the undersigned, hereby declare that the particulars provided above have been duly filled-in / provided by me / us and hereby further declare that the said particulars are correct and complete. I/We hereby absolve Bharti AXA General Insurance Company Limited of any responsibility or liability arising on account of incomplete or incorrect information provided by Me/Us.
  • I / We further undertake to immediately refund without demur any excess amount which has been credited to my account [due to any reason whatsoever] by Bharti AXA 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) Claim/Refund/ Any other payment; whether such refund is demanded by Bharti AXA General Insurance Company Limited or not,.
  • I / We agree that the payment to my account through NEFT will be valid discharge of the payment obligation of Bharti AXA General Insurance Company Limited for (i) the amount due to me, or (iii) Claim/Refund/ Any other payment.
  • 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.
  • I / We further undertake to provide Bharti AXA General Insurance Company Limited a notice of at-least 6 weeks, my/our decision to withdraw from this mode of electronic payment.
  • I / We further confirm that Bharti AXA General Insurance Company Limited will have, at its sole discretion, the right to revert to the option of payment by way of cheque if there are more than 2 consecutive failures in remittances for no fault of Bharti AXA General Insurance Company Limited.

I/We the Undersigned have read the above mentioned declarations / conditions and provide my / our free consent to the same.

Place:______

Customer / Beneficiary’s Signature

Date:______Name:

For Office use Only
Branch Code:______Received on:______(Date)
Client ID:
(As Assigned in the System)