Mandate Form for Electronic Transfer of Claim Payments
To,
Universal Sompo General Insurance Company Ltd.
Provider Name
Name [As per Bank
Account]
Full Address
Pin Code
Contact No Mobile No
Email ID
Bank Name
Branch Name
Branch Address
Branch Contact No
Branch IFSC Code
Account Type Savings A/C Current A/C Cash Credit
Account No.
[as appearing in the cheque book]
Name as per pan Card
PAN/TAN Card NO.
GSTIN No
Income Tax Detail Exempted at NIL Rate Exempted at Lower Rate Not Exempted
Payments Details Alerts Required
SMS YES NO If Yes Mobile No.
Auto Mailer YES NO If Yes E-Mail ID
I/we have read the declarations / conditions mentioned overleaf.
Place: Date:
Hospital Authorized Signatory: Hospital Stamp:
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MANDATORY REQUIREMENT
PLEASE ATTACH HERE
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.
Declaration:-
· 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.
· 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.
. 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.
. 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.
· 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 2 consecutive failures in remittances for no fault on the side of Universal Sompo General Insurance
Company Limited.
· After Universal Sompo General Insurance Company Limited issuing the Payment instructional
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.
· 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 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.
· I / We further undertake to inform Universal Sompo General Insurance Company Limited with an advance
notice of 6 weeks, to withdraw from this mode of electronic payment.
Hospital Stamp Hospital Authorized Signatory
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