NEFT/EFT Mandate form

(Payment through EFT Mechanism)

Customer Details

Group/Network
Name
Address
Landmark
City
State
Pincode
Contact No
Contact Person

Account details

Bank Name
Bank Address
Landmark
City
State
Pin code
Branch Name
Payee Name
IFSC Code
Account type
Full Account no.
Name as per
Bank Records
Cancel cheque
no**

(Please attach a blank cancelled cheque in original with payee name printed on the cheque)
If payee name is not printed, then bank certificate will be required.

I hereby declare that the particulars given above are correct and complete. If the transaction is
delayed or not effected at all reasons of incomplete or incorrect information, I would not hold
the user institution responsible.

Signature & Stamp of the Payee Verified By

Mailing Address: ICICI Lombard GIC Ltd, 9TH floor, North Wing, Tower-1, ICICI Bank Tower,Plot No.
12,Financial District, Nanakram Guda, Gachibowli, Hyderabad, 500032.
Corporate Office: ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple,
Prabhadevi, Mumbai 400 025.
Visit us at www.icicilombard.com
Email : customersupport@icicilombard.com
Now One Number for all your Insurance needs 1800 2 666 (Toll Free also accessible from your mobile)
IRDA Registration number: 115
Terms and Conditions for Payments through RTGS/NEFT

1. The details provided by the Customers in the Mandate Form shall be considered as final and ICICI Lombard General
Insurance Company Ltd. shall not be responsible for cross verification of any of the details provided therein.
2. The RTGS/ NEFT facility shall be effective for the respective Customer(s) within 15 days of the receipt of the Mandate
Form by ICICI Lombard General Insurance Company Ltd. and/ or within such period as may be reasonably required by
ICICI Lombard General Insurance Company Ltd. to activate the RTGS/ NEFT facility.
3. The Customer agrees that under the RTGS/ NEFT facility, there may be a risk of non-payment in the Account of
Customer on the day of the credit of Payments due to change in the applicable regulations pertaining to RTGS/ NEFT
facility or due to any other reasons without any fault/inaction/failure on part of ICICI Lombard General Insurance
Company or any factor beyond the control of ICICI Lombard General Insurance Company Limited.
4. The Customer agrees to indemnify, without delay or demur, ICICI Lombard General Insurance Company Ltd. and its
agents and keep ICICI Lombard General Insurance Company Ltd. and its agent indemnified harmless at all times from
and against any and all claims, damages, losses, costs, and expenses (including attorney's fees) which ICICI Lombard
General Insurance Company Ltd. may suffer or incur, directly or indirectly, arising from or in connection with, amongst
other things, either of the aforesaid reasons stated in above clauses.
5. ICICI Lombard General Insurance Company Ltd. may sub-contract and employ agents to carry out any of its
obligations under the RTGS/ NEFT facility. The Customer may discontinue or terminate the use of RTGS / NEFT facility by
giving a minimum of 15 days prior written notice to ICICI Lombard General Insurance Company Ltd. The date of notice
for ICICI Lombard will be the date of receipt of such notice by ICICI Lombard. The notice of such termination should be
given to ICICI Lombard only at its corporate
address and be addressed at ICICI Lombard GIC Ltd, ICICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial
District, Nanakram Guda, Gachibowli, Hyderabad-500032.
6. A confirmation of the receipt of termination notice given by the Customer will be acknowledged through a
confirmation letter by ICICI Lombard General Insurance Company Ltd. In no case can the Customer construe his
termination notice as effective unless a confirmation has been provided by ICICI Lombard to the Customer stating the
date of receipt of such communication by the Customer.
7. The Customer agrees that transaction(s) through RTGS/ NEFT facility may attract inward RTGS/ NEFT charges, which if
levied by the Customer's bank, shall be borne by the Customer
8. ICICI Lombard has the absolute discretion to amend or supplement any Terms and Conditions stated herein at any
time and will endeavor to give prior notice of Ten days for such changes wherever feasible for the terms and conditions
to be applicable. By using the new services, or at the completion of such period, whichever is earlier, the Customer shall
be deemed to have accepted the changed terms and conditions.
9. Submission of documents or bank details or any other information does not in any way, shape or form, imply or
express or suggest admission of liability by the company.
10. Notices under these terms and conditions may be given in writing by delivering them by hand or e-mail or on ICICI
Lombard General Insurance Company Ltd. Website www.icicilombard.com or by sending them by post to the last
address of the Customer.
11. These terms and conditions will be governed by the laws of India and any legal action or proceedings arising out of
these Terms and Conditions shall be initiated in the courts or tribunals at Mumbai in India.
12. I / We further undertake to refund any excess amount whether demanded by ICICI Lombard General Insurance
Company Ltd. or not, which has been credited in excess to my account at any time due to any reason within 7 days of
such receipt of such communication from ICICI Lombard of such excess credit or such information of excess credit
coming to the knowledge of the Customer through any other source.
13. I/ We agree that my/our claim payment will be credited from the date ICICI Lombard General Insurance Company
Ltd. gets confirmation from its bankers, This facility will continue unless it is revoked by any party and any issuance of
relevant credit instruction from ICICI Lombard General Insurance Company Ltd. to its bankers will be valid till such
instruction is complete irrespective of the fact that the notice period has expired provided such a credit request has
been made by ICICI Lombard General Insurance
Company Ltd. before the expiry of the notice period of the Customer.

(Please attach a blank cancelled cheque or photocopy of a cheque for verification of the particulars provided in this
regard)

Signature of Customer