Scribd
Upload
73 views2 pages

NEFT Mandate Format

The document is a mandate form for electronic transfer of claim payments, requiring personal and banking details from the claimant. It includes a declaration of correctness of the information provided and authorizes Liberty General Insurance Limited to process payments to the specified bank account. The form also requires the beneficiary's signature for validation.

Uploaded by

ashfaq alam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
73 views2 pages

NEFT Mandate Format

The document is a mandate form for electronic transfer of claim payments, requiring personal and banking details from the claimant. It includes a declaration of correctness of the information provided and authorizes Liberty General Insurance Limited to process payments to the specified bank account. The form also requires the beneficiary's signature for validation.

Uploaded by

ashfaq alam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 2

Mandate Form for Electronic Transfer of Claim Payments

Full Name ☐ Shri. ☐ Smt. ☐ Kum. ☐ M/s


(As appearing in Bank
records)

Complete Address
District
State
Pin Code

PAN Number

Mobile Number
Contact Details Landline Number
E-mail ID

Banker Details
Bank Name
Bank Branch Name
Bank Branch
Address
Account Number
Account Type ☐ Saving ☐ Current ☐ Cash Credit
IFSC Code
MICR Code
Banker Phone
Number/s

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 Liberty General Insurance Limited responsible.

I / We hereby authorize Liberty General Insurance Limited to make the payment/s, if any due to me on account
of any claim/s, in the account details whereof are given hereinabove. I/We understand and confirm that the
amount/s, if any, deposited by Liberty General Insurance Limited in abovementioned account will be deemed to
have been paid to and realized by me/us.

Please sign here

Beneficiary’s Signature

You might also like