ELECTRONIC FUNDS TRANSFER (NEFT/ RTGS)

FOR CLAIM PAYMENTS

Full Address

Pin Code
Contact No Mobile No

Email ID
Beneficiary Bank Details
Bank Name
Branch Name

Branch Address

Branch Contact No

Email ID

Branch IFSC Code

Account Type Savings A/C Current A/C Cash Credit

Account No.
[as appearing in the cheque book]

Beneficiary PAN & Alert Details

PAN Number
Payments Details Alerts Required

SMS YES NO If Yes Mobile No.

Auto Mailer YES NO If Yes E-Mail ID

Place: ____________________ Date: ________________

Authorized Signatory & Stamp(If applicable):

MANDATORY REQUIREMENT
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.
Please attach your cancelled cheque here.
 Declaration

i) 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.

ii) 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.

iii) 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.

iv) 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.

v) 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 two consecutive failures in remittances for no fault on the side of Universal Sompo General Insurance Company
Limited.

vi) After Universal Sompo General Insurance Company Limited issuing the Payment instruction 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.

vii) 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.

viii) 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.

ix) I / We further undertake to inform Universal Sompo General Insurance Company Limited with an advance notice of six weeks, to withdraw from this mode of
electronic payment.

I/ We have read the declarations/ conditions mentioned above.

Place: ____________________ Date: _______________

Authorized Signatory & Stamp(if applicable):

Registered Office: Universal Sompo General Insurance Co Ltd,8th Floor and 9th Floor (part - south side),Commerz , International Business park, Oberoi Garden City,
Off Western Express Highway, Goregaon East, Mumbai- 400063
Health Claims Management: Universal Sompo General Insurance Co Ltd, 1st Floor, Plot No.- C 56 A/13, Sector - 62, Noida, Uttar Pradesh -201309
Toll Free Helpline No: 1800 200 4030; Email ID: healthserve@universalsompo.com
Website: www.universalsompo.com; CIN# U66010MH2007PLC166770