The New India Assurance Company Limited
DECLARATION CUM NEFT Mandate Form
1. Name of the Hospital
2. Registered Entity/Trust/Society/Firm name of Hospital (If Different from Hospital Name)
3. Name of Entity raising invoice
4. TPA PPN
5. Hospital Address
6. Mobile/Landline Number of Hospital
7. Email ID
8. Permanent Account Number (PAN No.)used for filing income taxreturns.
09.Exact Name mentioned on PAN Card (*if name is other than hospital name provide ownership proof.)
10. Have GSTIN No –Choose one (Yes /No) – If Yes Please provide GSTIN Number
10 (a)Name as per GSTIN certificate
11. ROHINI Registration number
11 a).ROHINI Registration start date
11 b).ROHINI Registration Expiry date
12. NABH Registration number
12 a) NABH Category
12 b). NABH Registration start date
12 c).NABH Registration Expiry date
15. Particlars of Bank Account of Hospital(where fund transfer is requested)-Please attached scanned copy of
cancelled cheque
(A) Bank Name :
(B)Bank Branch Name :
(C) Bank Address :
(D) Account Type : (Savings/Current) as it appears on the chequebook
(E) Account Number (as it appears on the cheque book or as per RBI norms with full digits) :
(F) Account Holders Name (Beneficiary name to be mentioned at the time of fund transfer) :
(G)IFSC Code (Indian Financial System Code)
Declaration from Hospital
I/We hereby declare that the particulars given above are true, correct and complete and that I/We
have read, understood and agree to abide by the terms and conditions governing the RTGS/NEFT
payment facility.I/We also confirm that bank account and other financial details including PAN card
as mentioned in form are to be used for Cashless Claims made by New India Assurance Co Ltd to
our Hospital and we won’t be using any other bank account for cashless claim payments from New
India Assurance Co Ltd .I/We will be sharing same bank account details and other information as
mention in form to all concerned TPAs .
Sign and Stamp :
Name and Designation of Authorized
signatory(Hospital) : Place :
Date:
Declaration from TPA
I/We hereby declare that we have verified all the filled details and following provided by Hospital.
1.Complete NEFT mandate form.
2.Scanned copy of PAN card
Scanned copy of Latest Cancelled Chequeshowing beneficiary (Account holder ) name
/Passbook copy in case Account holder name not mentioned on cheque.
Sample Invoice Copy
Ownership proof wherever required- e.g. Certificate from CA
Scanned Copy of GSTIN Certificate
TPA Name :
Sign of TPA Representative:
Name of TPA
Representative: Place:
Date:
Medi Assist Insurance TPA Pvt. Ltd.
RTGS /NEFT Mandate Form
1. Name of the Hospital
2. Hospital Address
3. Mobile Number of Hospital Contact (City code – Number)
4. Dedicated Email ID for Settlement advice communication
5. Permanent Account Number (PAN No): Please attach scanned Copy of PAN card*
6. Exact Name mentioned on the PAN Card:
7. Particulars of Bank account (where fund transfer is requested)
(A) Bank Name:
(B) Bank Branch Name:
(C) Bank Address:
(D) 9 Digit MICR code present on the bank cheque: Please attach scanned Copy of cancelled cheque**
(E) Account Type: (savings / current ) as it appears on the cheque book
(F) Account Number(as it appears on the cheque book or as per RBI norm with full digits):
(G) Account Holders Name (Beneficiary name to be mentioned at time of fund transfer):
IFSC CODE (Indian Financial System Code)
1
I / We hereby declare that the particulars given above are true, correct and complete and that I/ We have
read, understood and agree to abide by the terms and conditions governing the RTGS /NEFT payment facility
as appended here to.
Name of the Authorized Signatory : __________________________________ Date: _______________
Designation of the Authorized Signatory : ________________________________
