Mandate Form for Electronic Transfer of Claim/Refund Payments
To
Bajaj Allianz General Insurance Company Ltd
Full Name:                               Shri/Smt/Kum/M/s        Gauerau Shanng
                                             As appears in your bank account)
                                            WANoLsMan1a YonRa
Full Address:
                                            DeLat   GrabPINcode
Contact/Mobile No
                                                                EmailiD
 Bank Name:
  Branch Name & Address                   CD       ChnBadhla Roatl
  Branch IFS Code for NEFT                    U       N B     C
  Name of the Account Holder                         Grauseu       ghaine
  (As per Bank Account)
  Account Type                                 Saving                    Current                    Cash Credit
  Account No
 as appearing in the cheque bock                                      100136 S
Iwe have read the declarations /conditions menticned balow.
MANDATORY REQUIREMENT
Preprinted copy of chegue with cancelled rermark having-Account holder name /Account no/IFS code.
if Name,Account no or IFS Code of the payee is not printed on the cheque leaf,please attached copy of first page
of the bank pass book.
                                        Cavrav
(Beneficiary's Signature)
DECLARATION
               I / We hereby deciare 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 Bajaj Allianz General Insurance Company Limited
               responsibie.
               I/We further undertake to refund, at any timeany excess amount whether demanded by Bajaj
               Allianz Ganeral Insurance Company Limited or not,which has been credited to my account [due to
               any reason] by Bajaj Allianz Genaral Insurance Company Limited
               I / We further undertake to infom Bajaj Allianz General Insurance Company Limited with an
               advancs
               notice of 6 weeks in case of any changes in the particulars of Bank / Mandate
               After Bajaj Alianz General Insurance Company Limited issuing the Payment instruction
               electronically through its bankerfor whatever reasons if i/we do not get the credit to mylour
               account, then same shall neither constitute the default in payment of amount due to me/us,or by
               Bajaj Allianz Generai Insurance Company Limited nor constitute defau of any terms and
               conditions oi any agresment with me/us.
I have verified the documents attached with the mandate and confirm that these documents correcty belong to the Partner ID

                                          Name of Partner ID

 Employee Code          Employee Name:                                    Designation_

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