The following is a form for receiving your claims from Bajaj Allianz in the form of direct bank transfer, this form is amended from. All the details in this form are very important they have to be filled very carefully and correctly.
The details to be filled in the form are as follows. Full name as it appears on your bank account, your complete address, your contact number, your email ID. And then you mentioned your bank details like your bank name, the name and address of the branch, your IFSC code for online transfer of your funds.
You also need to attach the cancelled check of your bank account to ensure the accuracy of the bank name, branch name, account number, and IFSC code. This is done so the Bajaj Allianz reviewers can check the details and cross-reference them with the information that you have given them.
This form and ensures that you have a smooth and quick settlement of a claim with Bajaj Allianz.
Bajaj Allianz Mandate Form for ECS Claim Payments
Text Version of this Form
Mandate Form for Electronic Transfer of Claim Payments
Partner ID (To be filled by Office):
Shri / Smt / Kum / M/s ____________________________________________
(As appears in your bank account)
Full Address: _____________________________________________________________
Contact / Mobile No:
____________________________________PIN Code: ________________
__________ ___Email ID:________________________________________
Branch Name & Address:
Branch Tel No & Contact No:
Branch IFSC Code for NEFT
Branch MICR Code
Name of the Account Holder :
(As per Bank Account)
Account Type Savings Current Cash Credit
(as appearing in the cheque book)
I/we have read the declarations / conditions mentioned overleaf.
Place: ____________________Date: _____________ (Beneficiary’s Signature)______________________________
PLEASE ATTACH HERE
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.
I have verified the documents attached with the mandate and confirm that these documents correctly belong to the Partner ID &
Partner Name mentioned in the mandate. ( To be verified by superior )
Employee Code_______ Employee Name:________________________ Designation_________________
Place ___________________ Date___________ Signature __________________________________
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 Bajaj Allianz General Insurance Company Limited
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 Bajaj Allianz 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
I / We further undertake to refund, at any time, any excess amount whether demanded by Bajaj
Allianz General Insurance Company Limited or not, which has been credited to my account [due to
any reason] by Bajaj Allianz 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.
I / We agree that the payment will be endeavoured 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 Bajaj Allianz General Insurance Company Limited into the aforesaid
account will be valid discharge to Bajaj Allianz 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.
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.
I / We further confirm that I/we understand, Bajaj Allianz General 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.
I / We further undertake to inform Bajaj Allianz General Insurance Company Limited with an
advance notice of 6 weeks, to withdraw from this mode of electronic payment.
I / We further confirm that Bajaj Allianz 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 2 consecutive failures in remittances for no fault on the side of Bajaj Allianz General
Insurance Company Limited.
After Bajaj Allianz 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
Bajaj Allianz 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.