1.

Payee Details
Group/ Network Name |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
A. Payee Name |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
B. Address with Pin Code |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
C. Contact No |__|__|__|__|__|__|__|__|__|__|
D. Contact Person |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
E. Pan Card No |__|__|__|__|__|__|__|__|__|__|
2. Accounts Details
A. Name of the bank |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
B. Address of the bank |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
C. IFSC code no. of the bank |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
D Full Account No |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
E. Proper A/C name |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| __|__|__|
F. Type of Accounts
1. Saving Account |__| 2. Current Account |__|
(Please attach a blank cancelled cheque copy and Pan Card Copy)

I hereby declare that the particulars given above are correct and complete. If the transaction is
delayed or not effected at all reasons of incomplete or incorrect information, I would not hold the user
institution responsible.
______________________________________ ______________________________________
Signature & Stamp of the Agent Verified by
(Bank Official Stamp and Signature)
NEFT/EFT Mandate form
(Payments through EFT mechanism)
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Mailing Address : ICICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad-500032
Corporate Office : ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.
Visit us at www.icicilombard.com Mail us at customersupport@icicilombard.com
Now One Number for all your Insurance needs 1800 2 666 (Toll Free also accessible from your mobile)
Insurance is the subject matter of the solicitation. IRDA Reg. No. 115,
Terms and Conditions for Payments through RTGS I NEFT
The details provided by the Customers in the Mandate Form shall be considered as final and shall not be
responsible for cross verification of any of the details provided therein.
The RTGS/ NEFTfacility shall be effective for the respective Customer(s) within 15 days of the receipt of the Mandate Form by ICICI Lombard General
Insurance Company Ltd. and/ or within such period as may be reasonably required by ICICI Lombard General Insurance Company Ltd. to activate the RTGS/
NEFTfacility
The Customer agrees that under the RTGS/ NEFTfacility, there may be a risk of non-payment in the Account of Customer on the day of the credit of
Payments due to any of the following events :
1. holiday at the concerned bank(s)
2. wrong credit entry which may be due to incorrect information provided by the Customer in the Mandate Form
3. force majeure event, which includes any event beyond the reasonable control of ICICI Lombard General Insurance Company Ltd., including, without
limitation, unavailability of any communication system, system failure, sabotage, fire, flood, explosion, acts of God, civil commotion, strikes or industrial
action of any kind, riots, insurrection, war or acts of government, changes in legislation and other allied acts of regulatory nature
4. change in the applicable regulations pertaining to RTGS/ NEFTfacility
5. By virtue of any default, error, inaccuracy or mistake caused by the Customer, Customer's bank or its employees and agents.
The Customer agrees to indemnify, without delay or demur, ICICI Lombard General Insurance Company Ltd. and its agents and keep ICICI Lombard
General Insurance Company Ltd. and its agent indemnified harmless at all times from and against any and all claims, damages, losses, costs, and
expenses (including attorney's fees) whichICICI Lombard General Insurance Company Ltd. may suffer or incur, directly or indirectly, arising from or in
connection with, amongst other things, either of the aforesaid reasons stated in clauses 2 and 5.
The Customer acknowledges that transaction through the RTGS/ NEFT facility is irrevocable upon execution and revocation of such transaction may not
be possible.
The Customer shall forthwith report to ICICI Lombard General Insurance Company Ltd. any error and/or dispute regarding the correctness in the
execution of a RTGS/ NEFTpayment or the amount credited to his Account at the earliest, preferably within 3 days of the RTGS/ NEFTtransaction.
The Customer agrees that ICICI Lombard General Insurance Company Ltd. may send information including data, statements and reports to the
Customer's bank via the electronic mode through RTGS/ NEFT and the Customer recognizes that such information could be of a confidential nature and
the information may be intercepted, read, modified or altered by any person during such transmission and ICICI Lombard General Insurance Company
Ltd. cannot be held liable for any such act by a third party.
The Customer agrees thatICICI Lombard General Insurance Company Ltd. can disclose the data, information of the Customer to RBI, any statutory body,
courts etc. so as to comply with any regulatory or statutory requirements.
ICICI Lombard General Insurance Company Ltd. may sub-contract and employ agents to carry out any of its obligations under the RTGS/ NEFTfacility The
Customer may discontinue or terminate the use of RTGS / NEFT facility by giving a minimum of 15 days prior written notice to ICICI Lombard General
Insurance Company Ltd. The date of notice for ICICI Lombard will be the date of receipt of such notice by ICICI Lombard. The notice of, such termination
should be given to ICICILombard only at its corporate address and be addressed at: ICICI Lombard General Insurance Company Ltd. Zenith House,
Keshav Rao Khadye Marg, Mahalaxmi, Mumbai-400034
Such a termination shall not affect the Customer's liability to fulfill and complete its obligations in connection with the RTGS/ NEFTfacility. The
termination of the RTGS/ NEFTfacility shall not affect any accrued rights and liabilities of the Customer and/or ICICI Lombard General Insurance
Company Ltd. In no case a notice should be given to any of the Branch offices of ICICILombard or to any of its agents.
A confirmation of the receipt of termination notice given by the Customer will be acknowledged through a confirmation letter by ICICI Lombard General
Insurance Company Ltd. In no case can the Customer construe his termination notice as effective unless a confirmation has been provided by
ICICILombard to the Customer stating the date of receipt of such communication by the Customer.
ICICI Lombard General Insurance Company Ltd. may withdraw, terminate or suspend the RTGS/ NEFTfacility anytime at its option either entirely or with
reference to a specific ICICI Lombard General Insurance Company Ltd. RTGS/ NEFTfacility without assigning any reasons whatsoever and without any
prior notice.
The Customer agrees that transaction(s) through RTGS/ NEFTfacility may attract inward RTGS/ NEFT charges, which if levied by the Customer's bank,
shall be borne by the Customer.
ICICILombard has the absolute discretion to amend or supplement any Terms and Condition stated herein at any time and will endeavor to giveprior
notice of Ten days for such changes wherever feasible for the terms and conditions to be applicable. By using the new services, or at the completion of
such period, whichever is earlier, the Customer shall be deemed to have accepted the changed terms and conditions.
* NEFT is applicable for only the corporates employees for whom HR has opted for NEFT as a mode of payment. Kindly check with your respective HR
department for this facility.
* In case of any issues, HR decison and approval will be taken into consideration.
Notices under these terms and conditions may be given in writing by delivering them by hand or e-mail or onICICI Lombard General Insurance Company
Ltd. . website or by sending them by post to the last address of the Customer.
These terms and conditions will be governed by the laws of India and any legal action or proceedings arising out of these Terms and Conditions shall be
initiated in the courts or tribunals at Mumbai in India.
I/ We authorize ICICI Lombard General Insurance Company Ltd. . to revoke the RTGS/NEFTfacility without any prior notice on the completion of 7 days of
the termination of business relationship between us.
I / We further undertake to refund any excess amount whether demanded by ICICI Lombard General Insurance Company Ltd. or not, which has been
credited in excess to my account at any time due to any reason within 7 days of such receipt of such communication from ICICI Lombard of such excess
credit or such information of excess credit coming to the knowledge of the Customer through any other source.
I/ We agree that the payment will be credited starting from the date ICICI Lombard General Insurance Company Ltd. gets confirmation from its bankers,
This facility will continue unless it is revoked by any party and any issuance of relevant credit instruction fromICICI Lombard General Insurance Company
Ltd. to its bankers will be valid till such instruction is complete irrespective of the fact that the notice period has expired provided such a credit request
has been made byICICI Lombard General Insurance Company Ltd. . before the expiry of the notice period of the Customer.
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 collect
our payments, as and when they become due directly through our bank accounts
I / We further confirm that we understand that, ICICI Lombard General Insurance Company Ltd. , shall accomplish this by issuing the Payment instruction
electronically through its banker to the Clearing Authority/centre and the Clearing Authority/centre would ensure credit to our specified bank account.
I / We further confirm that ICICI Lombard General Insurance Company Ltd. will have the right to return to the option of paying by cheque if there are more
than 2 consecutive failures in remittances for no fault on the side of ICICI Lombard General Insurance Company Ltd.
(For our records, please attach a blank cancelled cheque or photo copy of a cheque for verification of the above particulars)
_________________________________________
Signature of the declarant
Date
ICICI Lombard General Insurance Company Ltd.
www.icicilombard.pcom