NEFT/EFT Mandate form

(Payment through EFT Mechanism)

1. Provider details

A. NT Code
Group/Network Name
Address
Landmark
City
District
State
Pincode
B. Pan Card No**
PAN Card Holder's Name

2. Account details

Bank Name
Branch Name
MIRC No
IFSC Code
Account type
Full Account no.
Name as per Bank Records
Cancel cheque no**

**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

Signature & Stamp of the Provider

Mailing Address: Varun Towers-II, 1st, 4th (Half) , 5th and 6th floors, opp. HYDERABAD PUBLIC SCHOOL, Begumpet, Hyderabad,
Telangana 500016
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 [email protected]
Now One Number for all your Insurance needs 1800 2 666 (Toll Free also accessible from your mobile)
To,
ICICI Lombard General Insurance Company Ltd.

Sub: Release of payment due towards reimbursement of claims settled as network hospital.

This is with respect to the reimbursement(s) towards the claims settled by us as network hospital
under various health schemes administered by ICICI Lombard General Insurance Company Ltd.
Please note that all the reimbursements shall be made as per details provided herein below. I/We
affirm that payment made as per below details would release ICICI Lombard General Insurance
Company Ltd. towards any obligation and no dispute would be instituted against them for such
payment at any time.

Hospital Name
Payee Name
PAN No.
PAN Card Holder Name
Service Tax No.
NT Code

I/We hereby declare that the particulars given above are correct and complete. If the transaction
is delayed for reasons of any error, inaccuracy or mistake due to incompleteness or delay in
providing above details, I/We would not hold ICICI Lombard General Insurance Company Ltd.
responsible for same.

Date: Sign & Seal of Vendor

Place: Designation/ Association of authorizer in relation to Hospital (i.e.
Owner/Partner/CFO/COO/Accounts Head, etc)
Annexure: - PAN Card Copy
Mailing Address: ICICI Lombard Healthcare, Varun Towers-II, 1st, 4th (Half) , 5th and 6th floors, opp. HYDERABAD PUBLIC SCHOOL,
Begumpet, Hyderabad, Telangana 500016
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 [email protected]
Now One Number for all your Insurance needs 1800 2 666 (Toll Free also accessible from your mobile)
QC Checks for Payee Name confirmation Letters:-
1). Payee Name confirmation letter is required on the letter head of Network.
2). It will be accepted in original. All such payee name confirmation letters will be sent to ICICI
Lombard GIC LTD. on following address:-

ICICI Lombard HealthCare :

Varun Towers-II, 1st, 4th (Half) , 5th and 6th floors, opp.
HYDERABAD PUBLIC SCHOOL,
Begumpet,
Hyderabad, Telangana 500016

3). All payee name confirmation should be having appropriate SEAL & SIGN of networks as per
below:-

In case of Proprietary Concern: - It should contain the seal of concern with the sign. of
proprietor.

In case of Partnership Firm: - It should contain the seal of Partnership with the sign of all the
partners.

In case of Company: - It should contain the seal of company with the sign of designated Officer.
Designation of the officer needs to be mentioned with the signature. Please note that all
Payments to Network falling under this category issued as per the PAN card holder name
without any deviation

Mailing Address: : Varun Towers-II, 1st, 4th (Half) , 5th and 6th floors, opp. HYDERABAD PUBLIC SCHOOL, Begumpet, Hyderabad,
Telangana 500016
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 [email protected]
Now One Number for all your Insurance needs 1800 2 666 (Toll Free also accessible from your mobile)
 Contact Details

1. Contact Details
Name of person
Designation
Department
Contact No.
Alternative Contact Details
Name of person
Designation
Department
Contact No.
2. Contact Details for AL/Claim Queries
Name of person
Designation
Department
Email ID
Contact No.
Fax No.
3. Contact Details for Fund Transfer Details
Name of person
Designation
Department
Email ID
Contact No.
4. Name of person
Designation
Department
Email ID
Contact No.

Note :
Kindly note that the Email IDs & contact details should contain at least 1 member from the TPA, Accounts &
Marketing department for the purpose of communication related to AL/ Claim query (TPA), Payment query
(Accounts) , Other query (Marketing) and Payment details

Details in the mandate from verified & confirmed by:

Date & Time:

Mailing Address: : Varun Towers-II, 1st, 4th (Half) , 5th and 6th floors, opp. HYDERABAD PUBLIC SCHOOL, Begumpet, Hyderabad,
Telangana 500016
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 [email protected]
Now One Number for all your Insurance needs 1800 2 666 (Toll Free also accessible from your mobile)
 Terms and Conditions for Payments through RTGS I NEFT
• The details provided by the Vendors in the Mandate Form shall be considered as final and ICICI LOMBARD GIC LTD shall not be responsible for cross
verification of any of the details provided therein.
• The RTGS/ NEFT facility shall be effective for the respective Vendor(s) within 15 days of the receipt of the Mandate Form by ICICI LOMBARD GIC
LTD and/ or within such period as may be reasonably required by ICICILOMBARD GIC LTD to activate the RTGS/ NEFT facility
• The Vendor agrees that under the RTGS/ NEFT facility, there may be a risk of non -payment in the Account of vendor on the same 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 Vendor in the Mandate Form
3. Force majeure event, which includes any event beyond the reasonable control of ICICI LOMBARD GIC 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/ NEFT facility
5. By virtue of any default, error, inaccuracy or mistake caused by the Vendor, Vendor's bank or its employees and agents.
• The Vendor agrees to indemnify, without delay or demur, ICICI LOMBARD GIC LTD and its agents and keep ICICI LOMBARD GIC 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)
which ICICILOMBARD GIC LTD may suffer or incur, directly or indirectly, arising from or in connection with, either of the aforesaid reasons stated
in clauses 2 and 5.
• The Vendor acknowledges that transaction through the RTGS/ NEFT facility is irrevocable upon execution and revocation of such transaction may not
be possible
• The Vendor shall forthwith report to ICICI LOMBARD GIC LTD any error and/or dispute regarding the correctness in the execution of a RTGS/
NEFT payment or the amount credited to his Account at the earliest, preferably within 3 days of the RTGS/ NEFT transaction.
• The Vendor agrees that ICICI LOMBARD GIC LTD may send information including data, statements and reports to the Vendor’s bank via the
electronic mode through RTGS/ NEFT and the Vendor 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 GIC LTD cannot be held liable for any such act by a
third party.
• The Vendor agrees that ICICI LOMBARD GIC LTD can disclose the data, information of the Vendor to RBI, any statutory body, courts etc. so as to
comply with any regulatory or statutory requirements.
• ICICILOMBARD GIC LTD may sub-contract and employ agents to carry out any of its obligations under the RTGS/ NEFT facility
The Vendor may discontinue or terminate the use of RTGS / NEFT facility by giving a minimum of 15 days prior written notice to ICICI LOMBARD
GIC 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 ICICI Lombard only at its corporate address and be addressed at: ICICI Lombard GIC Ltd, 414, Veer Savarkar Marg, Near Siddhi
Vinayak Temple, Prabhadevi, Mumbai – 400025
• Such a termination shall not affect the Vendor's liability to fulfill and complete its obligations in connection with the RTGS/ NEFT facility.
The termination of the RTGS/ NEFT facility shall not affect any accrued rights and liabilities of the Vendor and/or ICICI LOMBARD GIC LTD. In no
case a notice should be given to any of the Branch offices of ICICI Lombard or to any of its agents.
• A confirmation of the receipt of termination notice given by the vendor will be acknowledged through a confirmation letter by ICICI Lombard GIC Ltd.
In no case can the vendor construe his termination notice as effective unless a confirmation has been provided by ICICI Lombard to the vendor stating the
date of receipt of such communication by the vendor.
• ICICILOMBARD GIC LTD may withdraw, terminate or suspend the RTGS/ NEFT facility anytime at its option either, entirely or with reference to a
specific ICICILOMBARD GIC LTD RTGS/ NEFT facility without assigning any reasons whatsoever however ICICI Lombard GIC Ltd shall give a
reasonable notice in respect of the same.
• The Vendor agrees that transaction(s) through RTGS/ NEFT facility may attract inward RTGS/ NEFT charges, which if levied by the Vendor's bank,
shall be borne by the Vendor.
• ICICI Lombard has the absolute discretion to amend or supplement any Terms and Condition stated herein at any time and will endeavor to give prior
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 Vendor shall be deemed to have accepted the changed terms and conditions.
• Notices under these terms and conditions may be given in writing by delivering them by hand or e-mail or .on ICICI Lombard GIC Ltd.
Website www.icicilombard.com or by sending them by post to the last address of the vendor.
• 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.
• 1/ we authorize ICICI Lombard GIC ltd. to revoke the RTGS/NEFT facility without any prior notice on the completion of 7 days of the termination of
business relationship between us.
• I/we further undertake to intimate ICICI Lombard GIC Ltd of any excess amount which has been credited in excess to my account at any time due to any
reason within 7 days of such receipt and agree to refund the excess amount within 7 days on receipt of communication from ICICI Lombard GIC Ltd in
respect of the same by drawing a cheque in favour of ICICI Lombard General Insurance Company Limited
• 1/ we agree that the payment will be credited starting from the date ICICI Lombard GIC Limited gets confirmation from its bankers, This facility will
continue unless it is revoked by any party and any issuance of relevant credit instruction from ICICI Lombard GIC Limited 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 by ICICI Lombard
GIC Ltd. before the expiry of the notice period of the vendor.
• 1/ 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 GIC Limited, 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 GIC Limited 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 GIC Limited.
(For our records, please attach a blank cancelled cheque or photo copy of a cheque for verification of the above particulars).

________________
(Seal and Signature of the vendor)