Na NEFT Format To Medsave Healthcare (TPA) Limited F-T01A, Lado Sarai, Mehrauli, New Dell Sirs, 11/ We furnish below details of my four bank account to be use for effecting payments due to us by NEFT / RTGS: Registration for NEFT/RTGS ‘Name @_b 7 ‘Category (Please elect one) olieyholder / Tatermes Se aE | Surveyor / Advocate / Investigator / Pane! Doctor / Dealer / Landlord / Vendor Polley Number (Poliyholdeis only) (512-6 34415040 0 000043 ‘Claim number, ifany, provided (Pofieyholders only) “Agency / Broker Code (Tor Agents / Brokers Corporate Agents /Bancassurance only) Permanent Address CHOUDWARE LANE, Te. PaTHRE. DEST PARBH Arc ‘Address for Communication Zo AMES KATE, Tak wo Of StppS [PAK Ag Ser. Rot PONE (BANK ACCOUNT DETAILS FOR NEFT/ RTGS PAYMENTS FSC Code HDEC 0600 LL | [Bank Name OTe BAN jank Branch Name SANG iBank Branch Address Were treay SCuINe > Che, Se ICR Code (9 Digit number) 41 Té [7T ato [str Full Bank Account No. (for NEFT)* TLAADS 00 IR75E * Please attach a copy of a cancelled cheque Teaf. Verily the details with your bank before submitting Twin fo receive alerts from the Company on processing of payments to my account through SMS and/or Email ‘Mobile Phone No. for SMS aler) F412 T9 4 — BLOCK tenes) saan) ewe wriein TOL AME NACMOUDKARE CKBL CoS We hereby declare that the particulars given above are correst and express my/our willingness to receive eredit of payments though the mode indicated above. Notwithstanding my/our choice of mode Medsave Healthcare (TPA) Lid eserves the right to issue a cheque / credit the account in the mode that they may deem fit. /We would not hold ‘Medsave Healthcare (TPA) Ltd responsible, ifthe transaction is delayed or not effected at all or credited to an incorrect account for reasons of incomplete /ineorret information, For Office Use: rp Reference No: — Bank Details verified by: Signatn? of Applicant Place: Pune. Dae osJoS/zoig ___| Pets apr in Sytem on: Details eaptured in System verified ‘And found correct: ‘Signature of Officer ‘Name & Designation Date