HDFC ERGO General Insurance Company Limited Consent for Mode of Claim Payment Name of Insured Policy Number Claim Number Beneficiary Name Mode of Payment Cheque Fund Transfer (Pheae tek or mode of payment) {Al Fields are Mandatory in case of Fue Transfer) Insured's Name as per Bank Account Bank Account Number Branch Name IFSC Code Email address Attachments canceled Cheque [] Bank Passbook Copy Pests dp wis Declaration: | Mr. / Mrs / Ms. undersigned, legal beneficiary of the above claim, declare that all details mentioned in this form are true and | agree to the mode of payment against the particular claim number mentioned above. Signature of Bonoficiary Date [D Siam Required incase of Company prod & Crate: 1"Foe 65- 165853yRedanaon HT Part ar, Crys, Marea #0 (20, Casarwr Sve as © ct Lea ues Pa Ache rt Rad, ‘rc (6 Mantel ~ 40009, Taos "8002700700 | Fax 8722 SERED | caGhacarncom | wwnraongacon CIN: UEECINEDONRALCTSMASD IRDA Rey No. 125.