Declaration for Third Party Cheque / Payment

Date: ………………..
To,
Kotak Mahindra General Insurance Co. Ltd.
8th Floor, Zone-IV, Kotak Infinity Park,
Malad East,
Mumbai – 400 097

Re: Submission of Premium through a third party for Insurance Proposal

Dear Sir,

I wish to submit the premium for proposal through a third party cheque / mode. Details
are as below –

Application Number /
Renewal Policy Number

Name of the Proposer

Product / Policy applied for

Cheque Number

Cheque date

Cheque Issued by (Drawer)

Drawer’s PAN Number

Drawer’s relation /
association with proposer

Reasons

We undertake that there are no other reasons besides above and request to allow
payment.

Thanking You.

Yours Faithfully

Proposer Sign Payer Sign

____________(Relation with Proposer)