ICICI Lombard General Insurance Company Ltd

PAY­IN­SLIP 0003334344 PAY­IN­SLIP 0003334344

Date to be filled Manually Date to be filled Manually

Date Deposited in Branch : Deposited in

Date :
: ______________ Branch:_____________

Naming as appearing in Name as appearing in

Account______________________________ Account:__________________________________________________________
A/C to be credited to : 000405070142
A/C to be credited to : 000405070142
Intermediary Id IM­705098 Payment Id 0003334344 Intermediary Id IM­705098 Payment Id 0003334344

Intermediary RAGINI Payin slip Intermediary Name RAGINI GUPTA Payin Slip Date 28/06/2023
28/06/2023
Name GUPTA date Subagent Name
Subagent Name Payment Mode Cheque No of cases 1
Payment Mode Cheque No of cases 1 Cheque/DD Date 27/06/2023 Cust Code Ipartner
Cheque/DD date 27/06/2023 Cust code Ipartner
TEL. MOBILE
BANK & NO. NO.
CHEQUE NO. Rs. Ps.
BRANCH
Hdfc 001064 4188 BANK & BRANCH CHEQUE NO. DENO. PIECES Rs. Ps.
Bank,INDORE Hdfc Bank,INDORE 001064 1000x 4188
500x
100x
50x
20x
10x
5x
TOTAL 4188 TOTAL AMOUNT RUPEES (in words) Rupees Rs. Ps.
Four Thousand One Hundred Eighty Eight Only COINS
OFFICER
TOTAL 4188
CHEQUE(S) SUBJECT TO FOR OFFICE USE
REALISATION TRAN. ID.
OFFICER VERIFYING OFFICER
Policy Details
Note : Please use seperate pay­in­slip for CASH DEPOSIT, SIGNATURE OF
PROPOSAL CUSTOMER TOTAL LOCAL, OUTSTATION & ICICI BANK CHEQUES DEPOSITOR
SR.NO. PRODUCT
NO. NAME PREMIUM
This is not payment receipt but only a proof of the payment recieved by the bank.
UNITED Policy issuance is subject to underwriting norms.Cash deposit towards premium
1 2576923682 3001 4188
RADIOS cannot exceed Rs.49,999/­. cash deposit is available only for motor products.

Policy Details
SR.NO. PROPOSAL NO. PRODUCT CUSTOMER NAME TOTAL PREMIUM
1 2576923682 3001 UNITED RADIOS 4188