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    ECS Form

    Uploaded by

    Anonymous pKsr5v
    The document is a mandate form for an electronic clearance system that collects personal and banking information from a policy holder in order to set up direct deposit reimbursements for insurance claims. It requests a cancelled check, declares that the information provided is true and correct, and agrees not to hold the insurance company responsible for delays or non-receipt of payments after instructions have been issued based on the form.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    ECS Form

    Uploaded by

    Anonymous pKsr5v
    162 views1 page
    The document is a mandate form for an electronic clearance system that collects personal and banking information from a policy holder in order to set up direct deposit reimbursements for insurance claims. It requests a cancelled check, declares that the information provided is true and correct, and agrees not to hold the insurance company responsible for delays or non-receipt of payments after instructions have been issued based on the form.

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    The document is a mandate form for an electronic clearance system that collects personal and banking information from a policy holder in order to set up direct deposit reimbursements for insurance claims. It requests a cancelled check, declares that the information provided is true and correct, and agrees not to hold the insurance company responsible for delays or non-receipt of payments after instructions have been issued based on the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    162 views1 page

    ECS Form

    Uploaded by

    Anonymous pKsr5v
    The document is a mandate form for an electronic clearance system that collects personal and banking information from a policy holder in order to set up direct deposit reimbursements for insurance claims. It requests a cancelled check, declares that the information provided is true and correct, and agrees not to hold the insurance company responsible for delays or non-receipt of payments after instructions have been issued based on the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Mandate Form for Electronic Clearance System

    Policy No/Certif No
    Policy Holder`s Name
    Address

    Telephone No

    Email ID

    MDID No
    Claim NO
    Name of Account Holder
    Name of Bank
    Branch Name
    Branch Address

    Type of
    Account:SB/CD
    Account No
    MICR Code
    Cancelled Cheque

    IFSC Code
    Y

    1) Please enclose the cancelled cheque of your bank account for our record, Your banker should be a participant of NEFT/RTGS Facility.
    2) I hereby declare that the information furnished in this ECS Form is true & correct to the best of my knowledge & belief.
    If I have made any false or untrue statement, suppression or concealment of any material fact, my right to claim reimbursement
    Shall be forfeited.
    3) I agree that I shall not hold TPA/Insurance Company responsible for delay or non receipt of the payment for any reason whatsoever after
    issue of the instructions for payment by Insurer/TPA based on the above.
    Date :
    Place:

    Siagnature of the Policy Holder

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