{"id":1411,"title":"Bank Account Mandate for Direct Credit","purpose":"service","insurer":{"slug":"universal-sompo-general-insurance","name":"Universal Sompo General Insurance Company Limited"},"source_pdf":"https://www.universalsompo.com/assets/file/claims/neft-bank-mandate-form-motor.pdf","sha256":"658d004de5b22b31a336ff33335a5218bcf6a7600746d9c72582a3560765b406","pages":1,"collected":"2026-10-17","instructions":{"about":"This form is used by the policyholder to provide bank account details for receiving direct credit payments from Universal Sompo General Insurance Co. Ltd.","notes":["Use BLOCK LETTERS in blank ink.","Bank details must match bank records and are available on cheque leaf or bank passbook.","This form is for one-time customer payment only.","Verified by company section is for office use only."],"title":"Bank Account Mandate for Direct Credit","submit":{"to":"","how":"","address":""},"purpose":"service","sections":[{"title":"Beneficiary Details","fields":[{"help":"Enter the full name as per bank records in block letters","type":"text","label":"Beneficiary Name : (Should be same as in Bank) First Name Middle Name Last Name","options":[],"required":true,"pdf_field":""},{"help":"Enter the address as per the policy in block letters","type":"text","label":"Address : (As per the policy)","options":[],"required":true,"pdf_field":""},{"help":"Enter city name in block letters","type":"text","label":"City :","options":[],"required":true,"pdf_field":""},{"help":"Enter the postal pin code","type":"number","label":"Pin Code:","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN No :","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"Enter Service Tax Registration Number if applicable","type":"text","label":"Service Tax Reg No:","options":[],"required":true,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E Mail:","options":[],"required":true,"pdf_field":""},{"help":"Enter phone number with STD code","type":"phone","label":"Phone No.(with STD code):","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile Number :","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Bank Account Details","fields":[{"help":"Enter bank account number as per bank records","type":"text","label":"Bank Account Number :","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account Type:","options":["Savings","Current","Other"],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank :","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"Bank Branch Name :","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch code","type":"text","label":"Bank Branch Code:","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code as per cheque leaf or bank","type":"text","label":"IFSC Code :","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR code as per cheque leaf or bank","type":"text","label":"MICR Code:","options":[],"required":true,"pdf_field":""},{"help":"Tick this box if you want payment by cheque instead of direct credit","type":"checkbox","label":"* I /we DO NOT wish to receive direct credits, but wish to receive payment by cheque. (Please   )","options":["Tick if you prefer payment by cheque instead of direct credit"],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declaration and Signature","fields":[{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing in DD/MM/YYYY format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Customer","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":[],"applies_to":"","attachments":["Self attested copy of PAN Card OR Service Tax Regn certificate (if applicable for Institutions)","Original cancelled Cheque (CTS- 2010) duly signed by insured"],"declarations":["The details given above are true and I have no objection for direct credits in the bank account mentioned above.","If the electronic credit is not effected, delayed or credited to a wrong account due to incorrect or incomplete information, USGIC is not liable.","If credit is not effected by the bank, USGIC may make payment by cheque and will not pay in cash.","Enclose copy of PAN or Service Tax registration certificate if applicable.","Enclose cancelled cheque as per CTS-2010 of the bank account mentioned.","If you prefer payment by cheque instead of direct credit, tick the provided checkbox."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"contactus@universalsompo.com","label":"Customer Care Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/resourse-grievance-redressal/","quote":"ms\nClaim Status\nCrop Insurance Claim Details\nTPA’s Servicing Group Health Insurance\nDownload Pulz App\nConnect with Us\ncontactus@universalsompo.com\ncontactclaims@universalsompo.com\nHealth Insurance :\nComplete Healthcare Insurance\nA Plus Health Insurance\nSaral Suraksh","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-200-4030","label":"Customer Care","level":null,"hours":"24/7","applies_to":"all","source_url":"https://www.universalsompo.com/resourse-grievance-redressal/","quote":"s or investment of premiums. Public receiving such phone calls are requested to lodge a police complaint.\nCustomer Care\n1800-200-4030\nCrop Helpline\n14447\n,\n1800-200-5142\nSenior Citizen\n1800-267-4030\nAbout Us\nContact Us\nGrievance Redressal\nLogin\nI am a C","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"14447","label":"Crop Helpline","level":null,"hours":null,"applies_to":"crop","source_url":"https://www.universalsompo.com/resourse-grievance-redressal/","quote":"Public receiving such phone calls are requested to lodge a police complaint.\nCustomer Care\n1800-200-4030\nCrop Helpline\n14447\n,\n1800-200-5142\nSenior Citizen\n1800-267-4030\nAbout Us\nContact Us\nGrievance Redressal\nLogin\nI am a Customer\nI am an Agen","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-200-5142","label":"Crop Helpline","level":null,"hours":null,"applies_to":"crop","source_url":"https://www.universalsompo.com/resourse-grievance-redressal/","quote":"receiving such phone calls are requested to lodge a police complaint.\nCustomer Care\n1800-200-4030\nCrop Helpline\n14447\n,\n1800-200-5142\nSenior Citizen\n1800-267-4030\nAbout Us\nContact Us\nGrievance Redressal\nLogin\nI am a Customer\nI am an Agent\nMy Transaction","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"gro@universalsompo.com","label":"Grievance Redressal Officer Email","level":1,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/resourse-grievance-redressal/","quote":"e Co Ltd.\nUnit No. 601 & 602, 6th Floor,\nReliable Tech Park, Thane - Belapur Rd,\nNavi Mumbai, Maharashtra 400708\nEmail: gro@universalsompo.com\nContact Us for Grievance\n1800-200-4030 / 1800-22-4030\n(24/7 Assistance Services)\nVisit Branch\nGrievance Redressal Offic","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-200-4030","label":"Grievance Redressal Contact","level":1,"hours":"24/7 Assistance Services","applies_to":"all","source_url":"https://www.universalsompo.com/resourse-grievance-redressal/","quote":"s or investment of premiums. Public receiving such phone calls are requested to lodge a police complaint.\nCustomer Care\n1800-200-4030\nCrop Helpline\n14447\n,\n1800-200-5142\nSenior Citizen\n1800-267-4030\nAbout Us\nContact Us\nGrievance Redressal\nLogin\nI am a C","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-22-4030","label":"Grievance Redressal Contact","level":1,"hours":"24/7 Assistance Services","applies_to":"all","source_url":"https://www.universalsompo.com/resourse-grievance-redressal/","quote":"ne - Belapur Rd,\nNavi Mumbai, Maharashtra 400708\nEmail: gro@universalsompo.com\nContact Us for Grievance\n1800-200-4030 / 1800-22-4030\n(24/7 Assistance Services)\nVisit Branch\nGrievance Redressal Officer (GRO)\nWalk-into any of our nearest branches and req","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Grievance cell, Universal Sompo General Insurance Co.Ltd, Unit No. 601 & 602, 6th Floor, Reliable Tech Park, Thane - Belapur Rd, Airoli, Navi Mumbai, Maharashtra 400708","label":"Grievance Cell Postal Address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/assets/file/withdrawn-products/pos-critical-Illness-insurance-policy/policy-wording.pdf","quote":"ww.universalsompo.com\nToll free: 1800-22-4030 Senior Citizen1800-267-4030\nE-mail: contactus@universalsompo.com Courier: Grievance cell, Universal Sompo General Insurance Co.Ltd, Unit No. 601 & 602, 6th Floor, Reliable Tech Park, Thane - Belapur Rd, Airoli, Navi Mumbai, Maharashtra 400708\nlnsured person may also approach the grievance cell at any of the company's branches with the details of grievance lf l","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"contactus@universalsompo.com","label":"Grievance Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/assets/file/withdrawn-products/pos-individual-accident-policy/policy-wordings.pdf","quote":"case You are aggrieved in any way, You may register a grievance or Complaint by visiting Our website or write to us on contactus@universalsompo.com. You may also contact the Branch from where You have bought the Policy or the Complaints Coordinator who can be reached","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1-800-224030","label":"Toll Free Number for Grievance (MTNL/BSNL Users)","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/assets/file/withdrawn-products/pos-individual-accident-policy/policy-wordings.pdf","quote":"the Complaints Coordinator who can be reached at Our Registered Office. You may also contact on Our Toll Free Numbers: 1-800-224030 (For MTNL/BSNL Users) or 1- 800– 2004030 or on chargeable numbers at +91-22-41659800/+91-22-41659900 You can also visit","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1-800-2004030","label":"Toll Free Number for Grievance","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/assets/file/withdrawn-products/pos-individual-accident-policy/policy-wordings.pdf","quote":null,"fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"+91-22-41659800","label":"Chargeable Number for Grievance","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/assets/file/withdrawn-products/pos-individual-accident-policy/policy-wordings.pdf","quote":"lso contact on Our Toll Free Numbers: 1-800-224030 (For MTNL/BSNL Users) or 1- 800– 2004030 or on chargeable numbers at +91-22-41659800/+91-22-41659900 You can also visit Our Company website and click under links Grievance Notification If the issue still","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"+91-22-41659900","label":"Chargeable Number for Grievance","level":null,"hours":null,"applies_to":"all","source_url":"https://www.universalsompo.com/assets/file/withdrawn-products/pos-individual-accident-policy/policy-wordings.pdf","quote":"ur Toll Free Numbers: 1-800-224030 (For MTNL/BSNL Users) or 1- 800– 2004030 or on chargeable numbers at +91-22-41659800/+91-22-41659900 You can also visit Our Company website and click under links Grievance Notification If the issue still remains unresolv","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/universal-sompo-general-insurance/1411-bank-account-mandate-for-direct-credit"}