{"id":1616,"title":"NEFT Form","purpose":"service","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/default-document-library/neft-form.pdf","sha256":"b08d8029e6e78d2939a8cd7bdea6eca9eab66556c57ffb7668eb0d1fc71785c6","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is used by the proposer or policyholder to provide their bank account details for claim payment through NEFT (Electronic Fund Transfer). The proposer or policyholder fills this form.","notes":["Provide bank details exactly as per bank records and cheque leaflets.","Attach self-attested identity proof and cancelled cheque or bank attested passbook copy with IFSC code.","All claim settlements should be made through NEFT as per IRDA circular.","Use the contact details provided for queries or submission."],"title":"NEFT Form","submit":{"to":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016","how":"post / e-mail / upload (as per contact details provided)","address":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016"},"purpose":"service","sections":[{"title":"Proposer/Policy Holder Bank Details","fields":[{"help":"Enter the name exactly as per bank records","type":"text","label":"Proposer (policy holder)/ Employee name*(as per bank records):","options":[],"required":true,"pdf_field":""},{"help":"Enter your bank account number","type":"text","label":"Proposer/ policy holder Bank account no.:","options":[],"required":true,"pdf_field":""},{"help":"Enter the bank's name","type":"text","label":"Name of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter the branch name of your bank","type":"text","label":"Branch name:","options":[],"required":true,"pdf_field":""},{"help":"Enter the bank branch address","type":"text","label":"Address of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code as per the cheque leaflet","type":"text","label":"IFSC code no. of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number of the proposer","type":"text","label":"PAN no. of Proposer:","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer or policyholder"},{"title":"Claim and Contact Details","fields":[{"help":"","type":"text","label":"Patient's Name: (in respect of whom claim is made):","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Card No./ UHID No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Group/Company Name (for Group/Corporate policy holders):","options":[],"required":null,"pdf_field":""},{"help":"If you have a claim number, provide it","type":"text","label":"Claim Number (if allotted):","options":[],"required":false,"pdf_field":""},{"help":"Enter a valid mobile or contact number","type":"phone","label":"Mobile/ Contact No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter a valid email address","type":"email","label":"Email:","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer or policyholder"}],"deadlines":[],"applies_to":"","attachments":["self-attested copy of a valid Identity proof of the Proposer/Policy holder (any of the mentioned documents in Proof of Identity under Part-D)","Cancelled cheque copy","Bank attested copy of Passbook with IFSC code"],"declarations":["The details provided in this form are final and ICICI Lombard is not responsible for cross verification.","RTGS/NEFT facility will be effective within 15 days of receipt of this form.","Proposer/policy holder agrees to indemnify ICICI Lombard against any claims arising from incorrect details or other reasons beyond ICICI Lombard's control.","Proposer/policy holder may terminate RTGS/NEFT facility with 15 days prior written notice to ICICI Lombard at its corporate address.","Transaction charges levied by the bank will be borne by the proposer/policy holder.","ICICI Lombard may amend terms and conditions with prior notice of 10 days wherever feasible.","Submission of bank details or documents does not imply admission of liability by ICICI Lombard.","Notices may be given by hand, email, website or post to the last known address.","These terms are governed by Indian law and disputes will be settled in Mumbai courts.","Proposer/policy holder undertakes to refund any excess amount credited within 7 days of communication.","Claim payment will be credited once ICICI Lombard receives confirmation from its bankers."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/icici-lombard-general-insurance/1616-neft-form"}