{"id":1622,"title":"Electronic Payout Mandate","purpose":"service","insurer":{"slug":"prudential-hcl-health-insurance","name":"Prudential HCL Health Insurance Limited"},"source_pdf":"https://www.icicilife.com/content/dam/icicipru/download-centre/Payout/7S%20Electronic%20payout%20mandate.pdf","sha256":"ce7766126347e9a6e8aeb431c3064b44e526856d6be44064515c60b11a376216","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is used by policyholders to request electronic payout of their policy benefits by providing bank account details and necessary documents.","notes":["Attach original cancelled cheque with printed account number and name.","Attach signed copy of PAN card.","Attach proof of premium payment if using NRE bank account.","If proposer is illiterate or disabled or signed in vernacular language, the form must be witnessed by someone other than advisor/agent/employee.","You can submit the form via courier, email, or at any ICICI Prudential branch."],"title":"Electronic Payout Mandate","submit":{"to":"Payout Department, ICICI Prudential Life Insurance Co. Ltd., Unit no. 901A, 901B, A & B Wing, Prism Tower, Mindspace, Link Road, Goregaon (W), Mumbai-400063; or lifeline@iciciprulife.com; or any ICICI Prudential branch","how":"Courier, Email, or Submit at branch","address":"Courier: Payout Department, ICICI Prudential Life Insurance Co. Ltd., Unit no. 901A, 901B, A & B Wing, Prism Tower, Mindspace, Link Road, Goregaon (W), Mumbai-400063; Email: lifeline@iciciprulife.com; Branch locator at www.iciciprulife.com/branchlocator"},"purpose":"service","sections":[{"title":"Acknowledgement Slip","fields":[{"help":"","type":"text","label":"Policy Number :","options":[],"required":null,"pdf_field":""},{"help":"Date of receipt of application","type":"date","label":"Date :","options":[],"required":null,"pdf_field":""},{"help":"Select documents submitted","type":"checkbox","label":"Documents Submitted :","options":["Self Attested Photo ID","Signed Cancelled Cheque"],"required":null,"pdf_field":""},{"help":"Stamp and time of receipt","type":"text","label":"STAMP & TIME","options":[],"required":null,"pdf_field":""},{"help":"Name of person receiving the form","type":"text","label":"Received By","options":[],"required":null,"pdf_field":""}],"filled_by":"office use"},{"title":"Policy and Trustee Details","fields":[{"help":"Enter your policy number","type":"text","label":"Policy Number","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of policyholder","type":"text","label":"Name of Policy holder","options":[],"required":true,"pdf_field":""},{"help":"Fill only if policy is MWPA","type":"text","label":"Trustee Name","options":[],"required":false,"pdf_field":""},{"help":"Fill only if policy is MWPA","type":"text","label":"Trustee PAN","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Bank Account Details to Receive Policy Benefits","fields":[{"help":"Enter bank name","type":"text","label":"Name of Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter branch address","type":"text","label":"Branch Address","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number as printed on cheque","type":"text","label":"Bank Account No.","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account Type","options":["Current Account","Savings/ NRO Account"],"required":true,"pdf_field":""},{"help":"9 digit code as appearing on cheque","type":"text","label":"MICR Code of Bank","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of your bank branch","type":"text","label":"IFSC Code of Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter name as per bank records","type":"text","label":"Name of Customer/Trustee* (as mentioned in the bank account and printed on your cheque)","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Signatures","fields":[{"help":"Sign here","type":"signature","label":"Signature of Policyholder","options":[],"required":true,"pdf_field":""},{"help":"Sign here if MWPA policy","type":"signature","label":"Signature of Trustee","options":[],"required":false,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing (DD/MM/YYYY)","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder and trustee"},{"title":"Witness Declaration (if applicable)","fields":[{"help":"Enter full name of witness","type":"text","label":"I (Full name of Witness)","options":[],"required":false,"pdf_field":""},{"help":"Enter relation with proposer","type":"text","label":"(Relation with Proposer)","options":[],"required":false,"pdf_field":""},{"help":"Enter address of witness","type":"text","label":"Adult and inhabitant of (Address)","options":[],"required":false,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Witness","options":[],"required":false,"pdf_field":""}],"filled_by":"witness"},{"title":"Contact Details","fields":[{"help":"Enter your email address","type":"email","label":"E-Mail ID","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile number","type":"phone","label":"Mobile no.","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":[],"applies_to":"","attachments":["Cancelled cheque of your bank account with printed account number and name","Signed copy of PAN card","Proof of premium payment, i.e bank statement, if receiving amount in NRE bank account"],"declarations":["The witness declares that they have read and explained the contents of this form to the proposer and that the proposer has understood it."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"email","value":"customersupport@prudentialhealth.in","label":"Customer Support Email","level":null,"hours":null,"applies_to":"health","source_url":"https://prudentialhealth.in/raise-grievance","quote":"7th Floor, One Unity Center, Senapati Bapat Marg,\nDadar West, Lower Parel, Mumbai – 400013\nGet in Touch\n➔\n1800 268 2000\ncustomersupport@prudentialhealth.in\nInsurance Plans\nHealth Insurance Plans\nPRUHealth Edge\nPRUHealth Signature\nPRUHealth Protect\nPRUHealth Guardian\nTools &","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800 268 2000","label":"Customer Support Toll-Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://prudentialhealth.in/raise-grievance","quote":"704 to 1708, 17th Floor, One Unity Center, Senapati Bapat Marg,\nDadar West, Lower Parel, Mumbai – 400013\nGet in Touch\n➔\n1800 268 2000\ncustomersupport@prudentialhealth.in\nInsurance Plans\nHealth Insurance Plans\nPRUHealth Edge\nPRUHealth Signature\nPRUHealth","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"resolutiondesk@prudentialhealth.in","label":"Grievance Redressal Team Email","level":2,"hours":null,"applies_to":"health","source_url":"https://storage.googleapis.com/pruinhlth-prod-prd-yoh0kt-asia-south1-bkt-pinnacle-corp-p2/pinnacle/Prospectus_PRU_Health_Guardian_af8a9e6ecb/Prospectus_PRU_Health_Guardian_af8a9e6ecb.pdf","quote":"s not satisɰed with the resolution provided, they may escalate the matter by writing to the Grievance Redressal Team at resolutiondesk@prudentialhealth.in In case the Insured Person/Policyholder is still not satisɰed with the resolution provided by the Grievance Redressal T","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"address","value":"Prudential HCL Health Insurance Ltd. Unit No. 501, 5th Floor, Building No. 03 Gigaplex IT / ITES SEZ, Plot No. IT-5 Airoli (W), Navi Mumbai Maharashtra – 400708","label":"Grievance Redressal Officer Postal Address","level":3,"hours":null,"applies_to":"health","source_url":"https://storage.googleapis.com/pruinhlth-prod-prd-yoh0kt-asia-south1-bkt-pinnacle-corp-p2/pinnacle/Prospectus_PRU_Health_Guardian_af8a9e6ecb/Prospectus_PRU_Health_Guardian_af8a9e6ecb.pdf","quote":"QVb6HQLRUFLWL]HQVPD\\ZULWHWRXVDWVHQLRUFLWL]HQ#SUXGHQWLDOKHDOWKLQ\n• &RXULHUb:ULWHWRRXU+HDG2ɲFHDWWKHDGGUHVVPHQWLRQHGbelow:\nPrudential HCL Health Insurance Ltd. Unit No. 501, 5th Floor, Building No. 03 Gigaplex IT / ITES SEZ, Plot No. IT5 Airoli (W), Navi Mumbai Maharashtra ȣ 400708 The Insured Person/Policyholder may also approach any of the Companyȧs branches with the details of the grievance. If th","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/prudential-hcl-health-insurance/1622-electronic-payout-mandate"}