{"id":1898,"title":"Health NEFT (health form)","purpose":"service","insurer":{"slug":"shriram-general-insurance","name":"Shriram General Insurance Company Limited"},"source_pdf":"https://cdn.shriramgi.com/webassets/download/health-form/Health_NEFT.pdf","sha256":"77d03ee0f9d267135b754ebb4bb0fea6d3c054af89bd2210daa7c4e274501fa9","pages":1,"collected":"2026-10-17","instructions":{"about":"This form is used by the proposer, insured, claimant, hospital, agent, or broker to request direct payment transfer via NEFT to their bank account for health insurance claims or payments.","notes":["If the attached cheque copy does not bear the account holder's name, provide photocopy of Bank statement or Bank attestation.","Please mention the complete account number as appearing on the cheque book.","Attach a photocopy of the cancelled cheque or cancelled blank cheque."],"title":"Health NEFT (health form)","submit":{"to":"","how":"","address":""},"purpose":"service","sections":[{"title":"Applicant and Bank Account Details","fields":[{"help":"Enter your policy or proposal number","type":"text","label":"Policy/Proposal Number _________________  (to be filled by Proposer/Insured only)","options":[],"required":null,"pdf_field":""},{"help":"Enter intermediary code if applicable","type":"text","label":"Intermediary Code _____________________ (to be filled by Intermediary only)","options":[],"required":null,"pdf_field":""},{"help":"Write your name and tick your role","type":"text","label":"I ____________________________________________________________________","options":["Proposer","Insured","Claimant","Hospital","Agent","Broker"],"required":null,"pdf_field":""},{"help":"Enter the name as per bank records","type":"text","label":"Account Holder's Name :","options":[],"required":true,"pdf_field":""},{"help":"Enter your bank's name","type":"text","label":"Bank :","options":[],"required":true,"pdf_field":""},{"help":"Enter the complete account number as appearing on the cheque book","type":"text","label":"Account Number :","options":[],"required":true,"pdf_field":""},{"help":"Select your account type and specify if others","type":"choice","label":"Type of Account :","options":["Savings Account","Current Account","Others (Please specify)"],"required":true,"pdf_field":""},{"help":"Enter the branch address of your bank","type":"text","label":"Branch Address :","options":[],"required":true,"pdf_field":""},{"help":"Enter the 9-digit MICR code from your cheque","type":"text","label":"MICR Code :","options":[],"required":true,"pdf_field":""},{"help":"Enter the IFSC code from your cheque book or bank branch","type":"text","label":"IFSC Code :","options":[],"required":true,"pdf_field":""},{"help":"Attach a photocopy of a cancelled cheque or blank cheque","type":"checkbox","label":"I have enclosed a photocopy of the cancelled cheque or cancelled blank cheque.","options":[],"required":true,"pdf_field":""},{"help":"Enter the date of signing","type":"date","label":"Date :              /            /","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Applicant : ___________________________","options":[],"required":true,"pdf_field":""}],"filled_by":"Proposer/Insured/Claimant/Hospital/Agent/Broker"},{"title":"Bank Attestation (If required)","fields":[{"help":"Date of attestation","type":"date","label":"Date :             /            /","options":[],"required":null,"pdf_field":""},{"help":"Bank official to sign and stamp","type":"signature","label":"Sign & stamp of Bank Official : _______________________","options":[],"required":null,"pdf_field":""},{"help":"Bank official to specify capacity","type":"choice","label":"in the capacity of (Please tick one)","options":[],"required":null,"pdf_field":""}],"filled_by":"Bank Official"}],"deadlines":[],"applies_to":"","attachments":["photocopy of the cancelled cheque or cancelled blank cheque","photocopy of Bank statement or Bank attestation if cheque copy does not bear account holder's name"],"declarations":["I declare that the particulars given above are correct and complete.","I will not hold Shriram General Insurance Limited responsible for delays or failures due to incomplete or incorrect information.","Shriram General Insurance Limited reserves the right to use alternative payout options including Cheque/Demand draft despite opting for NEFT."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"customer-care","channel":"phone","value":"1800-300-30000","label":"Customer Service Helpline number","level":1,"hours":null,"applies_to":"all","source_url":"https://www.shriramgi.com/grievance-redressal-mechanism","quote":"@shriramgi.com\nor you can also register your complaint at\nBima Bharosa Portal\nCall our Customer Service Helpline number 1800-300-30000 / 1800-103-3009 to report your grievance.\nOur senior citizen customers can reach us through the dedicated channel below","fetched_at":"2026-10-20"},{"purpose":"customer-care","channel":"phone","value":"1800-103-3009","label":"Customer Service Helpline number","level":1,"hours":null,"applies_to":"all","source_url":"https://www.shriramgi.com/grievance-redressal-mechanism","quote":"you can also register your complaint at\nBima Bharosa Portal\nCall our Customer Service Helpline number 1800-300-30000 / 1800-103-3009 to report your grievance.\nOur senior citizen customers can reach us through the dedicated channel below to service them","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"email","value":"gro@shriramgi.com","label":"Grievance Redressal Officer email","level":1,"hours":null,"applies_to":"all","source_url":"https://www.shriramgi.com/grievance-redressal-mechanism","quote":"al Officer at your nearest Shriram General Insurance\nBranch\n.\nYou can also write to us from your registered email ID at\ngro@shriramgi.com\nor you can also register your complaint at\nBima Bharosa Portal\nCall our Customer Service Helpline number 1800-300-30000","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-103-3009","label":"Grievance Cell No","level":null,"hours":null,"applies_to":"all","source_url":"https://cdn.shriramgi.com/webassets/download/policy-wordings/bd1c8925-acbd-4587-b36f-32bf85af43a5_Marine%20Cargo%20Insurance_%20Policy%20Wording.pdf","quote":"ress: Shriram General Insurance Co. Ltd. E-8, EPIP, RIICO Industrial Area, Sitapura, Jaipur – 302022 Grievance Cell No: 1800-103-3009, 1800-300-30000 E-mail ID: md@shriramgi.com Fax No.: 91-141-2770693 You can also reach us by email or register their co","fetched_at":"2026-10-20"},{"purpose":"grievance","channel":"phone","value":"1800-300-30000","label":"Grievance Cell No","level":null,"hours":null,"applies_to":"all","source_url":"https://cdn.shriramgi.com/webassets/download/policy-wordings/bd1c8925-acbd-4587-b36f-32bf85af43a5_Marine%20Cargo%20Insurance_%20Policy%20Wording.pdf","quote":"eneral Insurance Co. Ltd. E-8, EPIP, RIICO Industrial Area, Sitapura, Jaipur – 302022 Grievance Cell No: 1800-103-3009, 1800-300-30000 E-mail ID: md@shriramgi.com Fax No.: 91-141-2770693 You can also reach us by email or register their complaints on the","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/shriram-general-insurance/1898-health-neft-health-form"}