{"id":395,"title":"Part C – EFT","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/part-c-γçô-eft.pdf","sha256":"28bfb1d55fd8638935289aee46c74b5cd39661411e8084de2a115ece83ae4df9","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is for the proposer or policy holder to provide bank account details to enable claim payments through Electronic Fund Transfer (EFT). The proposer or policy holder fills it.","notes":["Provide bank details exactly as per bank records and documents.","Attach one of the specified bank documents for verification.","All claim settlements should be made through NEFT as per IRDA circular.","Use self-attested copies for identity proof.","For retail policies, provide proposer name and account details; for corporate policies, provide employee name and account details."],"title":"Part C – EFT","submit":{"to":"ICICI Lombard General Insurance Company Ltd.","how":"","address":"ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai - 400025"},"purpose":"service","sections":[{"title":"Bank Account Details for EFT","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 bank branch name","type":"text","label":"Branch name:","options":[],"required":true,"pdf_field":""},{"help":"Enter the full address of the bank branch","type":"text","label":"Address of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter the IFSC code as per the cheque leaf or passbook","type":"text","label":"IFSC code no. of the bank:","options":[],"required":true,"pdf_field":""},{"help":"Enter the PAN number of the proposer or policy holder","type":"text","label":"PAN No. of the Proposer:","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer / policy holder"},{"title":"Claim and Contact Details","fields":[{"help":"","type":"text","label":"C1. Patient's Name: (in respect of whom claim is made):","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"C2. Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"C3. Card No./ UHID No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"C4. Group/Company Name (for Group/Corporate policy holders):","options":[],"required":null,"pdf_field":""},{"help":"If claim number is available, provide it","type":"text","label":"C5. Claim Number (if allotted):","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"C6. Mobile/ Contact No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"C7. Email:","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer / policy holder"},{"title":"Signature","fields":[{"help":"Sign to authorize the bank details for EFT","type":"signature","label":"Account Holder's Signature","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer / policy holder"}],"deadlines":[],"applies_to":"claims under retail or corporate policies requiring NEFT/RTGS payment","attachments":["self-attested copy of a valid Identity proof of the Proposer/Policy holder (any document listed under Proof of Identity in Part-D)","Cancelled cheque copy","Bank attested copy of Passbook with IFSC code"],"declarations":["The bank details provided are final and ICICI Lombard is not responsible for verification.","RTGS/NEFT facility activates within 15 days of receipt of this form.","There is a risk of non-payment due to regulatory or other reasons beyond ICICI Lombard's control.","The proposer/policy holder indemnifies ICICI Lombard against any claims or losses arising from RTGS/NEFT transactions.","ICICI Lombard may subcontract agents to fulfill obligations under RTGS/NEFT.","Termination of RTGS/NEFT requires 15 days prior written notice to ICICI Lombard at its corporate address.","Termination is effective only after ICICI Lombard sends a confirmation letter.","Any inward RTGS/NEFT charges levied by the bank are borne by the proposer/policy holder.","ICICI Lombard may amend terms with 10 days prior notice where 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 are subject to Mumbai courts.","The proposer/policy holder undertakes to refund any excess credited amounts within 7 days of notification.","Claim payments will be credited once ICICI Lombard receives confirmation from its bankers and continue until revoked."],"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/395-part-c-eft"}