Annexure-I

Bank Details
1.

Name of the A/C holder

2.

Bank Name
Full bank A/C Number
(without / , - or any special
characters)

3.

4.

IFSC code

5.

Account type (Savings/Current)

6.

Bank Address

7.

Mobile Number

8.

E-mail ID

**Please, enclose cancelled cheque leaf.

Annexure-II
Check List

Sl. No.

Particulars

1.

Policy Copy

2.

Intimation Copy

3.

Phone Numbers

4.

Email ID

5.

Serial no. on the Document

Cashless/Prepost
/Reimbursement

Yes

(Signature of the Claimant)

No