Branch copy

Collecting Bank
Branch Code
Acknowledgement No
Collection A/c No
Date & Time
:
:
:
:
:
Axis Bank Ltd.
(Nomenclature- Branch Code/DDMMYY/Receipt No.)
!"#$%&' )*+&,-.%/0%$%&' 1.23
Received with thanks towards the below mentioned Application number in the Collection Account of TATA AG General nsurance Co. Ltd.
AppIication Number
Name
Amount Paid
Mode of Payment
Product Name
PoIicy Number (For RenewaI /Endorsement )
Rs.
120&"'45% ,6 )728 9"&+ ,662*%5
:$3.,#%% ;,/% ,6 )728 9"&+ ,662*%5<
Axis Bank's
Rubber Stamp
PIease Note :
This acknowledgement is subject to realization if paid through
8001592
tipu singh
15,541.00
Mandate
8/12/2014 4:59:42PM
743
743/120814/13153088
912020045079751
Private Car Insurance
0
Tear here
To be attached aIong with ProposaI form to be sent to Tata AIG GeneraI Insurance
Collecting Bank
Branch Code
Acknowledgement No
Collection A/c No
Date & Time
:
:
:
:
:
!"#$%&' )*+&,-.%/0%$%&' 1.23
Received with thanks towards the below mentioned Application number in the Collection Account of TATA AG General nsurance Co. Ltd.
AppIication Number
Name
Amount Paid
Mode of Payment
Product Name
PoIicy Number (For RenewaI /Endorsement )
120&"'45% ,6 )728 9"&+ ,662*%5
:$3.,#%% ;,/% ,6 )728 9"&+ ,662*%5<
Axis Bank's
Rubber Stamp
PIease Note :
This acknowledgement is subject to realization if paid through
Axis Bank Ltd.
743
743/120814/13153088
912020045079751
8/12/2014 4:59:42PM
8001592
tipu singh
Rs. 15,541.00
Mandate
Private Car Insurance
0