To

Service Hub,
United India Insurance Co. Ltd.,
Himalaya House, 7th Floor,
38-B, J.L.Nehru Road, Kolkata-700071

Sirs,
I / We furnish below details of my /our Bank Account & other details to be used for effecting payments
due to us by NEFT / RTGS towards full & final settlement of the claim in respect of the following
vehicle:
ACCIDENT TO VEHICLE NO: ON:
ALL FIELDS ARE MANADATORY- TO BE COMPLETED IN ALL RESPECT
1 Name of the Insured
2 Address Line 1
Address Line 2
Address Line 3
3 District
4 State
5 Pin Code
6 Date of birth
7 PAN Number
8 TAN NO *
9 Is Service Tax applicable? *
10 S.TAX Registration No *
11 Registration Number *
12 STD Code
13 Telephone Number (Landline)
14 Mobile Number
15 Email Address
16 Insureds Bank Account Number
17 Insureds Bank Name
18 Insureds Bank City
19 Insureds Bank Account IFSC CODE
20 Insureds Bank Account MICR Code
21 Insureds Bank Branch Name
22 Insureds Bank Branch Address-Line 1
Insureds Bank Branch Address-Line 2
Insureds Bank Branch Address-Line 3
* Applicable for Firms / Companies
Important: Please attach a copy of the cancelled cheque . Verify all the details before submitting.
I/We hereby declare that the particulars given above are correct and express my/our willingness to receive
credit of payments though the mode indicated above towards full & final settlement of my/our Motor OD
Claim. I/We would not hold United India Insurance Co. Ltd responsible, if the transaction is delayed or
not effected at all or credited to an incorrect account for reasons of incomplete /incorrect information.

Place:
Date: Signature of the Insured
Office Stamp, if any