IC Name: *
Policy No :*
Health India ID No.:
Policy Holder Name :*
Mobile No.:
Email ID:
Name of Account Holder:*
Account Number:*
IFSC Code:*
Name of Bank:*
Branch Name:
MICR Code:
Branch Address:
Type of Account:*
Submitted By : *
Upload Cancelled Cheque with duly filled and signed ECS Form*
(Allow Only : *.jpg,*.jpeg,*.png,*.tiff,*.pdf)
I accept all the below terms and conditions
*Terms and Conditions
  1. I hereby declare that the information furnished in this ECS Form is true & correct to the best of my knowledge & belief. If I have Made any false or untrue statement, suppression or concealment of any material fact, my right to claim reimbursement shall be Forfeited.
  2. I agree that I shall not hold TPA/Insurance Company responsible for delay or non-receipt of the payment for any reason whatsoever after issue of the instructions for payment by Insurer/TPA based on the above.
  3. As per the revised RBI guidelines, Canceled cheque should have pre-printed name of account holder.
  4. Note: your banker should be a participant of NEFT/RTGS Facility.