Bank Account Updation Mandate Direct Credit Mandate Date________________ Please fill the details in the table below and submit to the nearest USGI branch.Beneficiary Details All fields are mandatory Universal Sompo Location________________________________________________________ Beneficiary Name________________________________________________________ (Should be same as in Bank) Date of Birth________________________________________________________ Address________________________________________________________ (As in the agreement) ________________________________________________________ City______________________________Pin Code__________________ Fathers Name________________________________________________________ (Ignore in case of company) PAN No________________________________________________________ Service Tax Registration No__________________________ E Mail ________________________ Phone No.(with STD code)________________________ Mobile Number___________________ Bank Account DetailsAll fields are mandatory Name as in Bank Account________________________________________________________ (Should be same as above) Name of the Bank________________________________________________________ Bank Account Number________________________ Account Type ____________________ ( Savings /Current etc) Bank Branch Name ________________________ Bank Branch Code ________________ NEFT (IFSC Code)________________________________________________________ (The above details are available on the face of the cheque. If not, please speak to your branch and get the details / submit the copy of bank pass book where all the above details are available) I hereby understand and confirm that : 1.The details given above are true and I have no objection if Universal Sompo General Insurance Company Limited directly credits the rentamount in the bank account mentioned above. 2.In the event there is a change in my bank account, it would be intimated to USGI immediately failing which the payout will continue to happen in the old account and USGI will not be liable for the same. ( Payout to new account will happen after 15 days from receipt of this form at HO) 3.USGIC shall not make any payout either partially or wholly in the form of cash. 4.Service tax claimed (if any ) will be paid only on submission of original service tax invoice. 5.If the electronic credit is not effected, delayed or credited to a wrong account on account of incorrect or incomplete information provided, USGIC shall notbe held liable now or in future for such losses. 6.In the event the credit is not effected by your Banker for any reason, USGIC reserves the right to make the payment through cheque. Signature with stamp__________________________________________________ Name__________________________________________________ Instructions Attach a copy of your PAN and certificate of Service Tax registration Please attach a cancelled cheque of the bank account mentioned abovePLEASE SUBMIT THE FORM TO NEAREST BRANCH OFFICE OF USGI. For Admin use only PAN & Service Tax Number verified from the copies received YES / NO Self attested copy of PAN Card & ST Regn certificate is attachedYES / NO Authorised Signatory (ADMIN ) ___________________________________________________________ Universal Sompo General Insurance Company Limited INWARDSTAMP WITH DATE