WIC/LD/CLAIMS/012

Payment Advice Form

(to be attached along with discharge form)
Name of Policy Holder/ Life Assured/ Claimant:

_______________________________

Policy No.:

_______________________________

How do you wish the payment to be effected?

Cheque

Demand Draft Transfer to your bank account

(Bank Charges might be applicable for Bank transfer or Demand Draft)

In case of bank transfer, please provide the following:Bank Account Details:Name of the bank
Account Number
Currency of bank account
Name of account holder
Address of the bank
BIC Number
Bank sort code
IBAN number
Routing code/Swift code
I declare and state that the Company shall not be responsible for non credit of my bank account for
any reason whatsoever or if the credit is delayed. I also understand and agree that the Company
reserves the right to use any alternative payout option including a demand draft or cheque in spite of
my opting for the electronic payout method.
I understand and agree that the submission of this form does not mean or amount to the acceptance of
the claim by the company. I further understand and agree that this form will be valid only in the event
of the acceptance of the claim by the Company in my favour.
Dated at ______________________this ___________day of ____________ ____________
(City/Country)
(date)
(month)
(year)
____________________________________
Name of Policy Holder/ Life Assured/ Claimant
Verified by:
Full Name: _________________________
Address

: __________________________
__________________________

_________________________________________
Signature of Policy Holder/ Life Assured/ Claimant