ICICI Lombard General Insurance Company Ltd

PAY­IN­SLIP 1209242730 PAY­IN­SLIP 1209242730

Date to be filled Manually Bank ­ ICICI Bank / Axis Bank Date to be filled Manually

Date Deposited in Branch : Deposited in

: ______________ Date :
Branch:_____________
Naming as appearing in Name as appearing in
Account______________________________ Account:__________________________________________________________
Bank ­ ICICI Bank / Axis Bank A/C to be credited to : 000405070142
A/C to be credited to : 000405070142
Intermediary Id 201722081865 Payment Id 1209242730
Intermediary Id 201722081865 Payment Id 1209242730 RISHABH
Intermediary Name Payin Slip Date 10/06/2024
Intermediary RISHABH Payin slip TRACTORS
10/06/2024
Name TRACTORS date Subagent Name
Subagent Name Payment Mode Cheque No of cases 2
Payment Mode Cheque No of cases 2 Cheque/DD Date 19/04/2024 Cust Code NYSA
Cheque/DD date 19/04/2024 Cust code NYSA
TEL. MOBILE
BANK &
CHEQUE NO. Rs. Ps. NO. NO.
BRANCH
State Bank Of 963436 21263
BANK & BRANCH CHEQUE NO. DENO. PIECES Rs. Ps.
India,S10083250
State Bank Of
963436 1000x 21263
India,S10083250
500x
100x
50x
20x
10x
TOTAL 21263 5x
TOTAL AMOUNT RUPEES (in words) Rupees Rs. Ps.
OFFICER Twenty One Thousand Two Hundred Sixty Three COINS
Only
CHEQUE(S) SUBJECT TO TOTAL 21263
REALISATION FOR OFFICE USE
TRAN. ID.
Policy Details
OFFICER VERIFYING OFFICER
PROPOSAL CUSTOMER TOTAL Note : Please use seperate pay­in­slip for CASH DEPOSIT, SIGNATURE OF
SR.NO. PRODUCT
NO. NAME PREMIUM LOCAL, OUTSTATION & ICICI BANK CHEQUES DEPOSITOR
SHOBHA
1 3132644681 3008 10253 This is not payment receipt but only a proof of the payment recieved by the bank.
DEVI
Policy issuance is subject to underwriting norms.Cash deposit towards premium
2 3176042294 3008 KRIPA DEVI 11009 cannot exceed Rs.49,999/­. cash deposit is available only for motor products.

Policy Details
SR.NO. PROPOSAL NO. PRODUCT CUSTOMER NAME TOTAL PREMIUM
1 3132644681 3008 SHOBHA DEVI 10253
2 3176042294 3008 KRIPA DEVI 11009