POLICY DETAILS :
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IC Name *
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Policy No *
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Health India ID No.
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Policy Holder Name *
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Mobile No.
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Email ID
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ECS DETAILS :
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Name of Account Holder *
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Account Number *
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IFSC Code*
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Name of Bank *
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Branch Name
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MICR Code
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Branch Address
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Type of Account *
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Submitted By *
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Upload Cancelled Cheque with duly filled and signed ECS Form*
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(Allow Only : *.jpg,*.jpeg,*.png,*.tiff,*.pdf)
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