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eIA Service Request Form Guide

This document is an e-Insurance Account service request form for making changes to an existing account. The form requests information like the account holder's name, eIA number, and details related to a requested change in address, bank details, or authorized representative. Fields marked with an asterisk are mandatory to fill. The applicant needs to submit original or attested copies of identity documents and provide a signature and date. An acknowledgement slip will be issued confirming receipt of the application for the requested change.

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148 views1 page

eIA Service Request Form Guide

This document is an e-Insurance Account service request form for making changes to an existing account. The form requests information like the account holder's name, eIA number, and details related to a requested change in address, bank details, or authorized representative. Fields marked with an asterisk are mandatory to fill. The applicant needs to submit original or attested copies of identity documents and provide a signature and date. An acknowledgement slip will be issued confirming receipt of the application for the requested change.

Uploaded by

msn_test
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

e-Insurance Account (eIA)- Service Request

ormfill the form in Black ink and in CAPITAL letters only. Fields marked with asterisk (*) are compulsory
Please
eIA No.
Name
Original/Attested True copies verified OK Not OK Date D D/ MM /Y Y Y Y

Change in Address Correspondence Address Permanent Address

Landmark State*
City* PIN Code*
Country*

Permanent Address same as Correspondence Address

Change in Bank Details


Account Type* Savings A/c Current A/c
Account No.*
Bank Name*
Branch Name
Branch City* IFSC Code
MICR Code (11character code appearing on your cheque leaf)
Original Cancelled cheque Leaf given Yes No

Change in Authorized Representative


First Name *
Middle Name
Last Name *

Gender* Male Female Others Date of Birth* D D / M M /Y Y Y Y


Address* Same as Correspondence Address of eIA Applicant
Correspondence
Address*
Landmark State*
City* PIN Code*
Country*
Relationship with Applicant*
Contact Details Phone No. S T D N U M B E R Mobile No.* N U M B E R

Email ID*
Alternate Email ID
Place

Date D D / MM /Y Y Y Y Signature

Acknowledgement Slip

eIA No.
This is to acknowledge the receipt of application from Mr. / Ms. for change in

Contact Address Change in Bank Details Change in Authorised Representative

Place
AP Seal &
Date D D / M M /Y Y Y Y Signature
CAMS Repository Services Limited
Rayala Towers, 1st Floor, 158 Anna Salai, Chennai- 600 002

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