Insurance Claim Benefit Disbursement Authorization Form
Policyholder Information
Full Name
Policy Number
Date of Birth
Contact Number
Email
Address
Claim Information
Claim Number
Date of Claim
Claim Description
Disbursement Authorization
Preferred Payment Method
Bank Transfer
Cheque
Other
Bank Name
Account Holder Name
Account Number
IFSC/Bank Code
Additional Instructions
Authorization & Declaration
Signature
Date