Third Party Declaration

Application/Policy No.- ___________________

Payer Name :____________________________________________________________
Address: ___________________________________________________________________________
___________________________________________________________________________________
I am issuing cheque /demand draft no._________________ dated _____________________drawn on
bank for an amount of Rs. _____________ (Rupees _________________________________________
only) for Health Insurance policy/application submitted wherein the proposer is
Mr./Ms._______________________________________________________________
Kindly note the above mentioned proposer /insured
Mr/Ms._______________________________________ is
my/our__________________________________(mention relationship)
I am paying on behalf of Mr./Ms.___________________________________________________due to
reason ___________________________________________. Further, I understand that the
proposer & Insured of this policy shall be not be eligible for Income Tax benefit u/s
80D under this policy.
I hereby declare that the information given by me above is true & correct. Request you to
accept the remittance

Date : dd/mm/yyyy

______________

Place:
payer )

(Signature of

Declaration By Proposer/Insured
I ______________________hereby confirm that Mr./Ms. _____________________________________
Is paying on my behalf for above application no./policy no. I further confirm that all
information given above is true & correct

Date : dd/mm/yyyy

______________

Place:
proposer/insured)

(Signature of

Version No. 1.1 Date 23rd July 2014