Application for Empanelment
Personal Detail
First Name / Company Name
*
Last Name / Company Name
*
Regd. Address
*
Preferred GICHF Branch
*
Select
Ahmedabad
Bangalore
Barasat
Bhubaneshwar
Boisar
Borivali
Chandanagar
Chandigarh
Chennai
Chinchwad
Coimbatore
Dehradun
Delhi
Diamond-Harbour
Durgapur
Dwarka
Electronic City
Garia
Ghaziabad
Greater Noida
Gurgaon
Guwahati
Hadapsar
Head Office
Hinjewadi
Hubli
Hyderabad
Indore
Jaipur
Jodhpur
Kalyan
Kengeri
Kochi
Kolhapur
Kolkata
Kozhikode
LB Nagar
Lucknow
LUCKNOW - STRESS ASSET DIVISION
Ludhiana
Madurai
Malout
Mangalore
MARGAO
Meerut
Mumbai
Nagpur
Nashik
Navi Mumbai
Nellore
Nere Panvel
Noida
OnlineBranch
Panaji
Panvel
Patiala
Patna
Pitampura
Porur
Pune
Raipur
Siliguri
Suchitra
Surat
Tambaram
Thane
Thrissur
Trichy
Trivandrum
Vadodara
Varanasi
Vasai
Vijayawada
Virar
Vizag
White field
Yelahanka
PAN Number
*
Company Name
*
Status of Entity
*
Select
Proprietorship
Partnership
Pvt. Ltd Co.
LLP
1) Name of Partner/Director
*
PAN/Din Card No.
*
2) Name of Partner/Director
*
PAN/Din Card No.
*
3) Name of Partner/Director
PAN/Din Card No.
4) Name of Partner/Director
PAN/Din Card No.
5) Name of Partner/Director
PAN/Din Card No.
Liability of Owners / Directors
*
Select
Limited
Unlimited
NA
No. of Staff
*
Email Id
*
Mobile No.
*
Past Working Experience
*
Select
YES
NO
Company Name(s)
*
Product Name
*
Select
Home Loan
Personal Loan
Others
Other Product Name
*
Current Monthly Disbursement
*
(Rs. Cr.)
Remarks
Vendor's Data Sheet
Aadhar Card No.
*
Service Tax Registration No.
Are you a registered GST vendor?
*
Select
YES
NO
GST No.
Date of Registration / Establishment
*
Whether the Company is registered under MSME
(Micro/Small/Medium Enterprises)
*
Select
YES
NO
Have you or your firm is holding agency with any one of
our provider Company namely New India Assurance Ltd.,
United India Insurance Co. Ltd.,
Oriental Insurance Company Ltd.,
National Insurance Company Ltd.
*
Select
YES
NO
Name of Company
*
Select
New India Assurance Ltd.
United India Insurance Co. Ltd.
Oriental Insurance Company Ltd.
National Insurance Company Ltd.
Agent Code
*
Bank Details for NEFT/RTGS
Bank Name
*
Name of Account Holder
*
(as appearing on cheque leaf)
PAN card number of Bank A/C Holder
*
Complete Bank Account No.
*
(as appearing on cheque leaf)
Type of Bank Account
*
Select
Saving
Current
Bank Branch address
*
(as appearing on cheque leaf)
Bank IFSC Code
*
Bank MICR Code
Upload Documents
(Please upload only .PDF, .JPG, .PNG, .JPEG files)
Passport Photo
*
Aadhar Card
*
(Photo, Address and Aadhar no. clearly visible)
PAN Card (Only front view)
*
Cancelled Cheque
*
(Account no, IFSC and MICR code clearly visible)
Empanelment Agreement
Model Code of Conduct
Vendor Data Sheet
Payout Structure
Preferred date of personal disucssion
*
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