GICHF

Application for Empanelment

Personal Detail

First Name / Company Name *

Please enter Applicant First Name

Last Name / Company Name *

Please enter Applicant Last Name

Regd. Address *

Please enter Regd. Address

Preferred GICHF Branch *

Please select GICHF branch

PAN Number *

PAN Number required Minimum 10 characters required.

Company Name *

Company Name required

Status of Entity *

Please select Status of Entity

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 *

Please select Liability of Owners / Directors

No. of Staff *

Staff (Cadre wise) required

Email Id *

Please enter your Email Enter a valid Email

Mobile No. *

Please enter your Mobile Number Enter Valid Mobile Number

Past Working Experience *

Please select Past Working Experience

Company Name(s) *

Product Name *

Other Product Name *

Current Monthly Disbursement *
(Rs. Cr.)

Remarks

Vendor's Data Sheet

Aadhar Card No. *

Please enter your Aadhar Card No. Minimum 12 characters required.

Service Tax Registration No.

Are you a registered GST vendor? *

Please select GST Available

GST No.

Date of Registration / Establishment *

Please select Date of Registration.

Whether the Company is registered under MSME
(Micro/Small/Medium Enterprises) *

Please select Whether the Company is registered under under MSME

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. *

Please select your firm is holding agency with any one...

Name of Company *

Agent Code *

Bank Details for NEFT/RTGS

Bank Name *

Bank Name required

Name of Account Holder * (as appearing on cheque leaf)

Pleaes enter Name of Account Holder

PAN card number of Bank A/C Holder *

Please enter PAN card number of Bank A/C Holder Minimum 10 characters required.

Complete Bank Account No. * (as appearing on cheque leaf)

Please enter Bank Account No.

Type of Bank Account *

Please select Bank Account Type

Bank Branch address *

(as appearing on cheque leaf) Please enter Bank Branch Address

Bank IFSC Code *

Required IFSC Code Minimum 11 characters required.

Bank MICR Code

Upload Documents (Please upload only .PDF, .JPG, .PNG, .JPEG files)

Passport Photo *

Please upload Passport Photo

Aadhar Card *
(Photo, Address and Aadhar no. clearly visible)

Please upload Aadhar Card image Please select a valid image file.

PAN Card (Only front view) *

Please upload PAN Card image

Cancelled Cheque *
(Account no, IFSC and MICR code clearly visible)

Please upload Cancelled Cheque image

Empanelment Agreement

Model Code of Conduct

Vendor Data Sheet

Payout Structure

Preferred date of personal disucssion *

Please select Preferred date of personal disucssion.