AIC OF INDIA LTD.

Untitled Document

Grievance Received Date *

Reference Number*

Mode of Receipt/Source *

Select Language

Complainant Details

Channel/Grievance Against*

Farmer ID

Farmer Name *

Gender

Complainant Name

Middel Name

Last Name

Date of Birth

Address Line 1

Address Line 2

Address Line 3

State *

District *

City/Village

Post Office

Police Station

Pin Code

Mobile Number *

Alternate Contact Number

Email ID

Identity Document Type

Identity Document Number

Farmer Type

Product Detail

State *

Year *

Season *

Product/ Scheme *

District *

Level 4

Level 5

Level 6

Level 7

Policy/ Cover Note Number *

Crop Name

Policy Status

Sum Insured (Rs.)

Premium (Rs.)

Claim No.

Claim Amount Approved (Rs.)

Claim Amount Paid (Rs.)

Claim Status

Cause of Loss

Claim Intimation Date

Claim intimated By

Bank Detail

IFS Code

Branch Name

Bank Name

Bank Account Type

Bank Account Number

IGMS

Kindly enter either Receipt Number or BOC Collection Number or Cheque Number!

User Type *

Officer Designation

Officer Name

Addressed To Insurer

Insurance Type ID *

Policy Type ID *

Complaint Type ID(Grievance Type) *

Complaint Type Description (Grievance Sub-type)*

BOC Or Collection Number

Branch Code

Broker License Number

Certificate Number

Cheque Number

Claim CLSR Additional Info

Claim Payment Cheque Date

Claim Payment Cheque Number

Claim Payment Date

Designation

FAX Number

Intermediary License Number

Intermediary Name

Is Complainant Informed

Organization Name

Original IRDA Token Num

Other Ref Number

Other CLSR Additional Info

Premium Payment Ref Number

Receipt Number

Telephone Number

Remarks

Identifier Type*

Is Senior Citizen

Date Of Honoring Service

Policy Holder Or Claimant Name

Request IRDAI For Closure

Type Of Disposal

Insurer Complaint Desc Type ID

Escalated Date

Date Of Honoring Service

Policy Holder Or Claimant Name

Escalated Remark

Final Resolution Remark

Insurer Policy Number

Insurer Policy Type ID

Is Complaint Change By Insurer

Resolution Feedback Remarks

Resolution Satisfacton Level

TAT Crossed Remarks

Final Resolution Date

Grievance Description *

Online File Upload

Document Type

Farmer ID

Insured Name

Father Name

Mobile Number

Policy Status

Policy From Date

Policy To Date

Product / Scheme

Season

Year

State

District

Crop Code

Crop Name

Application Number

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