DISBURSAL REQUEST FORM
To be filled in by customer
Name of the Applicant : Application form number :
LAN :
TYPE OF DISBURSEMENT REQUEST
a. Disbursement b. Revalidation/Re-issuance of disbursement cheque
] First Disbursement ] Expiry of disbursement cheque validity
] Disbursement cheque issued with incorrect favoring
] Subsequent Disbursement
] Disbursement cheque required with new favoring
] Disbursement cheque Lost / Misplaced
FAVOURING & PAYMENT MODE DETAILS:
Sr. Payment Mode (FT/NEFT/
Amount Favouring Bank Account MICR
No Cheque/DD/RTGS)
ICICI Prudential
ICICI Lombard
Total
Other Details: Due date of PreEMI/EMI payment :
Disbursal requested date : __________________ 1st of Every Month 5th of Every Month
Deduction confirmation: I authorise ICICI bank to adjust following from disbursement amount
a. Processing fee: Rs. __________________
b. CIBIL Rs. __________________
c. CERSAI Rs. __________________
d. Administrative Charges Rs. __________________
e. Any other dues (Please specify) __________________ Rs. __________________
Date
Customer Signature
To be filled in by ICICI Bank representative
The following documents have been collected from : Name of the Applicant:
Application form number : LAN:
Loan documents (Facility agreement, Disbursement booklet, Terms and coditions) Property documents as per the P & D
Acknowledged Sanction Letter OCRs NOC as applicable
Special conditions on sanction letter, if any
Name of DMA / Sales Executive : Signature of DMA/Sales Executive :
Name & Emp ID of Marketing officer: Date
In case of any queries /Clarifications we shall get back to you within 2 working days
In case you want to get in touch with us, you can speak with ____________________ at the following Phone Nos : _____________________
*With ICICI Bank iMobile Application discover quick, simple and convenient way to access you Loan Account anytime, anywhere
You can also initiate the Subsequent disbursement request through i-Mobile Application
DISBURSEMENT REQUEST :
] Click on Loan Account No.
] Click on Disbursement Request under more options
] Initiate new request, fill details & upload demand letter
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