Welcome to Bajaj Allianz Family

AHMEDABAD BRANCH-4th Floor, Turquoise,Nr. Panchvati

Policy issuing office and Correspondence address
Circle,C.G Road,Ellisbridge,Ahmedabad,Gujarat,INDIA,380006

Insured Name Ajay Jayantibhai Prajapati Policy number 12-9901-0000008571-03

Name: Ajay Jayantibhai Prajapati

Address:
Line1: AT PRAJAPATI VAS TOWER CHOWK
Line2: Bavla Ahmedabad
City: AHMEDABAD State: 24 - GUJARAT
Post Code: 382220
Customer ID: 132386052

Dear Ajay Jayantibhai Prajapati,

It is our privilege to welcome you to the Bajaj Allianz General Insurance family.

We thank you for choosing Bajaj Allianz for your Insurance needs. We are one of India's leading general insurance companies with iAAA
rating from ICRA for the last ten consecutive years indicating the company's high claims paying ability and fundamentally strong
position in the industry. Please be assured that you have made right choice by choosing us and we will stand by you in your hour of
need.

Please find enclosed the policy schedule. We wish to inform you that the policy issued is based on the information submitted in the
proposal form as well as the acceptance of the terms and conditions, and this will be verified at the time of filing of claim. Request you
to kindly go through the same once again and in case of any disagreement, discrepancy or clarifications – write to us at
[email protected] within 15 days of the letter date. For policy wordings containing detailed terms, conditions and exclusions
of your insurance coverage, you will receive a hard copy on your correspondence address.

Once again, we welcome you to the Bajaj Allianz family and look forward to a long association with you.

We assure you the best of our services and look forward to a continual patronage and association with you.

For & on the behalf

Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory

Signature Not Verified

Digitally signed by DS BAJAJ ALLIANZ GENERAL
INSURANCE COMPANY LIMITED 01
Date: 2021.12.10 23:52:12 IST

Bajaj Allianz General Insurance Co. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. Reg. No.: 113 CIN: U66010PN2000PLC015329

Give a Missed Call on 808094506 SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com www.bit.do/bjazgi

[email protected] Demystify Insurance http://support.bajajallianz.com

Transcript of Proposal for ([OG-21-2202-9901-00006943-03]
PERSONAL ACCIDENT INSURANCE
UIN : BAJHLIP21218V022021

Dear Ajay Jayantibhai Prajapati,

We wish to inform you that your contract will be based on the information and declaration given by you through telephonic conversation / email / web-
inputs / TAB /CSC Centers or other means which would be considered as the final proposal, the transcript of which is as follows:

You are requested to yourself reconfirm the same at your end. In case of any disagreement or objection or any changes with respect to information
mentioned below, we request you to please revert within a period of 15 days from the date of your receipt of this document. In case of our non-receipt
of your disagreement or objection or any changes [as mentioned hereinabove] with respect to information mentioned below, it shall be deemed that
you have positively confirmed to us the correctness of the below mentioned transcript and declaration. Where you disagree to any of
information/contents of this transcript, standard Terms or conditions, you have the option to return the original Policy stating the reasons for your
objection, and upon our receipt of original Policy together with your request to cancel the Policy, you shall be entitled to a refund of the premium paid,
subject only to there being no claim made under the Policy and also subject to a deduction of the expenses incurred by us and the stamp duty
charges.

Proposer Details
Proposer Name Ajay Jayantibhai Prajapati

Are you an Existing Bajaj Allianz Customer: Yes/No If Yes, please mention the policy No

Gender Male Date of Birth 05/12/1995

PAN No UID/Unique ID NA

Bajaj Allianz Employee Code, if Proposer is BAGIC/BALIC Employee

Marital Status Unknown No of children NA

Occupation Other Class 2

Address
Permanent/ Residential Address Correspondence Address
(All the communications will be sent to the below address)

Address Line 1 AT PRAJAPATI VAS TOWER CHOWK Address Line 1 At Prajapati Vas Tower Chowk

Address Line 2 Bavla Ahmedabad Address Line 2 Bavla Ahmedabad

Address Line 3 Address Line 3

City/District AHMEDABAD City/District Ahmedabad

State 24 - GUJARAT State Gujarat

Pin Code 382220 Pin Code 382220

Telephone 9999999999 Telephone 7874483337

Mobile 7874483337 Mobile 7874483337

Email [email protected] Email [email protected]

Educational Qualification NA

Family Monthly Income 25000

In case of any offer, you would prefer to be contacted by 9999999999,[email protected]

Nationality Indian

Details of the Persons to be Insured

Sr DOB Any Existing Total Monthly
Name Age Gender(M/F) Occupation Premium
No (dd/mm/yy) Disability/Infirmity Income
AJAY
1 JAYANTIBHAI 05/12/1995 26.0 Male Other Class 2 No 25000 885
PRAJAPATI

Plan Details
Sr Medical Expenses Hospital Confinement
Name of Insured Basic SI Wider SI Comprehensive SI
No (Yes/No) Allowance (Yes/No)
AJAY JAYANTIBHAI
1 300000 0 300000 0 0
PRAJAPATI
Transcript of Proposal for ([OG-21-2202-9901-00006943-03]
PERSONAL ACCIDENT INSURANCE
UIN : BAJHLIP21218V022021

Kindly note that as the information/contents and declarations/confirmations provided by you as contained in this transcript is the basis on which we are
issuing / have issued the Policy to you, we advise you to please ensure that you have provided/disclosed and or not withheld any material
facts/information and declarations, as Policy becomes Void ab-initio if material facts are not provided/disclosed and or withheld and in such case no
claim, if any, will be considered by us apart from forfeiture of the premium.

Disclaimer

A. EXCLUSIONS AND TERMS AND CONDITIONS:

The detailed list of exclusions, standard terms and conditions, including the exclusion of pre-existing ailments/diseases, were fully explained to you and
for full details thereof please refer to the Policy wordings:

Answer given by You: Yes, I/we have been explained in full the details of exclusions, standard terms and conditions including the exclusion of pre-
existing ailments/diseases and knowing the same I/we have opted and proposed for this Policy.

B. The contents of the proposal [transcript of proposal of you is this document] and connected documents have been fully explained to him and you
have fully understood the significance of the proposed contract basis which you have confirmed for policy issuance.

C. In case of Disagreement or objection or any changes with respect to information, declarations, Terms and Conditions, exclusions and contents
mentioned hereinabove, please contact our toll free number & register your objections / changes / disagreement to the contents of this transcript or you
may also send us email or written correspondence at the following details within a period of 15 days from date of your receipt of this transcript along
with Policy.

Declaration
1. I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by
me are true and complete in all respects to the best of my knowledge and that I am authorised to propose on behalf of these other persons.

2. I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of
the insurer and that the policy will come into force only after full payment of the premium chargeable.

3. I further declare that I will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the
proposal has been submitted but before communication of the risk acceptance by the company.

4. I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person
to be insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be
insured/proposer and seeking information from any insurer to whom an application for insurance on the person to be insured /proposer has been made
for the purpose of underwriting the proposal and/or claim settlement.

5. I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the sole purpose of
underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.

Prohibition of Rebates
SECTION 41 OF INSURANCE ACT, 1938

No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in
respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium
shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate except such rebate as may be allowed in
accordance with the published prospectuses or tables of the Insurer. Any person making default in complying with the provisions of this section shall
be punishable with a penalty, which may extend to Ten Lakh Rupees.

This transcript is authorized by you through OTP from your registered mobile no 9999999999 on

Contact our Policy servicing branch at: AHMEDABAD BRANCH-4th Floor, Turquoise,Nr. Panchvati Circle,C.G Road,Ellisbridge,Ahmedabad,
** This is print of electronic records maintained by us in accordance with law and hence does not require signature.
Transcript of Proposal for ([OG-21-2202-9901-00006943-03]
PERSONAL ACCIDENT INSURANCE
UIN : BAJHLIP21218V022021

Bajaj Allianz General Insurance Co.Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411006. Reg.No.:113 CIN:U66010PN2000PLC015329

Give a Missed Call on 8080945060, SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com www.bit.do/bjazgi

[email protected] Demystify Insurance http://support.bajajallianz.com

PERSONAL ACCIDENT INSURANCE POLICY - POLICY SCHEDULE
UIN : BAJHLIP21218V022021

Policy issuing office and Correspondence address

Proposer Details
Proposer Name Ajay Jayantibhai Prajapati

Proposer Address AT PRAJAPATI VAS TOWER CHOWK, BAVLA AHMEDABAD, AHMEDABAD-382220, GUJARAT, INDIA

Phone No 9999999999 Email ID [email protected]

Customer ID 132386052 Previous Policy No OG-21-2202-9901-00006943

Policy Details
Policy Number 12-9901-0000008571-03 Endorsement No

Policy Issued on 10/12/2021 Policy Status ACTIVE

Period of Insurance From 16/12/2021 00:00 Hrs To Expiry Date 15/12/2022

15/12/2022 Midnight

GSTIN / UIN Unregistered Place of Supply/State 24 - GUJARAT

Company GST No: 24AABCB5730G1Z3 Code/Name

Company PAN AABCB5730G Invoice No: SYS-21-000001522141

Insured Member Details

Nominee Name & First policy inception
Member Name Customer ID Gender Date of Birth Age Relation
Relation date
Ajay Jayantibhai 1. Jayantibhai -
132386052 Male 05/12/1995 26.0 Self 14/12/2018
Prajapati Father
Insured Address AT PRAJAPATI VAS TOWER CHOWK,BAVLA AHMEDABAD,AHMEDABAD,GUJARAT,382220

Cover Details
Hospital
Compreh Confinement
Basic Basic Wider Wider Comprehen Medical
Member Name Occupation Premium ensive Allowance Per
SI CB% SI CB% sive SI Expense
CB% Day For 30
Days
Ajay Jayantibhai
Other Class 2 885 0 0% 0 0% 300000 30% Yes 0
Prajapati
Note: Basic :- Death Only
Wider :- Death + Permanent Disablement(PTD) +Permanent Partial Disablement(PPD)
Comprehensive :- Death + PTD + PPD + Temporary Disablement

Premium Details
Description Amount(INR) Description Amount(INR)

Base Premium 750 Family Discount 0

Gross Premium: Eight Hundred Eighty-Six Rupees Net Premium 750
State GST(9%) 68
Central GST(9%) 68

IGST 0

UTGST 0

CESS

Gross Premium 886

"As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th September of the next
financial year E. & O.E"

"In case no GSTIN or incorrect GSTIN is provided by the Proposer at Proposal stage, Bajaj Allianz General Insurance Company Ltd shall not be
responsible for any Input Tax Credit losses and no subsequent revision of invoice will be undertaken."
 PERSONAL ACCIDENT INSURANCE POLICY - POLICY SCHEDULE
UIN : BAJHLIP21218V022021

Exclusions
Member Name Exclusion

Ajay Jayantibhai
NA
Prajapati

ANY CLAIM AS A RESULT OF DISEASE OR CONDITIONS CONTRACTED DURING THE BREAK PERIOD
Special Exclusion at Policy STANDS EXCLUDED.
Level

Loan Details NA

Assignment Details NA

Type of Assignment NA

Assignment Wordings NA

Additional Remarks NA
Receipt Number: 54-21-000000282024 Date: 10/12/2021 Premium Payer ID: 132386052 Float: NA;
Premium Payment Details Payment Frequency: Single Premium ** If Premium paid through Cheque, the Policy is void ab-initio in
case of dishonour of Cheque
Financial Institution Ref. No. NA

AGENCY CODE 10074906 CONTACT NO 9712941922

AGENCY NAME Jagatsinh Anduji Chavda EMAIL ID [email protected]

For & on the behalf

Bajaj Allianz General Insurance Company Ltd.
Consolidated Stamp Duty of Rs. .5/- paid towards paid towards Insurance Premium
Stamps Vide Challan No. MH001915407201819M defaced number
0001369763201819/order no.CSD/45/2018/2156/18 dated 08-JUN-18 timing 17:49:13 of
Stamp Duty General Stamp of India.

Rs..5/-
This document is digitally signed,hence counter signature / stamp is not required
Principal Location : Bajaj Allianz House,Airport Road,Yerwada,Pune- 411006 PH-66026666
| Services Accounting Code : 997133 Accident and health insurance services. No reverse
Authorized Signatory charge is payable on these services.

SUB 10074906 / NA

Signature Not Verified

Digitally signed by DS BAJAJ
ALLIANZ GENERAL INSURANCE
COMPANY LIMITED 01
Date: 2021.12.10 23:52:12 IST
 PERSONAL ACCIDENT INSURANCE POLICY - POLICY SCHEDULE
UIN : BAJHLIP21218V022021

Policy Verification Claim Registration

Bajaj Allianz General Insurance Co. Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. Reg. No.: 113 CIN: U66010PN2000PLC015329

Give a Missed Call on 8080945060 ,SMS'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com www.bit.do/bjazgi

[email protected] Demystify Insurance http://support.bajajallianz.com

RECEIPT

AHMEDABAD BRANCH-4th Floor, Turquoise,Nr. Panchvati

Policy issuing office and Correspondence address
Circle,C.G Road,Ellisbridge,Ahmedabad,Gujarat,INDIA,380006

Proposer Name Ajay Jayantibhai Prajapati Policy Number 12-9901-0000008571-03

Receipt Number 54-21-000000282024 Receipt Date 10/12/2021

Business Channel PARTNERPORTAL

Received with thanks from: Ajay Jayantibhai Prajapati

Customer ID: 132386052 a total sum of Rupees Eight Hundred Eighty-Six Rupees Only by,

Instrument Type Instrument No Instrument Date Bank Name Branch Name Amount (Rs.)

Online Payment 91152404 10-Dec-2021 BN00000144 BN00000144 886.00

Total Amount: 886

Note: Issuance of this receipt does not amount of acceptance of the risk by Bajaj Allianz General Insurance Company Limited. The insurance cover for
the risk shall be as per the terms and conditions of the Insurance Policy if and when issued.
*Cheque/DD/PO receipt is valid subject to realisation of the instrument

For & on the behalf

Bajaj Allianz General Insurance Company Ltd.
Signature Not Verified
Digitally signed by DS BAJAJ ALLIANZ GENERAL
INSURANCE COMPANY LIMITED 01
Date: 2021.12.10 23:52:14 IST

Authorized Signatory

Bajaj Allianz General Insurance Co.Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411006. Reg.No.:113 CIN:U66010PN2000PLC015329

Give a Missed Call on 8080945060, SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com www.bit.do/bjazgi

[email protected] Demystify Insurance http://support.bajajallianz.com

TAX INVOICE
(Customer Copy)

Invoice Number SYS-21-000001522141 Customer ID 132386052

Invoice Date 10/12/2021 Policy No. 12-9901-0000008571-03

Recipient/ Details of Insured Supplier/ Details of Insurer

GSTIN Unregistered GSTIN 24AABCB5730G1Z3

PAN NA PAN AABCB5730G

Name (Proposer) Ajay Jayantibhai Prajapati Name Bajaj Allianz General Insurance Company Ltd.

Address-1 At Prajapati Vas Tower Chowk Address-1 4th Floor, Turquoise

Address-2 Bavla Ahmedabad Address-2 Nr. Panchvati Circle

Address-3 Address-3 C.G Road,Ellisbridge

Pin Code 382220 Pin Code 380006

City AHMEDABAD City AHMEDABAD

State GUJARAT State GUJARAT

Client Category NON HNI Place of Supply 24 - GUJARAT

Premium
Description Amount(INR) Description Amount(INR)

Net Premium 750 State GST(9%) 68

Receipt Number: 54-21-000000282024 Date: 10/12/2021
Central GST(9%) 68
Premium Payer ID: 132386052 Float: NA; ** If Premium paid
through Cheque, the Policy is void ab-initio in case of dishonour of 0
IGST(18%)
Cheque
Gross Premium 886

Total Invoice Value (In figures) : 886

Total Invoice Value (In Words) : Eight Hundred Eighty-Six Rupees
Amount of Tax Subject to Reverse Charge: No reverse charge is payable on these services.

Services Accounting Code: 997133 Accident and health insurance services.

Principal Location: Bajaj Allianz House, Airport Road, Yerwada, Pune- 411006 PH-66026666

For & on the behalf

Bajaj Allianz General Insurance Company Ltd.

Signature Not Verified

Digitally signed by DS BAJAJ ALLIANZ GENERAL
INSURANCE COMPANY LIMITED 01
Date: 2021.12.10 23:52:14 IST

Authorized Signatory

Important Notes:
* The invoice is issued as per Section 31 of the CGST Act
* In case no GSTIN or incorrect GSTIN is provided by the Proposer at Proposal stage, Bajaj Allianz General Insurance Company Ltd shall not be
responsible for any Input Tax Credit losses and no subsequent revision of invoice will be undertaken
* As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th September of the next
financial year E. & O.E

This is a digitally signed document and hence no physical signature is required

Bajaj Allianz General Insurance Co. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411006. Reg.No.:113 CIN:U66010PN2000PLC015329

Give a Missed Call on 8080945060, SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com www.bit.do/bjazgi

[email protected] Demystify Insurance http://support.bajajallianz.com