Welcome to Bajaj Allianz Family

JALGAON-2nd Floor,,Panna Heights,,Opp. Omkareshwar Mandir

Policy issuing office and Correspondence address
Jay Nagar,Jalgaon,Maharashtra,INDIA,425001

Insured Name Yatin Babulal Pahade Policy number 12-8451-0000088227-02

Name: Yatin Babulal Pahade

Address:
Line1: At Post Mumbai Galli Amalner Tal Amalner
Line2:
City: JALGAON State: 27 - MAHARASHTRA
Post Code: 425401
Customer ID: 183415239

Dear Yatin Babulal Pahade,

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
bagichelp@bajajallianz.co.in 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: 2022.05.16 16:09:05 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

bagichelp@bajajallianz.co.in Demystify Insurance http://support.bajajallianz.com

Transcript of Proposal for ([OG-22-2002-8451-00000006-02] HEALTH
GUARD-FLOATER)
UIN : BAJHLIP21227V042021
Dear Yatin Babulal Pahade,
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 Yatin Babulal Pahade

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

Gender Male Date of Birth 17/06/1980

PAN No UID/Unique ID NA

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

Marital Status No of children 2

Occupation Persons engaged in administrative functions

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

Address Line 1 At Post Mumbai Galli Amalner Tal Amalner Address Line 1 At Post Mumbai Galli Amalner Tal Amalner

Address Line 2 Address Line 2

Address Line 3 Address Line 3

City/District JALGAON City/District Jalgaon

State 27 - MAHARASHTRA State Maharashtra

Pin Code 425401 Pin Code 425401

Telephone 9923121548 Telephone 9999999999

Mobile 9923121548 Mobile 9999999999

Email rahul.pahade@gmail.com Email rahul.pahade@gmail.com

Educational Qualification NA

Family Monthly Income 40000

In case of any offer, you would prefer to be contacted by 9923121548,rahul.pahade@gmail.com

Nationality Indian

Policy Period 1 Year

Plan Floater

Sum Insured Options

a) Health Guard Individual Sum insured NA

b) Health Guard Family Floater Sum Insured 500000

Transcript of Proposal for ([OG-22-2002-8451-00000006-02] HEALTH
GUARD-FLOATER)
UIN : BAJHLIP21227V042021
Premium Payment Zone:
There are three Zones for Premium Payment-
Zone A
Delhi/NCR, Mumbai including (Navi Mumbai, Thane and Kalyan), Hyderabad and Secunderabad, Kolkata, Ahmedabad, Vadodara and
No Co-Payment
Zone B
Rest of India apart from Zone A & Zone C
* 15% Co-Payment Applicable if treatment availed in Zone A locations
Zone C
Goa, Chhattisgarh, Punjab, Chandigarh, Jammu & Kashmir, Jharkhand, Arunachal Pradesh, Bihar, Himachal Pradesh, Nagaland, Odisha,
Sikkim, Tripura, Uttarakhand, Manipur, Meghalaya, Mizoram, Andaman & Nicobar islands
*20% & 5% Co-Payment Applicable if treatment availed in Zone A and Zone B locations respectively
Note:-
Policyholder residing in Zone B and Zone C can choose to pay premium of Zone A and avail treatment all over India without any
co-payment.
Policyholders paying Zone A premium rates can avail treatment allover India without any co-payment.
But, those, who pay zone B premium rates and avail treatment in zone A city will have to pay 15% co-payment on admissible claim
amount.This Co - payment will not be applicable for Accidental Hospitalization cases."
Policyholder residing in Zone B can choose to pay premium for zone A and avail treatment all over India without any co-payment.
Co pay Discount:
Note:If opted voluntarily by the Insured then Insured will be eligible of additional 10% or 20% discount respectively on the policy
premium.In case of a claim has been admitted under In-Patient Hospitalization Treatment then, the insured person shall bear 10% or
20% respectively of the eligible claim amount payable under this cover.

Details of the Persons to be Insured

Nominee
Relationship Date of Birth Gender
Member Details Age Height Weight Nominee Relationship
with Proposer (DD/MM/YY) (M/F)
with Insured
1. Sneha Yatin
Yatin Babulal Pahade Self 17/06/1980 41 - - Male 1. Spouse
Pahade
1. Yatin
Sneha Yatin Pahade Spouse 29/04/1985 37 - - Female 1. Spouse
Pahade
1. Yatin
Niti Yatin Pahade Jain Daughter 12/12/2012 9 - - Female 1. Father
Pahade
1. Yatin
Reeti Yatin Pahade Jain Daughter 20/03/2014 8 - - Female 1. Father
Pahade
Sum Insured 500000

Add on Cover
Name of Add-On/Rider UIN Opted(Yes/No)

Non-Medical Expenses Cover BAJHLAP21586V012021 No

Waiver of Room Capping BAJHLA21577V012021 No

Health Prime Rider BAJHLIA22169V012122 No

Member Name Health Questionnaire Yes/No Details

Yatin Babulal Pahade Has any of the persons to be insured suffer from/or No NA
investigated for any of the following?Disorder of the heart,
or circulatory system, chest pain, high blood pressure,
stroke, asthma any respiratory conditions, cancer tumor
lump of any kind, diabetes, hepatitis, disorder of urinary
tract or kidneys, blood disorder, any mental or psychiatric
conditions, any disease of brain or nervous system, fits
(epilepsy) slipped disc, backache, any congenital/ birth
defects/ urinary diseases, AIDS or positive HIV, If yes,
indicate in the table given below.If yes please provide
details
Yatin Babulal Pahade Do you or any of the family members to be covered No NA
have/had any health complaints/met with any accident in
the past 4 years and prior to 4 years and have been taking
treatment, regular medication (self/ prescribed)or planned
for any treatment / surgery / hospitalization?
Yatin Babulal Pahade Do you smoke cigarettes or consume tobacco (chewing No NA
paste) / alcohol, nicotine or marijuana in any form? Please
give duration and daily consumption
Transcript of Proposal for ([OG-22-2002-8451-00000006-02] HEALTH
GUARD-FLOATER)
UIN : BAJHLIP21227V042021

Member Name Health Questionnaire Yes/No Details

Yatin Babulal Pahade Have you or any of your immediate family members (father, No NA
mother, brother, or sister) have/had cancer, heart attack, or
stroke and at what age? Prior to age 60?
Yatin Babulal Pahade Has any proposal for life, critical illness or health related No NA
insurance on your life or lives ever been postponed,
declined or accepted on special terms? If yes, give details
Yatin Babulal Pahade Are you vaccinated against Covid 19? (If yes, Give NA NA
Vaccination Details.)
Yatin Babulal Pahade Have you or any of the persons proposed to be insured NA NA
were/are detected as Covid positive (If Yes, Give Date of
Detection and Treatment Details.)
Sneha Yatin Pahade Has any of the persons to be insured suffer from/or No NA
investigated for any of the following?Disorder of the heart,
or circulatory system, chest pain, high blood pressure,
stroke, asthma any respiratory conditions, cancer tumor
lump of any kind, diabetes, hepatitis, disorder of urinary
tract or kidneys, blood disorder, any mental or psychiatric
conditions, any disease of brain or nervous system, fits
(epilepsy) slipped disc, backache, any congenital/ birth
defects/ urinary diseases, AIDS or positive HIV, If yes,
indicate in the table given below.If yes please provide
details
Sneha Yatin Pahade Do you or any of the family members to be covered No NA
have/had any health complaints/met with any accident in
the past 4 years and prior to 4 years and have been taking
treatment, regular medication (self/ prescribed)or planned
for any treatment / surgery / hospitalization?
Sneha Yatin Pahade Do you smoke cigarettes or consume tobacco (chewing No NA
paste) / alcohol, nicotine or marijuana in any form? Please
give duration and daily consumption
Sneha Yatin Pahade Have you or any of your immediate family members (father, No NA
mother, brother, or sister) have/had cancer, heart attack, or
stroke and at what age? Prior to age 60?
Sneha Yatin Pahade Has any proposal for life, critical illness or health related No NA
insurance on your life or lives ever been postponed,
declined or accepted on special terms? If yes, give details
Sneha Yatin Pahade Are you vaccinated against Covid 19? (If yes, Give NA NA
Vaccination Details.)
Sneha Yatin Pahade Have you or any of the persons proposed to be insured NA NA
were/are detected as Covid positive (If Yes, Give Date of
Detection and Treatment Details.)
Niti Yatin Pahade Jain Has any of the persons to be insured suffer from/or No NA
investigated for any of the following?Disorder of the heart,
or circulatory system, chest pain, high blood pressure,
stroke, asthma any respiratory conditions, cancer tumor
lump of any kind, diabetes, hepatitis, disorder of urinary
tract or kidneys, blood disorder, any mental or psychiatric
conditions, any disease of brain or nervous system, fits
(epilepsy) slipped disc, backache, any congenital/ birth
defects/ urinary diseases, AIDS or positive HIV, If yes,
indicate in the table given below.If yes please provide
details
Niti Yatin Pahade Jain Do you or any of the family members to be covered No NA
have/had any health complaints/met with any accident in
the past 4 years and prior to 4 years and have been taking
treatment, regular medication (self/ prescribed)or planned
for any treatment / surgery / hospitalization?
Niti Yatin Pahade Jain Do you smoke cigarettes or consume tobacco (chewing No NA
paste) / alcohol, nicotine or marijuana in any form? Please
give duration and daily consumption
Niti Yatin Pahade Jain Have you or any of your immediate family members (father, No NA
mother, brother, or sister) have/had cancer, heart attack, or
stroke and at what age? Prior to age 60?
Niti Yatin Pahade Jain Has any proposal for life, critical illness or health related No NA
insurance on your life or lives ever been postponed,
declined or accepted on special terms? If yes, give details
Niti Yatin Pahade Jain Are you vaccinated against Covid 19? (If yes, Give NA NA
Vaccination Details.)
Niti Yatin Pahade Jain Have you or any of the persons proposed to be insured NA NA
were/are detected as Covid positive (If Yes, Give Date of
Detection and Treatment Details.)
Transcript of Proposal for ([OG-22-2002-8451-00000006-02] HEALTH
GUARD-FLOATER)
UIN : BAJHLIP21227V042021

Member Name Health Questionnaire Yes/No Details

Reeti Yatin Pahade Has any of the persons to be insured suffer from/or No NA
Jain investigated for any of the following?Disorder of the heart,
or circulatory system, chest pain, high blood pressure,
stroke, asthma any respiratory conditions, cancer tumor
lump of any kind, diabetes, hepatitis, disorder of urinary
tract or kidneys, blood disorder, any mental or psychiatric
conditions, any disease of brain or nervous system, fits
(epilepsy) slipped disc, backache, any congenital/ birth
defects/ urinary diseases, AIDS or positive HIV, If yes,
indicate in the table given below.If yes please provide
details
Reeti Yatin Pahade Do you or any of the family members to be covered No NA
Jain have/had any health complaints/met with any accident in
the past 4 years and prior to 4 years and have been taking
treatment, regular medication (self/ prescribed)or planned
for any treatment / surgery / hospitalization?
Reeti Yatin Pahade Do you smoke cigarettes or consume tobacco (chewing No NA
Jain paste) / alcohol, nicotine or marijuana in any form? Please
give duration and daily consumption
Reeti Yatin Pahade Have you or any of your immediate family members (father, No NA
Jain mother, brother, or sister) have/had cancer, heart attack, or
stroke and at what age? Prior to age 60?
Reeti Yatin Pahade Has any proposal for life, critical illness or health related No NA
Jain insurance on your life or lives ever been postponed,
declined or accepted on special terms? If yes, give details
Reeti Yatin Pahade Are you vaccinated against Covid 19? (If yes, Give NA NA
Jain Vaccination Details.)
Reeti Yatin Pahade Have you or any of the persons proposed to be insured NA NA
Jain were/are detected as Covid positive (If Yes, Give Date of
Detection and Treatment Details.)

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.
Transcript of Proposal for ([OG-22-2002-8451-00000006-02] HEALTH
GUARD-FLOATER)
UIN : BAJHLIP21227V042021
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 9923121548 on

Contact our Policy servicing branch at: JALGAON-2nd Floor,,Panna Heights,,Opp. Omkareshwar Mandir Jay Nagar,Jalgaon,Maharashtra,
** This is print of electronic records maintained by us in accordance with law and hence does not require signature.

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

bagichelp@bajajallianz.co.in Demystify Insurance http://support.bajajallianz.com

HEALTH GUARD-FLOATER- POLICY SCHEDULE
UIN : BAJHLIP21227V042021

JALGAON-2nd Floor,,Panna Heights,,Opp. Omkareshwar Mandir Jay

Policy issuing office and Correspondence address Nagar,Jalgaon,Maharashtra,INDIA,425001

Proposer Details
Proposer Name Yatin Babulal Pahade

Proposer Address AT POST MUMBAI GALLI AMALNER TAL AMALNER, JALGAON-425401, MAHARASHTRA, INDIA

Phone No 9923121548 Email ID rahul.pahade@gmail.com

Customer ID 183415239 Previous Policy No OG-22-2002-8451-00000006

Policy Details
Policy Number 12-8451-0000088227-02 Endorsement No

Policy Issued on 16/05/2022 Policy Status ACTIVE

From 26/05/2022 00:00 Hrs To 25/05/2023
Period of Insurance Expiry Date 25/05/2023
Midnight

GSTIN / UIN Unregistered Place of Supply/State 27 - MAHARASHTRA

Code/Name
Company GST No: 27AABCB5730G1ZX

Company PAN AABCB5730G Invoice No: 272205I000699430

Insured Member Details

Nominee Name & First Policy
Member Name Customer ID Gender Date of Birth Age Relation
Relation Inception Date
YATIN BABULAL 1. Sneha Yatin
183415239 Male 17/06/1980 41 Self 26/05/2020
PAHADE Pahade - Spouse
SNEHA YATIN 1. Yatin Pahade -
183414927 Female 29/04/1985 37 Spouse 26/05/2020
PAHADE Spouse
NITI YATIN PAHADE 1. Yatin Pahade -
183414928 Female 12/12/2012 9 Daughter 26/05/2020
JAIN Father
REETI YATIN PAHADE 1. Yatin Pahade -
183414929 Female 20/03/2014 8 Daughter 26/05/2020
JAIN Father
Insured address AT POST MUMBAI GALLI AMALNER TAL AMALNER,,JALGAON,MAHARASHTRA,425401

Sum Insured & Cover Details

Daily Cash for Preventive Recharge
Inpatient Hospitalisation Convalescen Reinstateme Maternity
Member Name Accompanying Health Benefit
Treatment ce Benefit nt Benefit Expenses
an Insured Check Up Limit

Sum Sum
CB(CB%) SCB Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured
Insured Insured
1. Yatin Babulal 100000
Pahade 500000 NA 7500 5000 500000 25000 5000 0
(20%)
2. Sneha Yatin
Pahade
3. Niti Yatin
Pahade Jain
4. Reeti Yatin
Pahade Jain
Add On Cover
Name of Add-On/Rider UIN Opted(Yes/No)

Non-Medical Expenses Cover BAJHLAP21586V012021 No

Waiver of Room Capping BAJHLA21577V012021 No

Health Prime Rider BAJHLIA22169V012122 No

HEALTH GUARD-FLOATER- POLICY SCHEDULE
UIN : BAJHLIP21227V042021

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

Zone B / Zone C Discount 4600

Base Premium 23000
Family Discount 0
Premium Payment Zone Zone B Long Term Policy Discount 0

Voluntary Co-payment Opted-10%/20% 0 Voluntary Co-payment Discount@10%/20% 0

Premium on Add-on Cover 0 Room Rent Capping Discount 0

Plan Gold Plan Employee Discount 0

Premium on Health Prime Rider 0 Online Discount/Direct Customer Discount 0

Discount on Health Prime Rider 0 Wellness Discount 0

Total Discount 4600
Eligible Discount 4600
Gross Premium: Twenty-One Thousand Seven Hundred Net Premium 18400
Twelve Rupees
State GST(9%) 1656
Central GST(9%) 1656
IGST 0
UTGST 0
CESS
Gross Premium 21712
"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."

Exclusions
Member Name Exclusion

Yatin Babulal Pahade NA

Sneha Yatin Pahade NA

Niti Yatin Pahade Jain NA

Reeti Yatin Pahade
NA
Jain

Special Exclusion at Policy

NA
Level
Additional Remarks NA
This is to certify that Yatin Babulal Pahade has paid Rs.21712 towards Health Insurance premium for
Period and Policy Number as mentioned on the Policy Schedule and is eligible for Deduction under
Section 80-D of Income Tax (Amendment) Act, 1986
Notes:
80D Certificate 1. This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended
from time to time.
2. This certificate must be surrendered to the company in case of cancellation of this policy.
3. In event of incorrect representation of this declaration the liability shall be upon the policy holder.
4. This certificate will not be valid if premium payment has been made in cash.
Receipt Number: 54-22-000000135159 Date: 16/05/2022 Premium Payer ID: 183415239 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 10035925 CONTACT NO 09421532475

AGENCY NAME Mahavirhiralalsinghavi Hiralal EMAIL ID MAHAVIR.SINGHAVI@YAHOO.COM
 HEALTH GUARD-FLOATER- POLICY SCHEDULE
UIN : BAJHLIP21227V042021

For & on the behalf

Bajaj Allianz General Insurance Company Ltd. Consolidated Stamp Duty of Rs. 0/- 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 General Stamp of India.
Stamp Duty
Rs.0/-
This document is digitally signed,hence counter signature / stamp is not
required.
Principal Location : Bajaj Allianz House,Airport Road,Yerwada,Pune-
Authorized Signatory 411006 PH-66026666 | Services Accounting Code : 997133 Accident and
health insurance services. No reverse charge is payable on these
services.

SUB 10035925 / NA

Signature Not Verified

Digitally signed by DS BAJAJ ALLIANZ
GENERAL INSURANCE COMPANY LIMITED 01
Date: 2022.05.16 16:08:58 IST

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

bagichelp@bajajallianz.co.in Demystify Insurance http://support.bajajallianz.com

RECEIPT

JALGAON-2nd Floor,,Panna Heights,,Opp. Omkareshwar

Policy issuing office and Correspondence address
Mandir Jay Nagar,Jalgaon,Maharashtra,INDIA,425001

Proposer Name Yatin Babulal Pahade Policy Number 12-8451-0000088227-02

Receipt Number 54-22-000000135159 Receipt Date 16/05/2022

Business Channel BILLDESK

Received with thanks from: Yatin Babulal Pahade

Customer ID: 183415239 a total sum of Rupees Twenty-One Thousand Seven Hundred Twelve Rupees Only by,

Instrument Type Instrument No Instrument Date Bank Name Branch Name Amount (Rs.)
HGA4P0D9A00
Online Payment 16-May-2022 NA NA 21,712.00
473021932

Total Amount: 21712

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: 2022.05.16 16:09:06 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

bagichelp@bajajallianz.co.in Demystify Insurance http://support.bajajallianz.com

 HEALTH & WELLNESS CARD

JALGAON-2nd Floor,,Panna Heights,,Opp. Omkareshwar Mandir Jay Nagar,

Policy issuing office and Correspondence address Jalgaon,Maharashtra,INDIA,425001

Proposer Name Yatin Babulal Pahade Policy Number 12-8451-0000088227-02

Scan QR to view your policy details

Health Card Number: 31-8451-0013423343-0001
Customer ID: 183414929
Policy No: 12-8451-0000088227-02
Inception Date: 26/05/2022
Valid Up to: 25/05/2023
Member Name: Reeti Yatin Pahade Jain
Age: 8

HEALTH & WELLNESS CARD

Bajaj Allianz General Insurance Company

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance
Regulatory and Development Authority of India [IRDAI] vide Reg No. 113)

Regd.Office: Bajaj Allianz House, Airport Road, Yerwada, Pune-411006 (India)

Cashless hospitalization in network hospitals can be obtained only if this card is produced along
with a letter of authorization from Bajaj Allianz except for emergency cases. This is subject to
terms and conditions of the policy. Please quote your ID number for assistance. Intimation to
Bajaj Allianz Helpline is mandatory in case of any hospitalization.
HOSPITAL ALERT: In emergency, Patient may approach with id card; please call Bajaj Allianz
helpline to verify coverage and cashless authorization.

For help and more information:

Say Hi on WhatsApp on 7507245858, Give a Missed Call on 8080945060, SMS ‘WORRY’ to
575758, Contact our 24-Hour Call Center at 1800-209-5858
Email: Bagichelp@bajajallianz.co.in, Website www.bajajallianz.com
Corporate Identification Number: U66010PN2000PLC015329

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

bagichelp@bajajallianz.co.in Demystify Insurance http://support.bajajallianz.com

 HEALTH & WELLNESS CARD

JALGAON-2nd Floor,,Panna Heights,,Opp. Omkareshwar Mandir Jay Nagar,

Policy issuing office and Correspondence address Jalgaon,Maharashtra,INDIA,425001

Proposer Name Yatin Babulal Pahade Policy Number 12-8451-0000088227-02

Scan QR to view your policy details

Health Card Number: 31-8451-0013423342-0001
Customer ID: 183414928
Policy No: 12-8451-0000088227-02
Inception Date: 26/05/2022
Valid Up to: 25/05/2023
Member Name: Niti Yatin Pahade Jain
Age: 9

HEALTH & WELLNESS CARD

Bajaj Allianz General Insurance Company

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance
Regulatory and Development Authority of India [IRDAI] vide Reg No. 113)

Regd.Office: Bajaj Allianz House, Airport Road, Yerwada, Pune-411006 (India)

Cashless hospitalization in network hospitals can be obtained only if this card is produced along
with a letter of authorization from Bajaj Allianz except for emergency cases. This is subject to
terms and conditions of the policy. Please quote your ID number for assistance. Intimation to
Bajaj Allianz Helpline is mandatory in case of any hospitalization.
HOSPITAL ALERT: In emergency, Patient may approach with id card; please call Bajaj Allianz
helpline to verify coverage and cashless authorization.

For help and more information:

Say Hi on WhatsApp on 7507245858, Give a Missed Call on 8080945060, SMS ‘WORRY’ to
575758, Contact our 24-Hour Call Center at 1800-209-5858
Email: Bagichelp@bajajallianz.co.in, Website www.bajajallianz.com
Corporate Identification Number: U66010PN2000PLC015329

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

bagichelp@bajajallianz.co.in Demystify Insurance http://support.bajajallianz.com

 HEALTH & WELLNESS CARD

JALGAON-2nd Floor,,Panna Heights,,Opp. Omkareshwar Mandir Jay Nagar,

Policy issuing office and Correspondence address Jalgaon,Maharashtra,INDIA,425001

Proposer Name Yatin Babulal Pahade Policy Number 12-8451-0000088227-02

Scan QR to view your policy details

Health Card Number: 31-8451-0013423341-0001
Customer ID: 183414927
Policy No: 12-8451-0000088227-02
Inception Date: 26/05/2022
Valid Up to: 25/05/2023
Member Name: Sneha Yatin Pahade
Age: 37

HEALTH & WELLNESS CARD

Bajaj Allianz General Insurance Company

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance
Regulatory and Development Authority of India [IRDAI] vide Reg No. 113)

Regd.Office: Bajaj Allianz House, Airport Road, Yerwada, Pune-411006 (India)

Cashless hospitalization in network hospitals can be obtained only if this card is produced along
with a letter of authorization from Bajaj Allianz except for emergency cases. This is subject to
terms and conditions of the policy. Please quote your ID number for assistance. Intimation to
Bajaj Allianz Helpline is mandatory in case of any hospitalization.
HOSPITAL ALERT: In emergency, Patient may approach with id card; please call Bajaj Allianz
helpline to verify coverage and cashless authorization.

For help and more information:

Say Hi on WhatsApp on 7507245858, Give a Missed Call on 8080945060, SMS ‘WORRY’ to
575758, Contact our 24-Hour Call Center at 1800-209-5858
Email: Bagichelp@bajajallianz.co.in, Website www.bajajallianz.com
Corporate Identification Number: U66010PN2000PLC015329

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

bagichelp@bajajallianz.co.in Demystify Insurance http://support.bajajallianz.com

 HEALTH & WELLNESS CARD

JALGAON-2nd Floor,,Panna Heights,,Opp. Omkareshwar Mandir Jay Nagar,

Policy issuing office and Correspondence address Jalgaon,Maharashtra,INDIA,425001

Proposer Name Yatin Babulal Pahade Policy Number 12-8451-0000088227-02

Scan QR to view your policy details

Health Card Number: 31-8451-0013423340-0001
Customer ID: 183415239
Policy No: 12-8451-0000088227-02
Inception Date: 26/05/2022
Valid Up to: 25/05/2023
Member Name: Yatin Babulal Pahade
Age: 41

HEALTH & WELLNESS CARD

Bajaj Allianz General Insurance Company

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance
Regulatory and Development Authority of India [IRDAI] vide Reg No. 113)

Regd.Office: Bajaj Allianz House, Airport Road, Yerwada, Pune-411006 (India)

Cashless hospitalization in network hospitals can be obtained only if this card is produced along
with a letter of authorization from Bajaj Allianz except for emergency cases. This is subject to
terms and conditions of the policy. Please quote your ID number for assistance. Intimation to
Bajaj Allianz Helpline is mandatory in case of any hospitalization.
HOSPITAL ALERT: In emergency, Patient may approach with id card; please call Bajaj Allianz
helpline to verify coverage and cashless authorization.

For help and more information:

Say Hi on WhatsApp on 7507245858, Give a Missed Call on 8080945060, SMS ‘WORRY’ to
575758, Contact our 24-Hour Call Center at 1800-209-5858
Email: Bagichelp@bajajallianz.co.in, Website www.bajajallianz.com
Corporate Identification Number: U66010PN2000PLC015329

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

bagichelp@bajajallianz.co.in Demystify Insurance http://support.bajajallianz.com

 Certificate for the purpose of deduction under Section 80-D of Income Tax
Amendment Act, 1986

This is to certify that Yatin Babulal Pahade has paid Rs. 21712 towards Health Insurance premium for HEALTH
GUARD-FLOATER for the period from 26/05/2022 to midnight of 25/05/2023 under Policy no 12-8451-0000088227-02

FINANCIAL YEAR AMOUNT(RS)

2022-2023 21712.00

Issue Date: 16/05/2022

Place: JALGAON-2nd Floor,,Panna Heights,,Opp. Omkareshwar

For & on the behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory
This certificate must be surrendered to the company for issuance of fresh certificate in case of cancellation of the Policy or any alteration
in the insurance affecting premium.

Notes:
1. This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended from time to time.
2. This certificate must be surrendered to the company in case of cancellation of this policy.
3. In event of incorrect representation of this declaration the liability shall be upon the policy holder.
4. This certificate will not be valid if premium payment has been made in cash.

Signature Not Verified

Digitally signed by DS BAJAJ ALLIANZ GENERAL
INSURANCE COMPANY LIMITED 01
Date: 2022.05.16 16:08:59 IST

Policy Verification
Claim Registration

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

bagichelp@bajajallianz.co.in Demystify Insurance http://support.bajajallianz.com

TAX INVOICE
(Customer Copy)

Invoice Number 272205I000699430 Customer ID 183415239

Invoice Date 16/05/2022 Policy No. 12-8451-0000088227-02

Recipient/ Details of Insured Supplier/ Details of Insurer

GSTIN Unregistered GSTIN 27AABCB5730G1ZX

PAN NA PAN AABCB5730G

Name (Proposer) Yatin Babulal Pahade Name Bajaj Allianz General Insurance Company Ltd.

Address-1 At Post Mumbai Galli Amalner Tal Amalner Address-1 2nd Floor,

Address-2 Address-2 Panna Heights,

Address-3 Address-3 Opp. Omkareshwar Mandir Jay Nagar

Pin Code 425401 Pin Code 425001

City JALGAON City JALGAON

State MAHARASHTRA State MAHARASHTRA

Client Category NON HNI Place of Supply 27 - MAHARASHTRA

Premium
Description Amount(INR) Description Amount(INR)

Net Premium 18400 State GST(9%) 1656

Receipt Number: 54-22-000000135159 Date: 16/05/2022
Central GST(9%) 1656
Premium Payer ID: 183415239 Float: NA; ** If Premium paid
through Cheque, the Policy is void ab-initio in case of dishonour of 0
IGST(18%)
Cheque
Gross Premium 21712

Total Invoice Value (In figures) : 21712

Total Invoice Value (In Words) : Twenty-One Thousand Seven Hundred Twelve 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: 2022.05.16 16:09:06 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

bagichelp@bajajallianz.co.in Demystify Insurance http://support.bajajallianz.com