Bajaj Allianz General Insurance Company Ltd

[Corporate Identity Number (CIN) : U66010PN2000PLC015329]

Unique Identification Number (UIN) : IRDA/NL-HLT/BAGI/P-P/V.I/151/13-14
Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune
Transcript of Proposal for Group Personal Accident Policy Schedule Policy Schedule
Dear MS RIDDHI KESHARWANI,
We, Bajaj Allianz General Insurance Company Limited [âCompanyâ] wish to inform you that the your contract will based on the information and declaration given by you through
telephonic conversation / email / web-inputs / TAB 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 back within a period of 15 days from the date of your receipt of this document [but in case of short term policies, your revert shall reach us before the activities/risks
covered by policies are started]. 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, 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. Kindly note that as the information/contents and declarations/confirmations provided by you as
contained in this transcript is the basis on which we 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.

Personal Information of Insured

First Name RIDDHI
Middle Name Last Name KESHARWANI
Email Address RIDDHIKESHARWANI04@GMAIL.COM Mobile Number 9039202406
Date of Birth 01-AUG-00 Nationality INDIAN
Unique Identity (Aadhaar
Pan No No.)
Salary Occupation NA
Marital Status NA Family Monthly Income
Permanent Address Mailing Address
House No/ Building No/ House No/ Building No/
D7 HARSHIT NEO CITY
Flat No Flat No
Street/ Locality/ Street/ Locality/
D7 HARSHIT NEO CITY
Landmark Landmark
State CHATTISGARH State
City DURG City
Area Area
Pincode 491111 Pincode

Q1. Do you or any of the family members to be covered have/had any health complaints/disability/met with any accident in the past and/or have been taking treatment/
hospitalization? Please provide the details & duration of illness along with treatment taken in below table. NO
Total Pre
Insured/Beneficiar Relation with Sum insured Nominee Relation Add On Cover
Gender Date of Birth Nominee Name Monthly Existing
y Name Insured (Individual Basis) with Beneficiary Details INcome Diseases
MS RIDDHI Self Female 01-AUG-2000 1000000 Pravin kesharwani Father NA NO
KESHARWANI

A. Coverage Details :
1. Plan Name : Group Personal Accident for Account Holder of IPPB_Plan A
2. Period of Insurance : 03-OCT-23 to 01-OCT-24
3. Previous Insurance Provider : NA
4. Previous Policy number : NA
5. Previous Policy expiry Date : NA

To Support Go Green initiative, send policy copy link on registered mobile number / email id :
B. 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
C. 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.
D. 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:

For help and more information: Page 1 of 5

Contact our 24 Hour Call Centre at 1800-209-5858, 1800-102-5858 (Toll Free)
Email: Bagichelp@bajajallianz.co.in , Website www.bajajallianz.com Corporate Identification Number: U66010PN2000PLC015329

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi Demystify Insurance http://support.bajajallianz.com

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 prospectus 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.
Toll free Number: 1800-103-2529, 1800-102-5858 and 1800-209-5858
Email address: Bagichelp@bajajallianz.co.in
Website: www.bajajallianz.com
Contact our Policy servicing branch at: Shiv Mohan Bhavan,Vidhansabha Road,RAIPUR-492001,Phone No :0771-2532368
** This is print of electronic records maintained by us in accordance with law and hence does not require signature.
Scrutiny No: 366584094

For help and more information: Page 2 of 5

Contact our 24 Hour Call Centre at 1800-209-5858, 1800-102-5858 (Toll Free)
Email: Bagichelp@bajajallianz.co.in , Website www.bajajallianz.com Corporate Identification Number: U66010PN2000PLC015329

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi Demystify Insurance http://support.bajajallianz.com

 *366584094*

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of India [IRDAI] vide Regd. No.113)
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada, Pune â 411006 (India)

GROUP PERSONAL ACCIDENT POLICY SCHEDULE POLICY SCHEDULE UIN : IRDA/NL-HLT/BAGI/P-P/V.I/151/13-14

Policy issuing office and Correspondence address for communication by policyholder for Shiv Mohan Bhavan,Vidhansabha Road,RAIPUR-492001,Phone No :0771-2532368
claim, service request, notice, summons, etc. :
Insured Name MS RIDDHI KESHARWANI Child Certificate Number OG-24-2303-6401-00003687

INSURED DETAILS POLICY DETAILS

Policy Issued on 03-OCT-2023
D7 HARSHIT NEO CITY,
D7 HARSHIT NEO CITY,Amleshhwar, From: 03-OCT-2023 00:00
Insured Address Period of Insurance
DURG - 491111, To : 01-OCT-2024 Midnight
CHATTISGARH
Endorsement NA
Customer ID 405331274 Previous Policy Number NA
GSTIN / UIN NA
Policy Status ISSUED STATE CODE / NAME 22 - Chattisgarh
Company GST No : 22AABCB5730G1Z7
Invoice No : 393911309/0 Company PAN : AABCB5730G
Master Policy Number OG-21-9999-9960-00000050 Plan Chosen Group Personal Accident for Account Holder of IPPB_Plan A
Cover Details
PLAN RISK COVERED RATES/SUM INSURED
NO OF PERSONS :- Self
Group Personal Accident Wider Cover SUM_INSURED:-Rs.10,00,000
AGE :- 23
Premium Details
Discounts ( if Any ) Rs.0
Net Premium. Rs.218
Final Premium Rupees Two Hundred Fifty Eight only. State GST (9%) Rs.20
Central GST (9%) Rs.20
Gross Premium. Rs.258

Family Member Details

Insured Name Relation Gender DOB Rate(%) Nominee Name Nominee Relation Pre Existing Diseases
RIDDHI Self Female 01-AUG-2000 Pravin kesharwani Father N
KESHARWANI
Other Details
Scope of coverage 1 WIDER COVER FOR SUM INSURED 1000000 PER PERSON
Scope of coverage 2 ALL OTHER TERMS; CONDITIONS AND EXCLUSIONS AS PER THE STANDARD GROUP PERSONAL ACCIDENT POLICY.
Gross Monthly Income 8333
Special Terms and conditions NA
Bank Reference No. 2 AH3QBQ270H3
BAGIC. RM. Code 1436905
BAGIC RM Name ABHISHEK NAYAK
IMD RM. Code 4545
IMD RM Name PYTUY
Customer Consent YES
Electronic Insurance Account
Number (EIA No)
Remarks
S P Code

Receipt Number:2303-00425090 | Date:03-OCT-23 | Premium Payer ID:405331274 | Float: CF

Premium Details ** If Premium paid through Cheque, the Policy is void ab-initio in case of dishonour of Cheque.
Financial Institution Ref. No. 21709668

Agency Code 10088019,INDIA POST Contact No. 01123362147,0112336214

& Name PAYMENTS BANK 7
E-Mail ID.
For & on the behalf
Bajaj Allianz General Insurance Company Ltd. QR Code

Authorized Signatory

For help and more information: Page 3 of 5

Contact our 24 Hour Call Centre at 1800-209-5858, 1800-102-5858 (Toll Free)
Email: Bagichelp@bajajallianz.co.in , Website www.bajajallianz.com Corporate Identification Number: U66010PN2000PLC015329

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi Demystify Insurance http://support.bajajallianz.com

 *366584094*

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of India [IRDAI] vide Regd. No.113)
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada, Pune â 411006 (India)

GROUP PERSONAL ACCIDENT POLICY SCHEDULE POLICY SCHEDULE UIN : IRDA/NL-HLT/BAGI/P-P/V.I/151/13-14

Policy issuing office and Correspondence address for communication by policyholder for Shiv Mohan Bhavan,Vidhansabha Road,RAIPUR-492001,Phone No :0771-2532368
claim, service request, notice, summons, etc. :
Insured Name MS RIDDHI KESHARWANI Child Certificate Number OG-24-2303-6401-00003687
(This is system generated document and need not be countersigned.)

Principal Location : Shiv Mohan Bhavan, Vidhansabha Road, Pandri, RAIPUR - 492001 PH:0771-2532368 | Services Accounting Code : 997133 - Accident and health insurance services.
No reverse charge is payable on these services.
Schedule (1) | Printed on : 03-Oct-2023 05:27:05 pm |Silent Print|WEB|1436905

For help and more information: Page 4 of 5

Contact our 24 Hour Call Centre at 1800-209-5858, 1800-102-5858 (Toll Free)
Email: Bagichelp@bajajallianz.co.in , Website www.bajajallianz.com Corporate Identification Number: U66010PN2000PLC015329

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi Demystify Insurance http://support.bajajallianz.com

 *366584094*

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of India [IRDAI] vide Regd. No.113)
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada, Pune â 411006 (India)

GROUP PERSONAL ACCIDENT POLICY SCHEDULE POLICY SCHEDULE UIN : IRDA/NL-HLT/BAGI/P-P/V.I/151/13-14

Policy issuing office and Correspondence address for communication by policyholder for Shiv Mohan Bhavan,Vidhansabha Road,RAIPUR-492001,Phone No :0771-2532368
claim, service request, notice, summons, etc. :
Insured Name MS RIDDHI KESHARWANI Child Certificate Number OG-24-2303-6401-00003687

Bajaj Allianz General Insurance Company Limited.

(A Company incorporated under Indian Companies Act,
1956 and licensed by Insurance Regulatory and Development Authority of India[IRDA]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 al letter of authorization from Bajaj Allianz except for emergency cases.This is subject to
terms and conditions of the policy.
HEALTH & WELLNESS CARD 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 coverage
and cashless authorization.

helpline to coverage and cashless authorization.

For help and more information:
Contact our 24 Hour Call Center at 1800-102-5858,1800-209-5858,
Customer ID:405331274 Toll Free: 30305858(chargeable,add area code before this number in case of mobile call
Email us at Bagichelp@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329

Policy No : OG-24-2303-6401-00003687
ID Card No : 24-393911309
Valid Upto : 01-Oct-2024
RIDDHI KESHARWANI (23 Yrs)

For help and more information: Page 5 of 5

Contact our 24 Hour Call Centre at 1800-209-5858, 1800-102-5858 (Toll Free)
Email: Bagichelp@bajajallianz.co.in , Website www.bajajallianz.com Corporate Identification Number: U66010PN2000PLC015329

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi Demystify Insurance http://support.bajajallianz.com