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@BA44A4|Allianz @
Self Declaration of KYC Document Submission
eit Declaration of KYC Document Submission
For Individual Partner
To,
Bajaj Allianz General Insurance Co. Ltd
GE. Plaza, Airport Road,
Yerawada, Pune - 411008
Photograph of Payment Receiver
Name of Payment Receiver....... NROMANA KANKAI
ress. SE AAD, SC Coro NEAR FRAM PANCY
Aas AON OR ABAD MAA RIBAL £3 ath GR \AYATL
city. BA Aumnnane state. DE LANG AN Pin code... 2° 5468
Telephone No... : mobilen... FO6 42 AVE
(Please tick the relevant document inthe list below)
Proof of Identity (any one) Proof of Residential Address (any one)
D Passport D1 Telephone Bill (Land Line/Mobiley
PAN Card Bank Account Statement
[0 Voter's identity Card
BLUnique identity Card Adhar Card
{etter from a recognized Public Authority
Electricity Bil
Driving License Ration Card
1B Letter from a recognized Public Authority win Pras) [EI Valid Tease agreement
Insurance Policyhoider I-card/Certificate (wan Pot Employer's Certificate
5) oo) a) ara
1D Bank Letter for identification & proof of residenc Bank Letter for identification & proof of
residence
‘The documents provided as proof of identity and proofs of address have been self-attested. | have also attached my
recent photograph above.
date. 0519712022 pace, RARLTANAGAR
Signature of the Declarant
83] Allant General Insurance Company Ld, GE Pst, Arport Road, Yerowada, Pune 411 O06 Tel (751 O20) BSOIGTTT Fax (v91 090) BEOISTOT
& scanned with OKEN Scanner
