Welcome to Bajaj Allianz Family

BANCASSURANCE MUMBAI-Rustomjee Aspire Bldg,1st Floor,

Policy issuing office and Correspondence address for communication
Eastern Express Highway,Sion (E),Mumbai,Maharashtra,400022,
by policyholder for claim, service request, notice, summons, etc.
INDIA

Insured Name Laxman Dhotre Policy number 12-8451-0000054924-03

Name: Laxman Dhotre

Address:
Line1: 100/101 Vetal Nagar Ghokale Nagar Null Null Null
Line2:
City: PUNE State: 27 - MAHARASHTRA
Post Code: 411016
Email ID: [email protected]
Mobile Number: 8446115032
Customer ID: 55579516

Dear Laxman Dhotre,

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 follow below link
https://www.bajajallianz.com/download-documents/health-insurance/health-guard/Health-Guard-Policy-Wordings-print.pdf
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.

Signature Not Verified

Digitally signed by DS BAJAJ
ALLIANZ GENERAL INSURANCE
COMPANY LIMITED 01
Date: 2024.01.31 07:43:51
07:43:43 IST
Authorized Signatory

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

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HEALTH GUARD-FLOATER- POLICY SCHEDULE
UIN : BAJHLIP23212V062223

Policy issuing office and Correspondence address for communication BANCASSURANCE MUMBAI-Rustomjee Aspire Bldg,1st Floor,Eastern
by policyholder for claim, service request, notice, summons, etc. Express Highway,Sion (E),Mumbai,Maharashtra,400022,INDIA

Proposer Details
Proposer Name Laxman Dhotre

Proposer Address 100/101 VETAL NAGAR GHOKALE NAGAR null null null, PUNE, MAHARASHTRA, 411016, INDIA

Phone No 8446115032 Email ID [email protected]

Customer ID 55579516

Previous Policy No 12-8451-0000054924-01 Previous Policy Expiry Date 22/01/2024

Policy Details
Policy Number 12-8451-0000054924-03 Endorsement No NA

Policy
GSTINIssued
/ UIN on 31/01/2024 Policy Status ACTIVE
From 23/01/2024 00:00 Hrs To 22/01/2025
Period of Insurance Expiry Date 22/01/2025
Midnight

Unregistered Place of Supply/State 27 - MAHARASHTRA

Code/Name
Company GST No: 27AABCB5730G1ZX

Company PAN AABCB5730G Invoice No: 272401I002010789

Insured Member Details

Nominee Name & First Policy
Member Name Customer ID Gender Date of Birth Age Relation
Relation Inception Date

LAXMAN DHOTRE 55579516 Male 25/09/1984 39 Self 1. Kavita - Spouse 23/01/2014

1. Laxman Dhotre
KAVITA . 112218544 Female 24/04/1988 35 Spouse 23/01/2014
- Spouse
1. Laxman Dhotre
TANVI . 112218545 Female 28/04/2010 13 Daughter 23/01/2014
- Father
1. Laxman Dhotre
SANVI - PI01247694 Female 20/06/2018 5 Daughter 23/01/2014
- Father
Insured address 100/101 VETAL NAGAR GHOKALE NAGAR null null null, PUNE, MAHARASHTRA, 411016, INDIA

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. Sanvi - 340000
2. Laxman Dhotre 1500000 NA 7500 5000 1500000 35000 5000 0
(22.67%)
3. Tanvi .
4. Kavita .
Add On Cover
Name of Add-On/Rider UIN Opted(Yes/No)

Non-Medical Expenses Cover BAJHLAP21586V012021 No

Waiver of Room Capping BAJHLAP21577V012021 No

Health Prime Rider BAJHLIA24087V022324 No

HEALTH GUARD-FLOATER- POLICY SCHEDULE
UIN : BAJHLIP23212V062223

Premium Details
Description Amount Description Amount

Zone B / Zone C Discount 5150

Base Premium 25750
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

Premium on Respect Rider 0 Total Discount 5150

Discount on Respect Rider 0 Eligible Discount 5150
Gross Premium: Twenty-Four Thousand Three Hundred Net Premium 20600
Eight Rupees State GST(9%) 1854
Central GST(9%) 1854
IGST 0
UTGST 0
CESS 0
Gross Premium 24308

"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."

“I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover
notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.”

Exclusions
Member Name Exclusion

Kavita . Ok

Sanvi - Ok

Laxman Dhotre Ok

Tanvi . Ok

Special Exclusion at Policy

All waiting periods apply afresh on enhanced sum insured
Level
Additional Remarks NA

80D Certificate NA
Receipt Number: SYS-23-000008885947 Date: 30/01/2024 Premium Payer ID: 55579516 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 10031837 CONTACT NO 8698010101

AGENCY NAME Bajaj Finance Limited EMAIL ID INSURANCE.
 HEALTH GUARD-FLOATER- POLICY SCHEDULE
UIN : BAJHLIP23212V062223

For & on the behalf

Bajaj Allianz General Insurance Company Ltd. Consolidated Stamp Duty of Rs. 0.25/- paid towards Insurance Stamps
vide Challan No. MH009975032202324M Defaced No. 0005568654202324
Signature Not Verified Order No.CSD/17/2023/4571 Order Dated 10/11/2023 DEFACED DATE
dated 10/11/2023 timing 15:32:10 PM of General Stamp Office, Mumbai,
Digitally signed by DS BAJAJ Stamp Duty India
ALLIANZ GENERAL INSURANCE
COMPANY LIMITED 01 Rs.0.25/-
Date: 2024.01.31 07:43:51
07:43:44 IST 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 10031837 / 31837UCASH

“The amounts present in the document are calculated with INR currency if not mentioned otherwise.”

Policy Verification Claim Registration

Our Insurance Expert will call you for hassle free renewal and industry best offers on your coverage
Bajaj Allianz General Insurance Co.Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411006. Reg.No.:113 CIN:U66010PN2000PLC015329

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RECEIPT

BANCASSURANCE MUMBAI-Rustomjee Aspire Bldg,1st Floor,

Policy issuing office and Correspondence address for communication
Eastern Express Highway,Sion (E),Mumbai,Maharashtra,
by policyholder for claim, service request, notice, summons, etc.
400022,INDIA

Proposer Name Laxman Dhotre Policy Number 12-8451-0000054924-03

Receipt Number SYS-23-000008885947 Receipt Date 30/01/2024

Business Channel Urban Cashier(31837UCASH)

Received with thanks from: Laxman Dhotre

Customer ID: 55579516 a total sum of Twenty-Four Thousand Three Hundred Eight Rupees Only by,

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

Other Dues NA NA NA NA 24,308.00

Total Amount: 24308

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: 2024.01.31 07:43:51
07:43:43 IST

Authorized Signatory

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

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Transcript of Proposal for ([11-8451-0000054924-03] HEALTH GUARD-
FLOATER)
UIN : BAJHLIP23212V062223
Dear Laxman Dhotre,
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 Laxman Dhotre

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

Gender Male Date of Birth 25/09/1984

PAN No NA

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

Marital Status NA No of children 2

Occupation Others

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

100/101 Vetal Nagar Ghokale Nagar Null Null 100/101 Vetal Nagar Ghokale Nagar Null Null
Address Line 1 Address Line 1
Null Null

Address Line 2 NA Address Line 2 NA

Address Line 3 NA Address Line 3 NA

City/District PUNE City/District PUNE

State MAHARASHTRA State MAHARASHTRA

Pin Code 411016 Pin Code 411016

Telephone NA Telephone NA

Mobile 8446115032 Mobile 8446115032

Email [email protected] Email [email protected]

Educational Qualification NA

Family Monthly Income 50000

In case of any offer, you would prefer to be contacted by 8446115032 / [email protected]

Nationality Indian

Policy Period 1 Year

Sub Plan

Sum Insured Options

a) Health Guard Individual Sum insured NA

b) Health Guard Family Floater Sum Insured 1500000

Transcript of Proposal for ([11-8451-0000054924-03] HEALTH GUARD-
FLOATER)
UIN : BAJHLIP23212V062223
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

Laxman Dhotre Self 25/09/1984 39 - - Male 1. Kavita 1. Spouse

1. Laxman
Kavita . Spouse 24/04/1988 35 - - Female 1. Spouse
Dhotre
1. Laxman
Tanvi . Daughter 28/04/2010 13 - - Female 1. Father
Dhotre
1. Laxman
Sanvi - Daughter 20/06/2018 5 - - Female 1. Father
Dhotre
Sum Insured 1500000

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

Non-Medical Expenses Cover BAJHLAP21586V012021 No

Waiver of Room Capping BAJHLAP21577V012021 No

Health Prime Rider BAJHLIA24087V022324 No

Member Name Health Questionnaire Yes/No Details

Laxman Dhotre 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
Laxman Dhotre 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?
Transcript of Proposal for ([11-8451-0000054924-03] HEALTH GUARD-
FLOATER)
UIN : BAJHLIP23212V062223

Member Name Health Questionnaire Yes/No Details

Laxman Dhotre Do you smoke cigarettes or consume tobacco (chewing No NA

paste) / alcohol, nicotine or marijuana in any form? Please
give duration and daily consumption
Laxman Dhotre 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?
Laxman Dhotre 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
Laxman Dhotre Are you vaccinated against Covid 19? (If yes, Give NA NA
Vaccination Details.)
Laxman Dhotre 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.)
Kavita . 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
Kavita . 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?
Kavita . Do you smoke cigarettes or consume tobacco (chewing No NA
paste) / alcohol, nicotine or marijuana in any form? Please
give duration and daily consumption
Kavita . 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?
Kavita . 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
Kavita . Are you vaccinated against Covid 19? (If yes, Give NA NA
Vaccination Details.)
Kavita . 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.)
Tanvi . 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
Tanvi . 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?
Tanvi . Do you smoke cigarettes or consume tobacco (chewing No NA
paste) / alcohol, nicotine or marijuana in any form? Please
give duration and daily consumption
Tanvi . 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?
Tanvi . 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
Tanvi . Are you vaccinated against Covid 19? (If yes, Give NA NA
Vaccination Details.)
Transcript of Proposal for ([11-8451-0000054924-03] HEALTH GUARD-
FLOATER)
UIN : BAJHLIP23212V062223

Member Name Health Questionnaire Yes/No Details

Tanvi . 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.)
Sanvi - 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
Sanvi - 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?
Sanvi - Do you smoke cigarettes or consume tobacco (chewing No NA
paste) / alcohol, nicotine or marijuana in any form? Please
give duration and daily consumption
Sanvi - 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?
Sanvi - 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
Sanvi - Are you vaccinated against Covid 19? (If yes, Give NA NA
Vaccination Details.)
Sanvi - 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.)

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 ([11-8451-0000054924-03] HEALTH GUARD-
FLOATER)
UIN : BAJHLIP23212V062223
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 8446115032 on

Contact our Policy servicing branch at: BANCASSURANCE MUMBAI-Rustomjee Aspire Bldg,1st Floor,Eastern Express Highway,Sion (E),
** 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

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 HEALTH & WELLNESS CARD

Policy issuing office and Correspondence address for communication BANCASSURANCE MUMBAI-Rustomjee Aspire Bldg,1st Floor,Eastern
by policyholder for claim, service request, notice, summons, etc. Express Highway,Sion (E),Mumbai,Maharashtra,400022,INDIA

Proposer Name Laxman Dhotre Policy Number 12-8451-0000054924-03

Scan QR to view your policy details

Health Card Number: 31-8451-0012615386-0003
Customer ID: PI01247694
Policy No: 12-8451-0000054924-03
Inception Date: 23/01/2024
Valid Up to: 22/01/2025
Member Name: Sanvi -
Age: 5

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: [email protected], 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

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[email protected] Demystify Insurance https://www.bajajallianz.com/blog.html

 HEALTH & WELLNESS CARD

Policy issuing office and Correspondence address for communication BANCASSURANCE MUMBAI-Rustomjee Aspire Bldg,1st Floor,Eastern
by policyholder for claim, service request, notice, summons, etc. Express Highway,Sion (E),Mumbai,Maharashtra,400022,INDIA

Proposer Name Laxman Dhotre Policy Number 12-8451-0000054924-03

Scan QR to view your policy details

Health Card Number: 31-8451-0012615385-0003
Customer ID: 112218545
Policy No: 12-8451-0000054924-03
Inception Date: 23/01/2024
Valid Up to: 22/01/2025
Member Name: Tanvi .
Age: 13

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: [email protected], 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

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[email protected] Demystify Insurance https://www.bajajallianz.com/blog.html

 HEALTH & WELLNESS CARD

Policy issuing office and Correspondence address for communication BANCASSURANCE MUMBAI-Rustomjee Aspire Bldg,1st Floor,Eastern
by policyholder for claim, service request, notice, summons, etc. Express Highway,Sion (E),Mumbai,Maharashtra,400022,INDIA

Proposer Name Laxman Dhotre Policy Number 12-8451-0000054924-03

Scan QR to view your policy details

Health Card Number: 31-8451-0012615384-0003
Customer ID: 112218544
Policy No: 12-8451-0000054924-03
Inception Date: 23/01/2024
Valid Up to: 22/01/2025
Member Name: Kavita .
Age: 35

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: [email protected], 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

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[email protected] Demystify Insurance https://www.bajajallianz.com/blog.html

 HEALTH & WELLNESS CARD

Policy issuing office and Correspondence address for communication BANCASSURANCE MUMBAI-Rustomjee Aspire Bldg,1st Floor,Eastern
by policyholder for claim, service request, notice, summons, etc. Express Highway,Sion (E),Mumbai,Maharashtra,400022,INDIA

Proposer Name Laxman Dhotre Policy Number 12-8451-0000054924-03

Scan QR to view your policy details

Health Card Number: 31-8451-0012615383-0003
Customer ID: 55579516
Policy No: 12-8451-0000054924-03
Inception Date: 23/01/2024
Valid Up to: 22/01/2025
Member Name: Laxman Dhotre
Age: 39

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: [email protected], 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

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TAX INVOICE
(Customer Copy)

Invoice Number 272401I002010789 Customer ID 55579516

Invoice Date 31/01/2024 Policy No. 12-8451-0000054924-03

Recipient/ Details of Insured Supplier/ Details of Insurer

GSTIN Unregistered GSTIN 27AABCB5730G1ZX

PAN NA PAN AABCB5730G

Name (Proposer) Laxman Dhotre Name Bajaj Allianz General Insurance Company Ltd.

100/101 Vetal Nagar Ghokale Nagar Null Null

Address-1 Address-1 Rustomjee Aspire Bldg
Null

Address-2 NA Address-2 1st Floor,Eastern Express Highway

Address-3 NA Address-3 Sion (E)

Pin Code 411016 Pin Code 400022

City PUNE City MUMBAI

State MAHARASHTRA State MAHARASHTRA

Client Category NON HNI Place of Supply 27 - MAHARASHTRA

Premium Details
Description Amount Description Amount

Net Premium 20600 State GST(9%) 1854

Receipt Number: SYS-23-000008885947 Date: 30/01/2024
Central GST(9%) 1854
Premium Payer ID: 55579516 Float: NA; ** If Premium paid
through Cheque, the Policy is void ab-initio in case of dishonour 0
IGST(18%)
of Cheque
UTGST(9%) 0

CESS 0

Gross Premium 24308

Total Invoice Value (In Words) : Twenty-Four Thousand Three Hundred Eight 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: 2024.01.31 07:43:51
07:43:44 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
“I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified
under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.”

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

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