Welcome to Bajaj Allianz Family

Policy issuing office and Correspondence address for communication WEB SALES-Bajaj Finserv Building,1st Floor,Behind Weikfield It-
by policyholder for claim, service request, notice, summons, etc. Park,Viman Nagar,Pune,Maharashtra,411014,INDIA

Insured Name Mukesh Kumar Policy number 12-8456-0000069258-00

Name: Mukesh Kumar

Address:
Line1: Village Taharpur Near By Chamad Chawk
Line2:
City: ALIGARH State: 09 - UTTAR PRADESH
Post Code: 202137
Email ID: yuvrajsingh5141@gmail.com
Mobile Number: 6396437014
Customer ID: PI04519994

Dear Mukesh Kumar,

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 follow below link
https://www.bajajallianz.com/download-documents/health-insurance/My-Health-Care-Plan/My-Health-Care-Plan-PW.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
Date: 2025.06.02 10:49:20
10:49:12 IST
Authorized Signatory

Bajaj Allianz General Insurance Co. Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. IRDA 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

 MY HEALTH CARE - INDIVIDUAL- POLICY SCHEDULE
UIN : BAJHLIP23143V012223

Policy issuing office and Correspondence address for communication WEB SALES-Bajaj Finserv Building,1st Floor,Behind Weikfield It-Park,
by policyholder for claim, service request, notice, summons, etc. Viman Nagar,Pune,Maharashtra,411014,INDIA

Proposer Details
Proposer Name Mukesh Kumar

Proposer Address VILLAGE TAHARPUR NEAR BY CHAMAD CHAWK, ALIGARH, UTTAR PRADESH, 202137, INDIA

Phone No 6396437014 Email ID yuvrajsingh5141@gmail.com

Customer ID PI04519994

Previous Policy No NA Previous Policy Expiry Date NA

Policy Details
Policy Number 12-8456-0000069258-00 Endorsement No NA

Policy Issued on 02/06/2025 Policy Status ACTIVE

From 31/05/2025 00:00 Hrs To 30/05/2026

Period of Insurance Expiry Date 30/05/2026
Midnight

GSTIN / UIN Unregistered Place of Supply/State

Code/Name 09 - UTTAR PRADESH
Company GST No: 27AABCB5730G1ZX

Company PAN AABCB5730G Invoice No: 092506I000738225

Insured Member Details

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

Base 05/01/198 1. Umesh Devi

Mukesh Kumar PI04519994 Plan 5 Male 45 Self 31/05/2025
Cover 0 - Spouse

Insured address VILLAGE TAHARPUR NEAR BY CHAMAD CHAWK, ALIGARH, UTTAR PRADESH, 202137, INDIA

BASE Cover and Sum Insured details (All figures in Rupees)-

In-patient Hospitalization Treatment/ Medical
Pre- Post- Sum Insured
Advancement Surgery /Day care Treatment / Organ
hospitalizati hospitalization Room Rent Reinstatement on
Member Name Donor Expenses / Alternative Treatment Methods /
on Medical Medical Partial Exhaustion
Road Ambulance / Domiciliary Hospitalization
Expenses Expenses

Sum Insured CB(CB%) CB Amount Days Days Category /Limit No of times

Mukesh Kumar 500000 0% 0 60 90 Single Pvt Ac Unlimited

Family Visit PED waiting period Specific disease waiting period

Member Name
Sum Insured Months Months

Mukesh Kumar 25000 36 24

MY HEALTH CARE - INDIVIDUAL- POLICY SCHEDULE
UIN : BAJHLIP23143V012223

Member Name SelectNet Care Rider UIN : BAJHLIA2539V012425

Mukesh Kumar Opted

Premium Details
Description Amount Description Amount

Zone Discount 1735

Base Premium 11570
Family Discount 0
Long Term Policy Discount 0

Employee Discount 0
Online Discount/Direct Customer Discount 491
Loyalty Discount 467
Discount on SelectNet Care Rider 1775 0
Wellness Discount
Premium on Health Prime Rider 0 Early Entry Discount 0
Discount on Health Prime Rider 0 Fitness Discount 0
Premium on Respect Rider 0 Voluntary Co-payment Discount 0

Discount on Respect Rider 0 Total Discount 2694

Premium Payment Zone Zone B Net Premium* 7328
Voluntary Copayment Option 0% State GST(9%) 0

Premium on Add-on Covers 0 Central GST(9%) 0

Gross Premium in Eight Thousand Six Hundred Forty-Seven IGST 1319
word: Rupees
UTGST 0
CESS 0
Gross Premium 8647

"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.”

It is mandatory to keep your policy with updated contact (Mobile No., Email ID and PAN Card) and bank account details, to process any of your
service requests faster and hassle-free in future.
You can update the same through Caringly yours App – {https://play.google.com/store/apps/details?id=com.ba.cp.controller&hl=en_IN},
WhatsApp Service { Say ‘Hi’ on WhatsApp - +91 75072 45858}, Contact our 24-Hour Call Center at 1800-209-5858, 1800-102-5858, Give a Missed
Call on – 8080945060, SMS “WORRY” to 575758, Email – {bagichelp@bajajallianz.co.in}, website – {www.bajajallianz.com}, contact your agent or
nearest branch.
 MY HEALTH CARE - INDIVIDUAL- POLICY SCHEDULE
UIN : BAJHLIP23143V012223

“*“Premium mentioned above is for the entire policy term, GST will be deposited as and when instalment is received, and invoice is raised.(This is in
line with the provisions as per GST Rules.)”

Premium / Instalment Payment Details:

Description Amount(INR) Description Amount(INR)
Instalment Premium at Policy Inception 611 Net Instalment Paid 611

Instalment Frequency MONTHLY State GST (9%) 0

Gross Premium : Seven Hundred Twenty-One Rupees Central GST (9%) 0

IGST 110

UTGST 0

CESS 0

Gross Instalment Amount Paid 721

Revised Instalment Premium Post Endorsement NA

Exclusions
Member Name Exclusion

Mukesh Kumar NA

Special Exclusion at Policy

NA
Level

Additional Remarks NA
This is to certify that Mukesh Kumar has paid Rs.721 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: 54-25-000000397693 Date: 31/05/2025 Premium Payer ID: PI04519994 Float: NA;
Premium Payment Details Payment Frequency: Monthly ** If Premium paid through Cheque, the Policy is void ab-initio in case of
dishonour of Cheque
Financial Institution Ref. No. NA

AGENCY CODE 10043080 CONTACT NO 18002585970

AGENCY NAME Policybazaar Insurance Brokers EMAIL ID care@policybazaar.com

For & on the behalf

Bajaj Allianz General Insurance Company Ltd. Consolidated Stamp Duty of Rs. 0/- paid towards insurance policy stamps vide Challan
No. MH003479644202425M Defaced No. 0002709637202425 Order No. LOA/ENF-
Signature Not Verified 1/CSD/36/2024-25 Order Dated 15/07/2024 Defaced Dated 10/07/2024 timing 15:00:00 of
Digitally signed by DS BAJAJ Stamp Duty General Stamp Office, Mumbai, India.
ALLIANZ GENERAL INSURANCE
COMPANY LIMITED Rs.0/- This document is digitally signed,hence counter signature / stamp is not required
Date: 2025.06.02 10:49:20
10:49:11 IST
Principal Location : Bajaj Allianz House,Airport Road,Yerwada,Pune- 411006 PH-
66026666 | Services Accounting Code : 997133 Accident and health insurance services.
Authorized Signatory No reverse charge is payable on these services.

SUB 10043080 / NA

ANNEXURE

Installment Details

INSTALLMENT NO STATUS AMOUNT INSTALLMENT NO STATUS AMOUNT

1 To be Paid 721 7 To be Paid 721

 MY HEALTH CARE - INDIVIDUAL- POLICY SCHEDULE
UIN : BAJHLIP23143V012223

INSTALLMENT NO STATUS AMOUNT INSTALLMENT NO STATUS AMOUNT

2 To be Paid 721 8 To be Paid 721

3 To be Paid 721 9 To be Paid 721

4 To be Paid 721 10 To be Paid 721

5 To be Paid 721 11 To be Paid 721

6 To be Paid 721 12 To be Paid -5

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

Policy Verification Claim Registration

Bajaj Allianz General Insurance Co. Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. IRDA 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

Policy issuing office and Correspondence address for communication WEB SALES-Bajaj Finserv Building,1st Floor,Behind Weikfield
by policyholder for claim, service request, notice, summons, etc. It-Park,Viman Nagar,Pune,Maharashtra,411014,INDIA

Proposer Name Mukesh Kumar Policy Number 12-8456-0000069258-00

Receipt Number 54-25-000000397693 Receipt Date 31/05/2025

Business Channel POLICYBAZAAR INSURANCE BROKERS PRIVATE LIMTED(10043080)

Received with thanks from: Mukesh Kumar

Customer ID: PI04519994 a total sum of Eight Thousand Six Hundred Forty-Seven Rupees Only by,

Instrument Type Instrument No Instrument Date Bank Name Branch Name Amount (Rs.)
PB127250283IT
Online Payment 31-May-2025 NA NA 721.00
454514502

Total Amount: 8647

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
Date: 2025.06.02 10:49:20
10:49:11 IST

Authorized Signatory

Bajaj Allianz General Insurance Co. Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. IRDA 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

Transcript of Proposal for ([11-8456-0000972622-00] MY
HEALTH CARE - INDIVIDUAL)
UIN : BAJHLIP23143V012223
Dear Mukesh Kumar,
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 Mukesh Kumar

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

Gender Male Date of Birth 05/01/1980

PAN No NA

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

Marital Status NA No of children NA

Occupation Others

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

Address Line 1 Village Taharpur Near By Chamad Chawk Address Line 1 Village Taharpur Near By Chamad Chawk

Address Line 2 NA Address Line 2 NA

Address Line 3 NA Address Line 3 NA

City/District ALIGARH City/District ALIGARH

State UTTAR PRADESH State UTTAR PRADESH

Pin Code 202137 Pin Code 202137

Telephone 6396437014 Telephone NA

Mobile 6396437014 Mobile 6396437014

Email yuvrajsingh5141@gmail.com Email yuvrajsingh5141@gmail.com

Educational Qualification NA

Family Monthly Income 0

In case of any offer, you would prefer to be contacted by 6396437014 / yuvrajsingh5141@gmail.com

Nationality Indian

Policy Period 1 Year

Are you residing in India for more than 180 consecutive days?

The part of the table below was coming twice hence adding this block
Transcript of Proposal for ([11-8456-0000972622-00] MY
HEALTH CARE - INDIVIDUAL)
UIN : BAJHLIP23143V012223
Details of the Persons to be Insured
Relationship
Sub Plan Nominee
Member Name Plan with Gender Date of Birth Age Height Weight Relation
Opted Name
Proposer

1. Umesh
Mukesh Kumar Plan 5 Base Cover Self Male 05/01/1980 45 170 76 1. Spouse
Devi

BASE Cover and Sum Insured details (All figures in Rupees)-

In-patient Hospitalization Treatment/ Medical
Pre- Post- Sum Insured
Advancement Surgery /Day care Treatment / Organ
hospitalizati hospitalization Room Rent Reinstatement on
Member Name Donor Expenses / Alternative Treatment Methods /
on Medical Medical Partial Exhaustion
Road Ambulance / Domiciliary Hospitalization
Expenses Expenses

Sum Insured CB(CB%) CB Amount Days Days Category /Limit No of times

Mukesh Kumar 500000 0% 0 60 90 Single Pvt Ac Unlimited

Family Visit PED waiting period Specific disease waiting period

Member Name
Sum Insured Months Months

Mukesh Kumar 25000 36 24

Member Name SelectNet Care Rider UIN : BAJHLIA2539V012425

Mukesh Kumar Opted

Member Name Health Questionnaire Yes/No Details

Mukesh Kumar 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, anxiety, depression, any disease of brain or
nervous system, fits (epilepsy) slipped disc, backache, any
congenital/ birth defects/ urinary diseases, AIDS or positive
HIV?
Mukesh Kumar 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? Please
provide details
Mukesh Kumar Do you smoke cigarettes or consume tobacco (chewing Yes consume tobacco
paste) / alcohol, nicotine or marijuana in any form? Please
give duration and daily consumption?
Mukesh Kumar Have any of your immediate family members (father, No NA
mother, brother or sister) have/ had diabetes,
hypertension, cancer, heart attack, or stroke and at what
age? If yes, was it before age 60 years or after 60 years?
Mukesh Kumar 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
Mukesh Kumar Have you or any of the persons proposed to be insured No NA
were/are detected as Covid positive?
Transcript of Proposal for ([11-8456-0000972622-00] MY
HEALTH CARE - INDIVIDUAL)
UIN : BAJHLIP23143V012223
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.

I/We hereby give voluntary consent to BAGIC/Company to share my/our personal information and data provided in this proposal form with its group
companies or any other person in connection with the Insurance Policy or otherwise, including for providing products and services of group
companies that may be of interest to me/us, to be used in accordance with their respective privacy policies and subject to appropriate measures
being in place to safeguard my/our personal information.

Disclaimer
I have selected the option to pay premium for my policy through monthly instalments. I request Bajaj Allianz General Insurance Company Ltd to accept
monthly multiple instalments in advance along with the first installment.

A. EXCLUSIONS AND TERMS AND CONDITIONS:

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

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

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

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

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

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

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

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

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

Prohibition of Rebates
SECTION 41 OF INSURANCE ACT, 1938

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

This transcript is authorized by you through OTP from your registered mobile no 6396437014 on

Contact our Policy servicing branch at: WEB SALES-Bajaj Finserv Building,1st Floor,Behind Weikfield It-Park,Viman Nagar,Pune,
** This is print of electronic records maintained by us in accordance with law and hence does not require signature.
Transcript of Proposal for ([11-8456-0000972622-00] MY
HEALTH CARE - INDIVIDUAL)
UIN : BAJHLIP23143V012223

Bajaj Allianz General Insurance Co. Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. IRDA 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

Policy issuing office and Correspondence address for communication WEB SALES-Bajaj Finserv Building,1st Floor,Behind Weikfield It-Park,Viman
by policyholder for claim, service request, notice, summons, etc. Nagar,Pune,Maharashtra,411014,INDIA

Proposer Name Mukesh Kumar Policy Number 12-8456-0000069258-00

Scan QR to view your policy details

Health Card Number: 31-8456-0023087017-0001
Customer ID: PI04519994
Policy No: 12-8456-0000069258-00
First Policy Inception
Date: 31/05/2025
Valid Up to: 30/05/2026
Member Name: Mukesh Kumar
Age: 45

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 - 411 006. IRDA 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 Mukesh Kumar has paid Rs. 721 towards Health Insurance premium for MY HEALTH CARE -
INDIVIDUAL for the period from 31/05/2025 to midnight of 30/05/2026 under Policy no 12-8456-0000069258-00

FINANCIAL YEAR AMOUNT

2025-2026 721.00

Issue Date: 02/06/2025

Place: WEB SALES-Bajaj Finserv Building,1st Floor,Behind

For & on the behalf of

Bajaj Allianz General Insurance Company Ltd.
Signature Not Verified
Digitally signed by DS BAJAJ
ALLIANZ GENERAL INSURANCE
COMPANY LIMITED
Date: 2025.06.02 10:49:20
10:49:12 IST
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.

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

Policy Verification
Claim Registration

Bajaj Allianz General Insurance Co. Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. IRDA 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 092506I000738225 Customer ID PI04519994

Invoice Date 02/06/2025 Policy No. 12-8456-0000069258-00

Recipient/ Details of Insured Supplier/ Details of Insurer

GSTIN Unregistered GSTIN 27AABCB5730G1ZX

Name (Proposer) Mukesh Kumar PAN AABCB5730G

Name Bajaj Allianz General Insurance Company Ltd.

Address-1 Village Taharpur Near By Chamad Chawk

Address-1 Bajaj Finserv Building

Address-2 NA

Address-3 NA Address-2 1st Floor

Pin Code 202137 Address-3 Behind Weikfield It-Park,Viman Nagar

City ALIGARH Pin Code 411014

State UTTAR PRADESH City PUNE

Client Category NON HNI State MAHARASHTRA

Place of Supply 09 - UTTAR PRADESH

Premium Details
Description Amount Description Amount

Net Premium 611 State GST(9%) 0

Central GST(9%) 0

IGST(18%) 110

UTGST(9%) 0

CESS 0

Gross Premium 721

Total Invoice Value (In Words) : Seven Hundred Twenty-One 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
Date: 2025.06.02 10:49:20
10:49:11 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. Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. IRDA 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