BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED
Corporate Identity Number: U66010PN2000PLC015329, IRDA Registration No.113
Regd. Office and Head Office: Bajaj Allianz House, Airport Road, Yerawada, Pune-411006.
Policy Issuing, correspondence address for
communication by policy [or certificate of in- 1st Floor, Tower 1, Commer Zone,Samrat Ashok Path, Jail
surance] holder, policy/claim servicing, no- Road, Yerwada, Pune-411006 PH:66240100
tices and or summons
Policy
Insured Name PRIYANK OG-26-9906-1869-00007480
Number
Welcome to Bajaj Allianz Family
PRIYANK
SURENDRANAGAR, , , , SURENDRA NAGAR, -363001
Customer ID : 465153646
Dear Customer,
Thank you for choosing Bajaj Allianz General Insurer as your preferred insurer. Bajaj Allianz General Insurance
Company Limited, a consistently profitable insurer enjoys a reputation of expertise, stability and strength. We are a
customer focused market leader present in over 200 locations across India. As an organization we strive to under-
stand the risk management needs of our consumers and translate it into affordable products and services of global
quality that deliver value for money. Bajaj Allianz has an ISO Certified claims, Operations and Services processes
and has received iAAA rating for the last three consecutive years from ICRA Limited, an associate of Moody's In-
vestors Service, for claims paying ability. The rating indicates highest claims paying ability and a fundamentally
strong position in the industry.
We request you to kindly go through the contents of the policy schedule and the terms and conditions. In case of
any clarification or disagreement, please write to us at Bagichelp@bajajallianz.co.in within fifteen days of re-
ceipt of this policy.
We assure you the best of our services and look forward to a continual patronage and association with you.
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 other-
wise, 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 safe-
guard my/our personal information : Yes
For on the behalf
Bajaj Allianz General Insurance Company Ltd.
Authorized Signatory
For help and more information:
Contact our 24 Hour Call Centre at 1800-209-5858, 30305858 (Chargeable, add area code before this number in case of mobile call). E-mail: ba-
gichelp@bajajallianz.co.in, Website:www.bajajallianz.com
Corporate Identification Number: U66010PN2000PLC015329
Demystify Insurance : https://www.bajajallianz.com/blog.html https://www.facebook.com/BajajAllianz; https://twitter.com/BajajAllianz ht-
tps://www.linkedin.com/company/bajaj-allianz-general-insurance
BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED
Corporate Identity Number: U66010PN2000PLC015329, IRDA Registration No.113
Regd. Office and Head Office: Bajaj Allianz House, Airport Road, Yerawada, Pune-411006.
Policy Issuing, correspondence address for
communication by policy [or certificate of in- 1st Floor, Tower 1, Commer Zone,Samrat Ashok Path, Jail
surance] holder, policy/claim servicing, no- Road, Yerwada, Pune-411006 PH:66240100
tices and or summons
Insured Name PRIYANK Policy OG-26-9906-1869-00007480
Number
COMPULSORY PERSONAL ACCIDENT (OWNER-DRIVER) UNDER MOTOR INSURANCE POLICIES
Transcript of Proposal
UIN : IRDAN113RP0056V01201819
Dear PRIYANK ,
Policy Number : OG-26-9906-1869-00007480
We 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. 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 re-
turn 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.
Details provided by you:
A. Proposer details
1. Proposer Name : PRIYANK
2. Proposer Address : SURENDRANAGAR, ,
, , SURENDRA NAGAR, -363001
3. Proposer Mobile Number : ******9131
4. Proposer Residential Number : NA
5. Proposer e-mail id : **************142@gmail.com
6. Proposer Profession : NA
7. Do you have a valid driving license : Yes
8. Period of Insurance : From : 17-APR-2025 00:00 (Hrs) To : 16-APR-2026 Midnight
9. Sum Insured Opted : 1500000
10. Nominee Details : Kishanbhai Vaghela,Father
11. Add on Cover Opted (if any) : NA
12. To support our Go Green initiative, :
send policy copy link on registered mobile
number / email id:
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 con-
sidered by us apart from forfeiture of the premium.
A. EXCLUSIONS AND TERMS AND CONDITIONS:
The detailed list of exclusions, standard terms and conditions, including the exclusions, as mentioned in this tran-
script 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 condi-
tions including the exclusions 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 you 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 Con-
ditions, exclusions and contents mentioned hereinabove, please contact our toll free number and register your ob-
jections / changes / disagreement to the contents of this transcript or you may also send us email or written corres-
pondence 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 as in this transcript 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, as in this transcript, 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 and realization of the premium chargeable.
3. I further declare that I will notify in writing any change occurring in general health of me and other persons to be
insured/proposer after the proposal has been submitted [as in this transcript] 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 any-
thing 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 pur-
pose of underwriting the proposal and/or claim settlement.
5. I authorize the company to share information pertaining to my proposal [as in this transcript] including the medic-
al 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.
NOTE : 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.
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: 1st Floor, Tower 1, Commer Zone,Samrat Ashok Path, Jail Road, Yerwada,
Pune-411006 PH:66240100
For Bajaj Allianz General Insurance Company Ltd,
INSURANCE ACT, 1938 SECTION 41 - PROHIBITION OF REBATES
No person shall allow or offer to allow either directly or indirectly, as an inducement to any person to take out or re-
new 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 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 IN BREACH OF COMPLYING WITH THE PROVI-
SIONS OF THIS SECTION SHALL BE PUNISHABLE WITH FINE WHICH MAY EXTEND TO RUPEES TEN
LAKH.Bajaj Allianz General Insurance Co Ltd
** This is print of electronic records maintained by us in accordance with law and hence does not require signature.
Scrutiny No:
For on the behalf
Bajaj Allianz General Insurance Company Ltd.
Authorized Signatory
For help and more information:
Contact our 24 Hour Call Centre at 1800-209-5858, 30305858 (Chargeable, add area code before this number in case of mobile call). E-mail: ba-
gichelp@bajajallianz.co.in, Website:www.bajajallianz.com
Corporate Identification Number: U66010PN2000PLC015329
Demystify Insurance : https://www.bajajallianz.com/blog.html https://www.facebook.com/BajajAllianz; https://twitter.com/BajajAllianz ht-
tps://www.linkedin.com/company/bajaj-allianz-general-insurance
BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED
Corporate Identity Number: U66010PN2000PLC015329, IRDA Registration No.113
Regd. Office and Head Office: Bajaj Allianz House, Airport Road, Yerawada, Pune-411006.
COMPULSORY PERSONAL ACCIDENT (OWNER-DRIVER) UNDER MOTOR INSURANCE POLICIES
POLICY SCHEDULE
UIN : IRDAN113RP0056V01201819
Policy Issuing, correspondence address for
communication by policy [or certificate of in- 1st Floor, Tower 1, Commer Zone,Samrat Ashok Path, Jail
surance] holder, policy/claim servicing, no- Road, Yerwada, Pune-411006 PH:66240100
tices and or summons
INSURED DETAILS POLICY DETAILS
Insured Name PRIYANK Policy Number OG-26-9906-1869-00007480
SURENDRANAGAR, , , , SURENDRA Policy Issued on 15-APR-2025 09:28 AM
Insured NAGAR, -363001
From : 17-APR-2025 00:00
Address
Period of (Hrs)
Geographical India Insurance
Area To : 16-APR-2026 Midnight
Customer ID Cover Note
465153646 /
Details
Previous Policy
Details NA Contact Details ******9131
UIN/GSTIN NA Company GSTIN 27AABCB5730G1ZX
Place of Supply/ 24 - Gujarat Company PAN AABCB5730G
State Code/Name
Invoice No 451842307/1
Premium Computation Table
Compulsory Personal Accident Cover for Own-
331
er Driver Sum Insured : Rs. 15 lakhs
Add on Cover (if any) NA Final Premium ( Rupees Three Hun-
State GST 30 dred Ninety One Only )
Central GST 30
Final Premium Rs. 391
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
I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the ag-
gregate 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.
Nominee Details
Name of Nominee Relationship with Insured
Kishanbhai Vaghela Father
******9131
Agency Code 10043080:POLICYBAZAAR INSURANCE Contact No.
and Name BROKERS PRIVATE LIMTED **************142@gmai
Email-ID
l.com
Private Car/Two The Policy covers use of the vehicle for any purpose other than:
Wheeler a)Hire or Reward
b)Carriage of goods(other than samples or personal luggage)
Limitation as to Use c)Organized racing
d)Pace making
e)Speed testing
f)Reliability Trials
g)Any purpose in connection with Motor Trade
Commercial
The Policy covers use of the vehicle for any purpose other than:
Vehicle
a)Organised racing
b)Speed testing
Any person including insured:
Provided that a person driving holds an effective driving license at the time of the
accident and is not disqualified from holding or obtaining such a license.
Driver
Provided also that the person holding an effective Learner's License may also
drive the vehicle and that such a person satisfies the requirements of Rule 3 of the
Central Motor Vehicles Rules, 1989.
Add On Cover Plan Name: NA Cover Description: NA
Additional Details NA
Remarks/ Exclusions (If Any) NA
Receipt No. 9906-11768404, Date 15-APR-25 ** If Premium paid through Cheque,
Premium Details
the Policy is void ab-initio in case of dishonour of Cheque.
Date and signature of pro-
.
posal
IMPORTANT NOTICE : The insured is not indemnified if the vehicle is used or driven otherwise than in accordance
with this Schedule. Any payment made by the Company by reason of wider terms appearing in the Certificate in or-
der to comply with the Motor Vehicle Act, 1988 is recoverable from the insured. See the clause headed "AVOID-
ANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY".
For & On Behalf of Bajaj Allianz General Insurance Company Ltd.
Stamp
Duty
Rs.0.50
Authorized Signatory This document is digitally signed, hence counter signature / stamp is not required
Printed , Signed and Executed at Pune
Regd Office : Bajaj Allianz House,Airport Road, Yerwada Pune-411006 (India), A Company incorporated under Indian Companies Act, 1956 and licensed by In-
surance Regulatory and Development Authority of India [IRDA] vide Reg No.113, Corporate Identification Number U66010PN2000PLC015329.
Consolidated Stamp Duty of Rs. 0.50/- paid for insurance policy stamps vide Order No. CSD/19/2025/816 dated 01-MAR-25 of General Stamp Office, Mumbai, In-
dia.
