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Bajaj Allianz General Insurance Company Ltd.

D.NO.75-8-7/2, Sona Complex, Gandhipuram2, Nr E Seva Complex, , Rajahmundry-520010 Contact No:0883-6651031,

RECEIPT
Receipt Number Receipt Date Business Channel 1814-00033870 05/04/2012 MD

Received with thanks from

MR AJAY DINESH VARMA G

(Customer ID : 43574209 ) a total sum of Rupees Nine Hundred Fifty Nine Only by,

Instrument Type Cash

Instrument No.

Instrument Date

Bank Name

Branch Name

Amount 959

Total Amount
Note : SC NO:17433648-10012147

Rs.

959.00

Issuance of this receipt does not amount to 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. * Receipt Subject to realisation of cheque(s)

For & on behalf of Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory

Regd.Office: GE Plaza,Airport Road, Yerwada, Pune - 411006

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