Bajaj Allianz Life Insurance Company Limited

Renewal Premium Receipt

Receipt No:0741895991 Collected By:

Date:23/01/2019 Time:10:50:33 PM Collected At:
Policy No/Membership No:0227638757 Mode of Premium payment:NACH
Policy Holder:MR M SIVANANDAM Life Assured/Member:MR M SIVANANDAM
72/NA NANJUNDAPURAM
NADUTHERU~
KALAPPANAYAKKAN PATTI
NAMAKKAL TAMIL NADU
637404

Bajaj Allianz Super CashGain Insurance Pan /Form 60:

Product Name and UIN: VALIDATED
Plan-116N102V01
Rider 1: Accidental Death Benefit Rider Rider1 Premium: 43.14
Rider 2: Waiver of Premium Rider Rider2 Premium: 10.91
Rider 3: Total / Partial Permanent Disability Rider3 Premium: 37.67
DOC.: 22/07/2011 DOM: 22/07/2031
Policy Term: 20 Premium Paying Term: 15
Premium Amount: 4831.28 Sum Assured: 119146
Premium Frequency: HLY No. of Installment Due: 0
Deposit B/F: 0.0 Receivable B/F: 0.0
Deposit C/F: 0.0 Receivable C/F: 0.0
OS Interest: 0.0 Premium Due Date: 22/01/2019
Gross Amount: 5033.76 GST: 0.0

Agent Code:2000000090 Agent Name:GLOBAL FINSOL PRIVATE LIMITED

This is System Generated Receipt hence requires no signature. Mudrank No.:0000086840201819Date:04-APR-18

BEWARE OF SPURIOUS PHONE CALLS AND FICTITIOUS/FRAUDULENT OFFERS - IRDAI clarifies to public that -
1. IRDAI or its officials do not involve in activities like sale of any kind of insurance or financial products nor invest premiums.
2. IRDAI does not announce any bonus. Public receiving such phone calls are requested to lodge a police complaint along with details of phone call, number.

Disclaimer:1. Amount held in deposit will not attract any interest. 2. Receipt is subject to
realization of negotiable instrument / Bankers instruction. 3. For Eligibility under Income Tax
Act 1961, please refer to relevant provisions of Income Tax Act and rules. 4. Goods and
Service Tax and
Relevant Cess are charged at the rates applicable from time to time. 5. In ULIP, all renewals
received for any unit transaction till the cut-off time of a day shall be processed at the unit
price of the same day. The renewals received after the cut-off time of a day shall be
processed at the unit price of the next business day. Currently the cut-off time is 3.00pm for
applicability of unit price for a particular day. Please refer to policy terms for further details.
6. In the event you note any error in the acknowledgment, you are required to immediately
bring it to the notice of the Company. 7. Advance premium for life insurance can be paid in
full anytime during the same financial year of the due date of premium. For premium due
due dates in next financial year, advance premium can be paid in this financial year up to 3
months in advance from the due date of premium.
For any Policy servicing related issues kindly approach the nearest branch office of Bajaj
Allianz Life Insurance Company.
1 Bajaj Allianz Life Insurance Company Limited. IRDAI Reg. No. 116,
2 Regd. Address: G.E. Plaza, Airport Road, Yerawada, Pune - 411006.
3 Corporate Identity Number (CIN) - BALIC: U66010PN2001PLC015959
4 The Logo of Bajaj Allianz Life Insurance Co. Ltd. is provided on the basis of license given by
BajajFinserv Ltd. to use its Bajaj Logo and Allianz SE to use its Allianz logo,
5 In case of Unit-linked insurance policies (ULIPs), the investment risk in the investment
portfolio is borne by the policyholder.
6 Policyholder has the option to receive the claims/maturity payments/other sum due to
him/her from the Company through electronic mode. If you wish to receive the payment
through electronic mode, kindly furnish your Bank Account details (Account No., Name &
Address of the Bank and IFSC No.) along with a copy of cancelled cheque at the Office of the
Company. Please ensure to keep your bank particulars updated in case of any subsequent
change.
7 Policy holder has an option to pay his / her renewal premium through online modes (using
creditcard / debit card / Net Banking) or policy holder can make payment through ECS / ADI.
For more details, please contact our toll free numbers.
8 E-mail: customercare@bajajallianz.co.in | Visit: www.bajajallianz.com | Toll free number:1800
209 7272, 1800 103 7272, 1800 233 7272 | Insurance is the subject matter of solicitation