Bajaj Health Insurance

*97427244*
BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of India [IRDAI] vide Regd. No.113)
Regd. Office: GE Plaza, Airport Road, Yerwada, Pune 411006 (India)
Welcome to Bajaj Allianz Family

497498 5th floor Isana Kattima building, Poonamallee High
Policy issuing office and Correspondence address for communication Road, Arumbakkam,, , Chennai-600106 Phone No :044-
by policyholder for claim, service request, notice, summons, etc. 43904400
Proposer Name S RAGHU Policy Number OG-19-1501-8430-00000567
S RAGHU
NO 4 NAVARALAR NAGAR
THIRUMANGALAM ROAD NEXT TO
PHARMA PLUS ANNA NAGAR WEST,
CHENNAI, TAMIL NADU,

Pin - 600040
Customer ID : 129091284 *OG-19-1501-8430-00000567*
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 understand 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 process and has received iAAA rating for
the last three consecutive years from ICRA Limited, an associate of Moody's Investors 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
customercare@bajajallianz.co.in within fifteen days of receipt of this policy.
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.
Authorized Signatory
For help and more information: Page 1 of 13

Contact our 24 Hour Call Centre at 1800-209-5858, 1800-102-5858 (Toll Free)
Email: customercare@bajajallianz.co.in , Website www.bajajallianz.com
Corporate Identification Number: U66010PN2000PLC015329 | Demystify Insurance http://support.bajajallianz.com
http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi

*97427244*

HEALTH GUARD (FLOATER) TRANSCRIPT OF PROPOSAL UIN. IRDAI/HLT/BAGI/P-H/V.II/113/16-17

Dear S RAGHU,
We wish to inform you that the your contract will be 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 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, 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.
Personal Information
First Name S
Middle Name Last Name RAGHU
Email Address KARTHIKRAGHU1997@GMAIL.COM Mobile Number 9940241193
Date of Birth 25-MAY-67 Nationality
Pan No NA Unique Identity
(Aadhaar No.)
Salary Occupation
Marital Status Family Monthly
Income
Permanent Address Mailing Address
House No/ NO 4 NAVARALAR NAGAR House No/ NO 4 NAVARALAR NAGAR
Building No/ Flat THIRUMANGALAM ROAD NEXT TO PHARMA Building No/ Flat THIRUMANGALAM ROAD NEXT TO PHARMA
No PLUS ANNA NAGAR WEST No PLUS ANNA NAGAR WEST
Street/ Locality/ Street/ Locality/
Landmark Landmark
State TAMIL NADU State TAMIL NADU
City CHENNAI City CHENNAI
Area CHENNAI Area CHENNAI
Pincode 600040 Pincode 600040
Q1.Has any of the persons to be insured suffer from/or 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, any accident or any other disease. If yes, indicate in the table given below.
Ans. No
Q2. Do you or any of the family members to be covered have/had any health complaints/met with any accident in the past 4yrs
or prior to 4yrs and have been taking treatment/ hospitalization? Please provide the details & duration of illness along with
treatment taken in below table
Ans. No


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Insured/ Gender Date of Birth Relation Height Weight Add On Cumulat Sum Nominee Name Nomine
Beneficiary Name with (in cm) (in kg) Cover ive insured e
Insured Details Bonus (Floater relation
Basis) with
Benefici
ary
S RAGHU Male 25-MAY- SELF 170 90 NA 0(0%) 500000 R GEETHA SPOUSE
1967
Details if Q1 &/or NA
2 is Answered as
YES
R GEETHA Female 21-JUN-1974 SPOUSE 162 75 NA S RAGHU SPOUSE
2 is Answered as
YES
R KARTHIK Male 18-NOV- SON 165 78 NA S RAGHU FATHER
1997
2 is Answered as
YES
S R VIJAYARAJ Male 13-NOV- SON 157 47 NA S RAGHU FATHER
2002
2 is Answered as
YES
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 considered by us apart from forfeiture of the
premium.
A. Coverage Details:
1. Plan Name : Health Guard Family-Floater: Gold Plan
2. Premium Payment Zone :B
3. Period of Insurance : From: 22-OCT-2018 10:00 Hrs. To : 21-OCT-2019 Midnight
4. Is Voluntary Co-payment Opted : No
Amount of Voluntary Co-payment opted :0
5. Add On Cover Opted : No
6. Previous Insurance Provider : NA
7. Previous Policy number : NA
8. Previous Policy expiry Date : NA


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B. 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.
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.
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 insurerand 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 beensubmitted 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 beinsured/proposer or from any past or present employer concerning anything which affects the
physical or mental health of the person to be insured/proposer andseeking information from any insurer to whom an
application for insurance on the person to be insured /proposer has been made for the purpose ofunderwriting 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 theproposal and/or claims settlement and with any Governmental
and/or Regulatory authority.
Toll free Number: 1800-103-2529, 1800-22-5858, 1800-102-5858 and 1800-209-5858

Email address: customercare@bajajallianz.co.in
Website: www.bajajallianz.com
Contact our Policy servicing branch at:

497498 5th floor Isana Kattima building, Poonamallee High Road, Arumbakkam,, , , Chennai-600106 Phone No :044-43904400
This is print of electronic records maintained by us in accordance with law and hence does not require signature.
Scrutiny No:97427244


*97427244*


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 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 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 PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE WITH FINE WHICH
MAY EXTEND TO RUPEES TEN LAKH.Bajaj Allianz General Insurance Co Ltd
Authorized signatory


*97427244*

HEALTH GUARD (FLOATER) POLICY SCHEDULE UIN. IRDAI/HLT/BAGI/P-H/V.II/113/16-17

PROPOSER DETAILS POLICY DETAILS

NO 4 NAVARALAR NAGAR Policy Issued on 31-OCT-2018
THIRUMANGALAM ROAD NEXT TO Period of From: 22-OCT-2018 10:00 Hrs.
PHARMA PLUS ANNA NAGAR WEST, Insurance
Proposer Address To : 21-OCT-2019 Midnight
CHENNAI, TAMIL NADU, OG-19-1501-8430-00000567-EN03
Pin - 600040 Endorsement
End Dt.03-NOV-2018 Wef.22-OCT-2018
Customer ID 129091284 Policy Status Issued
Previous Policy No. - Expiry Date -
Insured Member Details
Member Name Customer ID Gender Date Of Birth Age Relation Nominee Name & Relation
25-MAY-
S RAGHU 129091284 Male 51 SELF R GEETHA SPOUSE
1967
R GEETHA 129092402 Female 21-JUN-1974 44 SPOUSE S RAGHU SPOUSE
R KARTHIK 129092403 Male 18-NOV-1997 20 SON S RAGHU FATHER
S R VIJAYARAJ 129092404 Male 13-NOV-2002 15 SON S RAGHU FATHER
GSTIN / UIN STATE CODE /NAME
NA 33 - Tamil Nadu
Sum Insured & Cover Details
Daily Cash for Accompanying
Inpatient Hospitalization Treatment Convalescence Benefit Maternity Expenses
an Insured Child
Cumulative
Sum Insured Sum Insured Sum Insured Sum Insured
Bonus
500000 0(0%) 5000 5000 25000
Premium Details
Description Amount(INR) Description Amount(INR)
Base Premium 21295 Less: Long Term Policy Discount 0
Less: Employee Discount 0
Premium Payment Zone B Less: Voluntary Co-payment Discount @ 10% / 20% 0
Voluntary Co-payment Opted- 10%/20% 0% Net Premium 21295
State GST (9%) 1917
Gross Premium: Rupees Twenty Five Thousand One Central GST (9%) 1917
Hundred Twenty Nine Only
Gross Premium 25129


*97427244*

HEALTH GUARD (FLOATER) POLICY SCHEDULE UIN. IRDAI/HLT/BAGI/P-H/V.II/113/16-17

Special Terms & Conditions NA

Member Name Special Condition Member level
It is hereby agreed and understood that this Policy Excludes For
S RAGHU any claims in respect of any disorder, injury, disease,
disability or treatment directly caused by or attributable to
Hyperlipidemia, Cardiovascular diseases, Cerebrovascular
diseases its complications & related disorders/any other ailment
S RAGHU existing on or before the commencement date. The above
Special Exclusions exclusion shall cease to apply from 4th year, if you have
maintained a Health Guard Policy with us for a continuous
period of a full 3 years without break from the date of your first
Health Guard Policy with Us.
R GEETHA NA
R KARTHIK NA
S R VIJAYARAJ NA
Maternity benefit is applicable for female member/s only.
Additional Remarks Daily Cash for Accompanying an Insured Child benefit is applicable only for children up to 12 years
This is to certify that S RAGHU has paid RS.25128 towards Health Insurance for Period and Policy
80 D Certificate Number as mentioned on the Policy Schedule and is eligible for Deduction under Section 80-D of
Income Tax (Amendment) Act, 1986
Receipt Number: Date: | Premium Payer ID: | Float:
Premium Details
** If Premium paid through Cheque, the Policy is void ab-initio in case of dishonour of Cheque
Financial Institution Ref. No. NA
Agency Code & Name 10051763/G R RANGARAMANUJAM RAJASEKAR
Contact No. 9841072725 E-Mail GRR.HOME@GMAIL.COM
For & on the behalf
This document is digitally signed, hence counter signature / stamp is not

Authorized Signatory required.
null
BAGIC GST No : 33AABCB5730G1Z4

| Principal Location : 497/498, 5th
floor, Isana Kattima building,
Poonamallee High Road,
Arumbakkam, Chennai - 600106
PH:044-43904400 | Services
Accounting Code : 997133 -
Accident and health insurance
services. No reverse charge is
payable on these services. | Invoice
No. : 104864831/3
Schedule (3) | Printed on : 03-NOV-2018 06:30:13|10051763@general.bajajallianz.co.in|Web|Sub 10051763 / NA


*97427244*

HEALTH GUARD (FLOATER) ANNEXURE

HEALTH & WELLNESS CARD
Customer ID : 129091284
Policy No : OG-19-1501-8430-00000567
ID Card No : 19-104864831
Valid Up to : 21-OCT-2019
S RAGHU (51Yrs.)
Bajaj Allianz General Insurance Company Limited

(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: GE Plaza, 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:
Contact our 24 Hour Call Center at 1800-209-5858 (Toll Free), 30305858
(chargeable,add area code before this number in case of mobile call)
Email: customercare@bajajallianz.co.in, Website www.bajajallianz.com
Corporate Identification Number: U66010PN2000PLC015329


*97427244*


Policy No : OG-19-1501-8430-00000567
ID Card No : 19-104864831A
R GEETHA (44Yrs.)

hospitalization.


*97427244*


Policy No : OG-19-1501-8430-00000567
ID Card No : 19-104864831B
R KARTHIK (20Yrs.)

hospitalization.


*97427244*


Policy No : OG-19-1501-8430-00000567
ID Card No : 19-104864831C
S R VIJAYARAJ (15Yrs.)

hospitalization.


*97427244*


ENDORSEMENT DETAILS
Endorsement No. Effective Date Issue Date Endorsement Title
OG-19-1501-8430-00000567-EN03 22-OCT-2018 03-NOV-2018 Change in Insured Member Details
Endorsement Wordings: Notwithstanding anything to the contrary in this policy or in any of its conditions, it is hereby agreed
and declared that the following insured details has been corrected as below with effect from 22-OCT-2018 the Date of Birth of
the insured is corrected as 21-JUN-1974 18-NOV-1997 ,the Gender of the insured is Corrected as
For & on the behalf

Schedule (3) | Printed on : 03-NOV-2018 06:30:13|10051763@general.bajajallianz.co.in|Web|Sub 10051763 / NA


*97427244*

HEALTH GUARD (FLOATER) RECEIPT

RECEIPT
Receipt Number 1501-00967982

Receipt Date 24/10/2018
Business Channel ML
Received with thanks from S RAGHU

(Customer ID : 129091284) a total sum of Rupees Twenty Five Thousand One Hundred Twenty Eight Only by,
Instrument Type Instrument No Instrument Date Bank Name Branch Name Amount
Cheque 000039 22/10/2018 STANDARD CHARTERED BANK RAJAJI SALAI 25,128
Total Amount 25128
Note : 97427244
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

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


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*97427244*

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

Welcome to Bajaj Allianz Family

CHENNAI, TAMIL NADU,

For & on the behalf

For help and more information: Page 1 of 13

Corporate Identification Number: U66010PN2000PLC015329 | Demystify Insurance http://support.bajajallianz.com

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

HEALTH GUARD (FLOATER) TRANSCRIPT OF PROPOSAL UIN. IRDAI/HLT/BAGI/P-H/V.II/113/16-17

For help and more information: Page 2 of 13

Corporate Identification Number: U66010PN2000PLC015329 | Demystify Insurance http://support.bajajallianz.com

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

HEALTH GUARD (FLOATER) TRANSCRIPT OF PROPOSAL UIN. IRDAI/HLT/BAGI/P-H/V.II/113/16-17

For help and more information: Page 3 of 13

Corporate Identification Number: U66010PN2000PLC015329 | Demystify Insurance http://support.bajajallianz.com

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

HEALTH GUARD (FLOATER) TRANSCRIPT OF PROPOSAL UIN. IRDAI/HLT/BAGI/P-H/V.II/113/16-17

B. EXCLUSIONS AND TERMS AND CONDITIONS:

Toll free Number: 1800-103-2529, 1800-22-5858, 1800-102-5858 and 1800-209-5858

Contact our Policy servicing branch at:

For help and more information: Page 4 of 13

Corporate Identification Number: U66010PN2000PLC015329 | Demystify Insurance http://support.bajajallianz.com

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

HEALTH GUARD (FLOATER) TRANSCRIPT OF PROPOSAL UIN. IRDAI/HLT/BAGI/P-H/V.II/113/16-17

INSURANCE ACT, 1938 SECTION 41 - PROHIBITION OF REBATES

For help and more information: Page 5 of 13

Corporate Identification Number: U66010PN2000PLC015329 | Demystify Insurance http://support.bajajallianz.com

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

HEALTH GUARD (FLOATER) POLICY SCHEDULE UIN. IRDAI/HLT/BAGI/P-H/V.II/113/16-17

PROPOSER DETAILS POLICY DETAILS

For help and more information: Page 6 of 13

Corporate Identification Number: U66010PN2000PLC015329 | Demystify Insurance http://support.bajajallianz.com

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

HEALTH GUARD (FLOATER) POLICY SCHEDULE UIN. IRDAI/HLT/BAGI/P-H/V.II/113/16-17

Special Terms & Conditions NA

This document is digitally signed, hence counter signature / stamp is not

BAGIC GST No : 33AABCB5730G1Z4

For help and more information: Page 7 of 13

Corporate Identification Number: U66010PN2000PLC015329 | Demystify Insurance http://support.bajajallianz.com

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

HEALTH GUARD (FLOATER) ANNEXURE

HEALTH & WELLNESS CARD

HEALTH & WELLNESS CARD

Bajaj Allianz General Insurance Company Limited

For help and more information: Page 8 of 13

Corporate Identification Number: U66010PN2000PLC015329 | Demystify Insurance http://support.bajajallianz.com

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

HEALTH GUARD (FLOATER) ANNEXURE

HEALTH & WELLNESS CARD

HEALTH & WELLNESS CARD

Bajaj Allianz General Insurance Company Limited

For help and more information: Page 9 of 13

Corporate Identification Number: U66010PN2000PLC015329 | Demystify Insurance http://support.bajajallianz.com

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi

97427244