Bajaj Allianz Life Insurance Co. Ltd.

Certificate For Premium Paid

(01-Apr-2020 to 31-Mar-2021)

Date: 17/01/2021

This is to certify that the premium under the following policies taken by the policy holder MR PUSHPENDRA SINGH has been received by Bajaj Allianz Life Insurance
Company Limited during the financial year 2020-2021.

Policy No Product Premium Due Sum Assured Premium Premium Life Insurance Health Care Service Financial Year
Date Adjustment Amount Premium(1) Premium(2) Tax/GST
Date Received Including cess
FUTURE_GAI
0328829045 09/APR/2020 480000 09/04/20 4000 4000 0 0 2020-21
N_SIZE_1
FUTURE_GAI
0328829045 09/MAY/2020 480000 09/05/20 4000 4000 0 0 2020-21
N_SIZE_1
FUTURE_GAI
0328829045 09/JUN/2020 480000 09/06/20 4000 4000 0 0 2020-21
N_SIZE_1
FUTURE_GAI
0328829045 09/JUL/2020 480000 09/07/20 4000 4000 0 0 2020-21
N_SIZE_1
FUTURE_GAI
0328829045 09/AUG/2020 480000 09/08/20 4000 4000 0 0 2020-21
N_SIZE_1
FUTURE_GAI
0328829045 09/SEP/2020 480000 09/10/20 4000 4000 0 0 2020-21
N_SIZE_1
FUTURE_GAI
0328829045 09/OCT/2020 480000 09/10/20 4000 4000 0 0 2020-21
N_SIZE_1
FUTURE_GAI
0328829045 09/NOV/2020 480000 04/12/20 4000 4000 0 0 2020-21
N_SIZE_1
Total : 32000.0 32000.0 0.0 0.0

Note:
Receipts issued subject to realization of cheques.
(1) Life Insurance Premium is eligible for tax rebate/deduction under Section 80C.
(2) HCB/C1/Post Hospitalization/Surgical Benefit Rider Premium is eligible for tax rebate/deduction under Section 80D..

* Single Premium Policies with cover less than 5 times the premium paid will not be eligible for tax deduction under section 80C. This
certificate is issued for the purpose of claiming deductions, rebates as per the provisions of Income Tax Act, 1961.
For your actual eligibility please refer to provisions of IT Act 1961 as modified and consult your tax consultant.

Tax will be deducted under section 194DA of the Income Tax Act, 1961 subject to conditions as mentioned in Section 10(10D) of Income Tax Act,1961.If PAN is
updated in system, TDS will be deducted @ 5% on income from policy.In the absence of PAN, TDS will be deducted @ 20% on income from policy. TDS once
deducted will not be refunded.Please update your PAN in system so that TDS certificate can be issued. In the absence of PAN, TDS certificate cannot be issued.

Please consult your Income Tax advisor/consultant for tax treatment under Income Tax Act,1961.

For NRI customers TDS shall be deducted under section 195 of Income Tax Act,1961 at applicable rates.

Note: This is a computer-generated letter and does not required a signature.