GLOBAL PERSONAL GUARD POLICY (INDIVIDUAL)- POLICY SCHEDULE

UIN: IRDAI/HLT/BAGI/P-P/V.I/30/14-15

GHATKOPAR-Bajaj Allianz General Insurance Company Limited,,Unit

No.301 And 302,3rd Floor,,Silver Point, Plot No.17/18, Cts No.501/1,
Policy issuing office and Correspondence address New Maneklal Estate, Ghatkopar (W),Mumbai,Maharashtra,400086,
INDIA

Proposer Details
Proposer Name Akhilesh F Sharma

Proposer Address MALDEPUR POST MITTUPUR MALDEPUR, AZAMGARH,,AZAMGARH,UTTAR PRADESH,276143

Phone No 9323912244 Email ID generalf5@lnk.fit

Customer ID PI20764639 Previous Policy No OG2119076402000095

Policy Details
Policy Number 12-8428-0000073456-00 Endorsement No 13-8428-0000073456-00-03

Policy Issued on 17/12/2021 Policy Status ACTIVE

Period of Insurance From 22/12/2021 00:00 Hrs To 21/12/2022 Midnight Expiry Date 21/12/2022

GSTIN / UIN Unregistered

Place of Supply/State
09 - UTTAR PRADESH
Code/Name
Company GST No: 27AABCB5730G1ZX

Company PAN AABCB5730G Invoice No: 272112I000483173

Insured Member Details

Nominee Name & First Policy
Member Name Customer ID Gender Date of Birth Age Relation Occupation
Relation Inception Date
Other Class 1. Nilam Sharma
Akhilesh Sharma PI20764639 Male 08/12/1983 38 Self 22/12/2021
2 - Spouse
Insured Address MALDEPUR POST MITTUPUR MALDEPUR, AZAMGARH,,AZAMGARH,UTTAR PRADESH,276143

Cover Details
Death Permanent Total Disability Permanent Partial Disability
Member Name Premium
Cumulative Cumulative Cumulative
Sum Insured Sum Insured Sum Insured
Bonus ( %) Bonus ( %) Bonus ( %)

Akhilesh Sharma 1259 200000 0 (0%) 100000 0 (0%) 100000 0 (0%)

Optional Cover
Accidental Adventure Sports Benefit Air Coma Due to
Children's EMI
Hospitalization Ambulance Accidental
Education Benefit Payment Cover
Expenses Death PTD Cover Bodily Injury
Member Name

Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured

Akhilesh
200000 NA NA 0 0 0 0
Sharma

Loan Road Travel

Loss of Income due to
Fracture Care Hospital Cash Benefit Protector Ambulance Expenses
Member Disability from Accident
Cover Cover Benefit
Name
Per Day Number of Weekly
Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured
Benefit Days Benefit Amt.
Akhilesh
100000 NA NA 0 1000 100000 0 0
Sharma

Add on Cover
GLOBAL PERSONAL GUARD POLICY (INDIVIDUAL)- POLICY SCHEDULE
UIN: IRDAI/HLT/BAGI/P-P/V.I/30/14-15

Health Prime Rider

Member Name
UIN: BAJHLIA22169V012122

AKHILESH SHARMA No

Premium Details
Description Amount(INR) Description Amount(INR)

Base Premium 174 Family Discount 0

Premium on Add-on Cover 894 Long Term Policy Discount 0

Premium on Health Prime Rider 0 Employee Discount 0

Discount on Health Prime Rider 0 Online Discount/Direct Customer 0

Gross Premium: One Thousand Two Hundred Sixty Rupees Net Premium 1068

State GST(9%) 0

Central GST(9%) 0

IGST 192

UTGST 0

CESS

Gross Premium 1260

"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 E. & O.E"

"In case no GSTIN or incorrect GSTIN is provided by the Proposer at Proposal stage, Bajaj Allianz General Insurance Company Ltd shall not be
responsible for any Input Tax Credit losses and no subsequent revision of invoice will be undertaken."

Exclusions
Member Name Exclusion

Akhilesh Sharma NA

Special Exclusion at Policy

Level NA

Loan Details NA

Assignment Details NA

Type of Assignment NA

Assignment Wordings NA

Additional Remarks
80 D Certificate
Premium Details
Financial Institution Ref. No.
NA
This is to certify that Akhilesh F Sharma has paid Rs.520 towards Health Insurance premium for Period
and Policy Number as mentioned on the Policy Schedule and is eligible for Deduction under Section 80-
D of Income Tax (Amendment) Act, 1986
Notes:
1. This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended
from time to time.
2. This certificate must be surrendered to the company in case of cancellation of this policy.
3. In event of incorrect representation of this declaration the liability shall be upon the policy holder.
4. This certificate will not be valid if premium payment has been made in cash.
Receipt Number: 54-21-000000293826, SYS-21-000001573740 Date: 17/12/2021, 17/12/2021
Premium Payer ID: PI20764639 Float: NA; Payment Frequency: Single Premium ** If Premium paid
through Cheque, the Policy is void ab-initio in case of dishonour of Cheque
NA
 GLOBAL PERSONAL GUARD POLICY (INDIVIDUAL)- POLICY SCHEDULE
UIN: IRDAI/HLT/BAGI/P-P/V.I/30/14-15
AGENCY CODE 10026896 CONTACT NO 9999999999
AGENCY NAME Chandnilkhona L EMAIL ID GENERALF5@LNK.FIT

For & on the behalf

Bajaj Allianz General Insurance Company Ltd. Consolidated Stamp Duty of Rs. 1/- paid towards Insurance Premium Stamps Vide Challan No
MH002405964202122M defaced number 0001482221202122/order no. CSD/82/2021/2306 dated
12-APR-21 timing 13:29:05 of General Stamp of India.

Stamp Duty
This document is digitally signed,hence counter signature / stamp is not required
Rs.1/- Principal Location : Bajaj Allianz House, Airport Road, Yerwada, Pune- 411006 PH-66026666 |
Services Accounting Code : 997133 Accident and health insurance services.
No reverse charge is payable on these services.
Authorized Signatory

SUB 10026896 / NA

Signature Not Verified

Digitally signed by DS BAJAJ ALLIANZ
GENERAL INSURANCE COMPANY LIMITED 01
Date: 2022.06.22 11:46:47 IST

Policy Verification Claim Registration

Bajaj Allianz General Insurance Co.Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411006. Reg.No.:113 CIN:U66010PN2000PLC015329

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