Bajaj Allianz Life Insurance Co. Ltd.

Certificate For Premium Paid

(01-Apr-2021 to 31-Dec-2021)

Date: 17/12/2021

This is to certify that the premium under the following policies taken by the policy holder MR RAHUL PANDEY has been received by Bajaj Allianz Life Insurance
Company Limited during the financial year 2021-2022.

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
0362921892 07/APR/2021 1000000 07/04/21 10000 10000 0 0 2021-22
N_SIZE_1
FUTURE_GAI
0362921892 07/MAY/2021 1000000 07/05/21 10000 10000 0 0 2021-22
N_SIZE_1
FUTURE_GAI
0362921892 07/JUN/2021 1000000 07/06/21 10000 10000 0 0 2021-22
N_SIZE_1
FUTURE_GAI
0362921892 N_SIZE_1 07/JUL/2021 1000000 07/07/21 10000 10000 0 0 2021-22

FUTURE_GAI
0362921892 N_SIZE_1 07/AUG/2021 1000000 07/08/21 10000 10000 0 0 2021-22

FUTURE_GAI
0362921892 N_SIZE_1 07/SEP/2021 1000000 07/09/21 10000 10000 0 0 2021-22

FUTURE_GAI
0362921892 N_SIZE_1 07/OCT/2021 1000000 08/10/21 10000 10000 0 0 2021-22

FUTURE_GAI
0362921892 N_SIZE_1 07/NOV/2021 1000000 09/11/21 10000 10000 0 0 2021-22

FUTURE_GAI
0362921892 07/DEC/2021 1000000 08/12/21 10000 10000 0 0 2021-22
N_SIZE_1
Total : 90000.0 90000.0 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.

In compliance of the provisions relating to deduction of tax at source under section 194 DA of Income Tax Act, 1961 as introduced by Finance Act, 2014, any
payment (except payment exempted u/s 194DA) made by Bajaj Allianz Life Insurance Company Limited shall be subject to deduction of applicable TDS. In absence
of PAN details, TDS would be deducted @ 20% instead of 1% in case where PAN is provided. TDS once deducted shall not be refunded.

Please update your PAN immediately. Kindly ignore if PAN details already provided.

For further details, please consult your Income Tax advisor/consultant.

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