Bajaj Allianz General Insurance Company LTD: Ans. No

Bajaj Allianz General Insurance Company Ltd
[Corporate Identity Number (CIN) : U66010PN2000PLC015329]

[Unique Identification Number (UIN) : BAJHLIP21127V032021]
Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune
Transcript of Proposal for (Health Ensure Individual)
Dear LOGESHWARAN V,
Policy Number OG-21-4649-8435-00000004
We wish to inform you that the your contract will 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 of Insured
First Name LOGESHWARAN

Middle Name Last Name V
Email Address LOGESHWARAN5177@GMAIL. Mobile Number 8220271472
COM
Date of Birth 12-AUG-2001 Nationality NA
Pan No NA Unique Identity (Aadhaar No.) NA
Salary NA Occupation NA
Marital Status NA Family Monthly Income 12000
Permanent Address Mailing Address

House No. / Building Name - NO 3/11 House No. / Building Name - NO 3/11
Flat No PERIYAVADAMBACHERI Flat No PERIYAVADAMBACHERI
SULLUR TK ,OPPOSITE TO SULLUR TK ,OPPOSITE TO
SIVAN KOVIL COIMBATORE SIVAN KOVIL COIMBATORE
Street / Locality / Landmark VADAMBACHERRY Street / Locality / Landmark VADAMBACHERRY
State TAMIL NADU State TAMIL NADU
City COIMBATORE City COIMBATORE
Area VADAMBACHERRY Area VADAMBACHERRY
Pincode 641669 Pincode 641669
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, 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
Insured/ Gender Date of Birth Relation Height Weight Add On Cumulat Sum Nominee Name Nomine
Beneficiary Name with Cover ive insured e
Insured Details Bonus (Individ relation
ual with
Basis) Benefici
ary
LOGESHWARAN V Male 12-AUG- SELF 167 55 NA 0(0%) 300000 VEERAPATHIRAN FATHER
2001 V
Details if Q1 &/or NA
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 Ensure Individual
2. Premium Payment Zone :B
3. Period of Insurance : From: 15-OCT-2020 00:00 Hrs. To : 14-OCT-2021 Midnight
4. Is Voluntary Co-payment Opted : Yes
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
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.
C. 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.
D. 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 insurer and 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 been submitted 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 be insured/proposer or from any past or present employer concerning anything which affects the
physical or mental health of the person to be insured/proposer and seeking information from any insurer to whom an
application for insurance on the person to be insured /proposer has been made for the purpose of underwriting 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 the proposal and/or claims settlement and with any Governmental
and/or Regulatory authority.
NOTE: 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 or
continuing a Policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or
tables of the insurer.
Bajaj Allianz General Insurance Co Ltd
Toll free Number: 1800-103-2529, 1800-22-5858, 1800-102-5858 and 1800-209-5858

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

Raagavis Center Ground 1st and 2nd Floor , 21A, Nethaji Nagar, Nanjudapuram main road, , Ramanathapuram Coimbatore, , COIMBATORE-641045 Phone No :7824074304
This is print of electronic records maintained by us in accordance with law and hence does not require signature.
Scrutiny No:
216170151
-----------------------------------------------------------------
*216170151*
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: Bajaj Allianz House, Airport Road, Yerwada, Pune 411006 (India)
HEALTH ENSURE - POLICY SCHEDULE UIN. BAJHLIP21127V032021

Raagavis Center Ground 1st and 2nd Floor , 21A, Nethaji
Policy issuing office and Correspondence address for Nagar, Nanjudapuram main road, , Ramanathapuram
communication by policyholder for claim, service request, notice, Coimbatore, , COIMBATORE-641045 Phone No
summons, etc. :7824074304
Proposer Name LOGESHWARAN V Policy Number OG-21-4649-8435-00000004
PROPOSER DETAILS POLICY DETAILS

NO 3/11 PERIYAVADAMBACHERI Policy Issued on 15-OCT-2020
SULLUR TK ,OPPOSITE TO SIVAN KOVIL Period of From: 15-OCT-2020 00:00 Hrs.
COIMBATORE, VADAMBACHERRY, Insurance
Proposer Address To : 14-OCT-2021 Midnight
COIMBATORE, TAMIL NADU, Customer ID 194682739
Pin - 641669 Policy Status Issued
Previous Policy No. - Expiry Date -
Insured Member Details
Member Name Customer ID Gender Date Of Birth Age Relation Nominee Name & Relation
LOGESHWARAN V 194682739 Male 12-AUG-2001 19 SELF VEERAPATHIRAN V FATHER
GSTIN / UIN Place of Supply/State Code/ Name
NA 33 - Tamil Nadu
Company GST No.: Invoice No.:
33AABCB5730G1Z4 218977341/1
Company PAN:
AABCB5730G
Sum Insured & Cover Details
Inpatient Hospitalization Treatment
Member Name
Sum Insured Cumulative Bonus
LOGESHWARAN V 300000 0(0%)
Premium Details
Description Amount(INR) Description Amount(INR)
Base Premium 2652 Less: Long Term Policy Discount 0
Premium Payment Zone B Less: Employee Discount 0
Loading Rate 0% Loading Amount 0
Less: Online Discount/Direct Customer 0 Net Premium 2652
Discount
State GST (9%) 239
Gross Premium: Rupees Three Thousand One Hundred Central GST (9%) 239
Thirty Only
Gross Premium 3130
Special Terms & Conditions NA
Member Name Special Condition Member level
Special Exclusions
LOGESHWARAN V NA
Additional Remarks
This is to certify that LOGESHWARAN V has paid RS.3130 towards Health Insurance for Period and
80 D Certificate Policy Number as mentioned on the Policy Schedule and is eligible for Deduction under Section 80-
D of Income Tax (Amendment) Act, 1986
Receipt Number : 4649-00001940 | Date : 15-OCT-20 | Premium Payer ID : 194682739 | Float : CF
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 10035203/S AND R INSURANCE BROKERS PRIVATE LIMITED
8888888888
Contact No. E-Mail srinulic1301@gmail.com
18001035858
For help and more information: Page 4 of 9
Contact our 24 Hour Call Centre at 1800-209-5858, 1800-102-5858 (Toll Free)
Email: Bagichelp@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

*216170151*

HEALTH ENSURE - POLICY SCHEDULE UIN. BAJHLIP21127V032021

For & on the behalf

Bajaj Allianz General Insurance Company Ltd.
This document is digitally signed, hence counter signature / stamp is not

Authorized Signatory required.
Consolidated Stamp Duty of Rs.0.5/- paid towards
Insurance Stamps vide Challan No.
MH013770432201920M Defaced No.
0000433117202021 Order
No.CSD/22/2020/1432/2020 Order Dated
09.06.2020Defaced date dated 09-JUN-20 timing
12:23:03 of General Stamp Office,Mumbai,India.
Principal Location : 497/498, 5th

floor, Isana Kattima building,
Poonamallee High Road,
Arumbakkam, Chennai - 600106
PH:044-43904400 | Services
Accounting Code : NA. No reverse
charge is payable on these services.
Schedule (1) | Printed on : 15-OCT-2020 07:40:06|SilentPrint|Web|Sub 10035203 / SR00035332


*216170151*

HEALTH ENSURE - ANNEXURE



*216170151*


HEALTH & WELLNESS CARD
HEALTH & WELLNESS CARD
Customer ID : 194682739
Policy No : OG-21-4649-8435-00000004
ID Card No : 21-218977341-1
Valid Up to : 14-OCT-2021
LOGESHWARAN V (19Yrs.)
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: Bajaj Allianz House, 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: Bagichelp@bajajallianz.co.in, Website www.bajajallianz.com
Corporate Identification Number: U66010PN2000PLC015329


*216170151*




*216170151*

HEALTH ENSURE - RECEIPT

RECEIPT
Receipt Number 4649-00001940

Receipt Date 15/10/2020
Business Channel ML
Received with thanks from LOGESHWARAN V

(Customer ID : 194682739) a total sum of Rupees Three Thousand One Hundred Thirty Only by,
Instrument Type Instrument No Instrument Date Bank Name Branch Name Amount
Credit Card WAP-12427262 15/10/2020 NA NA 3,130
Total Amount 3130
Note :
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

Bajaj Allianz General Insurance Company Ltd.
Authorized Signatory
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada, Pune - 411006


Bajaj Allianz General Insurance Company LTD: Ans. No

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Bajaj Allianz General Insurance Company Ltd

[Corporate Identity Number (CIN) : U66010PN2000PLC015329]

Personal Information of Insured

First Name LOGESHWARAN

Permanent Address Mailing Address

B. EXCLUSIONS AND TERMS AND CONDITIONS:

Bajaj Allianz General Insurance Co Ltd

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

Contact our Policy servicing branch at:

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

HEALTH ENSURE - POLICY SCHEDULE UIN. BAJHLIP21127V032021

PROPOSER DETAILS POLICY DETAILS

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 ENSURE - POLICY SCHEDULE UIN. BAJHLIP21127V032021

For & on the behalf

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

Principal Location : 497/498, 5th

For help and more information: Page 5 of 9

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 ENSURE - ANNEXURE

For help and more information: Page 6 of 9

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 ENSURE - ANNEXURE

HEALTH & WELLNESS CARD

HEALTH & WELLNESS CARD

Bajaj Allianz General Insurance Company Limited

For help and more information: Page 7 of 9

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 ENSURE - ANNEXURE

For help and more information: Page 8 of 9

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 ENSURE - RECEIPT

Receipt Number 4649-00001940

Received with thanks from LOGESHWARAN V

For & on the behalf

For help and more information: Page 9 of 9

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

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

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