*228300445*

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)

MEDICLAIM INSURANCE POLICY SCHEDULE UIN : BAJHLIP21536V022021

Policy issuing office and Correspondence address for communication by policyholder for 497/498, 5th floor, Isana Kattima building,Poonamallee High Road, Arumbakkam,Chennai-
claim, service request, notice, summons, etc. : 600106,Phone No :044-43904400
Insured Name MRS PREMA S Child Certificate Number OG-21-1501-6021-00001168

INSURED DETAILS POLICY DETAILS

47 TH STREET , Policy Issued on 07-DEC-2020
Insured Address ASHOK NAGAR, Period of Insurance From: 06-DEC-2020 00:00
CHENNAI - 600083, To : 05-DEC-2021 Midnight
TAMIL NADU Endorsement NA
Customer ID 200104991 Previous Policy Number NA
GSTIN / UIN NA
Policy Status ISSUED STATE CODE / NAME 33 - Tamil Nadu
Company GST No : 33AABCB5730G1Z4
Invoice No : 231154540/0
Company PAN : AABCB5730G
Master Policy Number OG-20-9999-9960-00000092 Phone No. 9566275373
Cover Details
PLAN RISK COVERED RATES/SUM INSURED
NO OF PERSONS :- Self
Self Inpatient Hospitalization ZONE :- Rest of India
SUM_INSURED:-Rs.5,00,000
AGE :- 64
Self Critical Illness ZONE :- Rest of India
SUM_INSURED:-Rs.1,00,000
Premium Details
Discounts ( if Any ) Rs.0
Net Premium. Rs.6,768
Final Premium Rupees Seven Thousand Nine Hundred and Eighty Six only. State GST (9%) Rs.609
Central GST (9%) Rs.609
Gross Premium. Rs.7,986
Family Member Details
Insured Name Relation Gender DOB Rate(%) Nominee Name Nominee Relation Pre Existing Diseases
PREMA S Self FEMALE 24-MAY-1956 SUBRAMANIAN S SPOUSE No
Other Details
Scope of coverage 1 ALL TERMS AND CONDITIONS ARE AS PER GROUP MEDICLAIM POLICY OF CANARA BANK CUSTOMERS.
Bank Reference No. 2 1835111000678
BAGIC. RM. Code 26723
BAGIC RM Name YASAR S
IMD RM. Code 115231
IMD RM Name SUBIN
Pre-existing Disease N
Portability Y
Previous Policy Number 120100/12586/2018/A016898/576
IT IS HEREBY AGREED AND UNDERSTOOD THAT THE MEDICLAIM INSURANCE POLICY IS ISSUED WITH PORTABILITY BENEFIT FROM MEDICLAIM
POLICY OF APOLLO MUNICH HEALTH INSURANCE CO. LTD. AND CONTINUITY IS EXTENDED FROM 05-12-2014. THE CONTINUITY FOR CONTINUITY
Additional Remarks FOR 6 YEARS IS EXTENDED ON SUM INSURED OF RS. 500000 FOR PREMA S. ALL OTHER TERMS, CONDITIONS, COVERAGE AND EXCLUSIONS OF THE
POLICY REMAIN UNALTERED, ALL WAITING PERIODS APPLY AFRESH ON ENHANCED SUM INSURED. ANY DISEASE/INJURY CONTRACTED DURING
BREAKIN PERIOD WILL NOT BE PAYABLE.
Electronic Insurance Account
Number (EIA No)
Customer Consent YES
Remarks
S P Code SP0045136243
80 D Certificate This is to certify that MRS PREMA S has Paid Rs.7,107 towards Health Insurance 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 .
UW Remarks NA
Premium Details Receipt Number:1501-01141808 | Date:07-DEC-20 | Premium Payer ID:200054856 | Float: CF
** If Premium paid through Cheque, the Policy is void ab-initio in case of dishonour of Cheque.
Financial Institution Ref. No. 1835111000678

Agency Code 10045514,CANARA BANK Contact No.

& Name E-Mail ID. CB4148@CANARABAN
K.COM
For help and more information: Page 1 of 3
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

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi Demystify Insurance http://support.bajajallianz.com

 *228300445*

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)

MEDICLAIM INSURANCE POLICY SCHEDULE UIN : BAJHLIP21536V022021

Policy issuing office and Correspondence address for communication by policyholder for 497/498, 5th floor, Isana Kattima building,Poonamallee High Road, Arumbakkam,Chennai-
claim, service request, notice, summons, etc. : 600106,Phone No :044-43904400
Insured Name MRS PREMA S Child Certificate Number OG-21-1501-6021-00001168
For & on the behalf
Bajaj Allianz General Insurance Company Ltd. QR Code

Authorized Signatory
(This is system generated document and need not be countersigned.)
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.
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. : 231154540/1
Schedule (1) | Printed on : 30-Jan-2021 02:05:31 pm |Silent Print|WEB|2616

For help and more information: Page 2 of 3

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

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi Demystify Insurance http://support.bajajallianz.com

 *228300445*

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)

MEDICLAIM INSURANCE POLICY SCHEDULE UIN : BAJHLIP21536V022021

Policy issuing office and Correspondence address for communication by policyholder for 497/498, 5th floor, Isana Kattima building,Poonamallee High Road, Arumbakkam,Chennai-
claim, service request, notice, summons, etc. : 600106,Phone No :044-43904400
Insured Name MRS PREMA S Child Certificate Number OG-21-1501-6021-00001168

Bajaj Allianz General Insurance Company Limited.

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and
Development Authority of India[IRDA]vide Reg No. 113) Regd.Office:Bajaj Allianz House,Airport Road,
Yerwada,Pune-411006(India)
HEALTH & WELLNESS CARD Cashless hospitalization in network hospitals can be obtained only if this card is produced along
with al 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 coverage
and cashless authorization.
helpline to coverage and cashless authorization.
Customer ID:200104991 For help and more information:
Contact our 24 Hour Call Center at 1800-102-5858,1800-209-5858,1800-22-5858, Toll Free:
30305858(chargeable,add area code before this number in case of mobile call Email us at
Bagichelp@bajajallianz.co.in or Visit our Website www.bajajallianz.com Corporate
Identification Number U66010PN2000PLC015329

Policy No : OG-21-1501-6021-00001168
ID Card No : 21-231154540
Valid Upto : 05-Dec-2021
PREMA S (65 Yrs)

For help and more information: Page 3 of 3

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

http://www.facebook.com/BajajAllianz http://twitter.com/BajajAllianz www.bit.do/bjazgi Demystify Insurance http://support.bajajallianz.com