Welcome to Bajaj Allianz Family

THANE BRANCH-Office No 201 To 206, ,2nd Floor, Sun

Policy issuing office and Correspondence address for communication
Magnetica,,Nr Teen Haath Naka,Nr New Rto, Loius Wadi.,Thane,
by policyholder for claim, service request, notice, summons, etc.
Maharashtra,400602,INDIA

Insured Name Sumit Kumar Verma Policy number 12-8450-0000066186-03

Name: Sumit Kumar Verma

Address:
Line1: Hpcl Mumbai Refinery B D Patil Marg
Line2:
City: Mumbai State: 27 - MAHARASHTRA
Post Code: 400074
Mobile Number: 9096876749
Customer ID: 114701301

Dear Sumit Kumar Verma,

It is our privilege to welcome you to the Bajaj Allianz General Insurance family.

We thank you for choosing Bajaj Allianz for your Insurance needs. We are one of India's leading general insurance companies with iAAA
rating from ICRA for the last ten consecutive years indicating the company's high claims paying ability and fundamentally strong
position in the industry. Please be assured that you have made right choice by choosing us and we will stand by you in your hour of
need.

Please find enclosed the policy schedule. We wish to inform you that the policy issued is based on the information submitted in the
proposal form as well as the acceptance of the terms and conditions, and this will be verified at the time of filing of claim. Request you
to kindly go through the same once again and in case of any disagreement, discrepancy or clarifications – write to us at
bagichelp@bajajallianz.co.in within 15 days of the letter date.For policy wordings containing detailed terms, conditions and exclusions
of your insurance coverage follow below link
https://www.bajajallianz.com/download-documents/health-insurance/health-guard/Health-Guard-Policy-Wordings-print.pdf
Once again, we welcome you to the Bajaj Allianz family and look forward to a long association with you.

We assure you the best of our services and look forward to a continual patronage and association with you.

For & on the behalf

Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory

Signature Not Verified

Digitally signed by DS BAJAJ ALLIANZ GENERAL
INSURANCE COMPANY LIMITED 01
Date: 2023.03.11 11:12:18 IST

Bajaj Allianz General Insurance Co. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. Reg. No.: 113 CIN: U66010PN2000PLC015329

Give a Missed Call on 808094506 SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com http://www.linkedin.com/company/bajaj-allianz-general-insurance

bagichelp@bajajallianz.co.in Demystify Insurance https://www.bajajallianz.com/blog.html

HEALTH GUARD - INDIVIDUAL- POLICY SCHEDULE
UIN : BAJHLIP23065V052223

THANE BRANCH-Office No 201 To 206, ,2nd Floor, Sun Magnetica,,Nr

Policy issuing office and Correspondence address for communication
Teen Haath Naka,Nr New Rto, Loius Wadi.,Thane,Maharashtra,400602,
by policyholder for claim, service request, notice, summons, etc. INDIA

Proposer Details
Proposer Name Sumit Kumar Verma

Proposer Address HPCL MUMBAI REFINERY B D PATIL MARG, MUMBAI, MAHARASHTRA, 400074, INDIA

Phone No 9096876749 Email ID sumit.verma27@rediffmail.com

Customer ID 114701301

Previous Policy No 12-8450-0000066186-02 Previous Policy Expiry Date 14/03/2023

Policy Details
Policy Number 12-8450-0000066186-03 Endorsement No NA

Policy Issued on 11/03/2023 Policy Status ACTIVE

From 15/03/2023 00:00 Hrs To 14/03/2024

Period of Insurance Expiry Date 14/03/2024
Midnight

GSTIN / UIN Unregistered Place of Supply/State

Code/Name 27 - MAHARASHTRA
Company GST No: 27AABCB5730G1ZX

Company PAN AABCB5730G Invoice No: 272303I001292995

Insured Member Details

Nominee Name First Policy
Member Name Customer ID Plan Gender Date of Birth Age Relation
& Relation Inception Date
Sumit Kumar 1. Sulochana
114701301 Gold Male 27/08/1991 31.0 Self Verma - 15/03/2020
Verma
Mother
Insured address HPCL MUMBAI REFINERY B D PATIL MARG, MUMBAI, MAHARASHTRA, 400074, INDIA

Sum Insured & Cover Details

Daily Cash for Preventive
Inpatient Hospitalisation Treatment Convalesce Reinstateme Maternity Recharge
Member Name Accompanying Health
nce Benefit nt Benefit Expenses Benefit Limit
an Insured Check Up

Sum Sum
CB(CB%) SCB Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured
Insured Insured
Sumit Kumar 150000
300000 NA 5000 0 300000 0 3000 0
Verma (50%)

Add on Cover
Waiver of Room Capping Non-Medical Expenses Cover Health Prime Rider
Member Name
UIN: BAJHLA21577V012021 UIN: BAJHLAP21586V012021 UIN: BAJHLIA22169V012122

SUMIT KUMAR VERMA No No No

HEALTH GUARD - INDIVIDUAL- POLICY SCHEDULE
UIN : BAJHLIP23065V052223

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

Zone B / Zone C Discount 0

Base Premium 8100
Family Discount 0
Premium Payment Zone Zone A Long Term Policy Discount 0

Voluntary Co-payment Opted-10%/20% 0 Voluntary Co-payment Discount@10%/20% 0

Premium on Add-on Cover 0 Room Rent Capping Discount 0

Employee Discount 0
Premium on Health Prime Rider 0
Online Discount/Direct Customer Discount 0
Discount on Health Prime Rider 0
Wellness Discount 0
Premium on Respect Rider 0
Total Discount 0
Discount on Respect Rider 0 Eligible Discount 0
Gross Premium: Nine Thousand Five Hundred Fifty-Eight Net Premium 8100
Rupees
State GST(9%) 729
Central GST(9%) 729
IGST 0
UTGST 0
CESS 0
Gross Premium 9558

"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."

“I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover
notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.”

Exclusions
Member Name Exclusion

Sumit Kumar Verma NA

Special Exclusion at Policy

NA
Level

Additional Remarks
80D Certificate
Premium Payment Details
Financial Institution Ref. No.
NA
This is to certify that Sumit Kumar Verma has paid Rs.9558 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: 54-22-000001220490 Date: 11/03/2023 Premium Payer ID: 114701301 Float: NA;
Payment Frequency: Single Premium ** If Premium paid through Cheque, the Policy is void ab-initio in
case of dishonour of Cheque
NA

AGENCY CODE 10022164 CONTACT NO 09322246701

AGENCY NAME Swatijoshi EMAIL ID SWATIYJ@GMAIL.COM
 HEALTH GUARD - INDIVIDUAL- POLICY SCHEDULE
UIN : BAJHLIP23065V052223

For & on the behalf

Bajaj Allianz General Insurance Company Ltd. Consolidated Stamp Duty of Rs. 0.25/- 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
Rs.0.25/- This document is digitally signed,hence counter signature / stamp is not required
Principal Location : Bajaj Allianz House,Airport Road,Yerwada,Pune- 411006 PH-
66026666 | Services Accounting Code : 997133 Accident and health insurance services.
Authorized Signatory No reverse charge is payable on these services.

SUB 10022164 / NA

Policy Verification Claim Registration

Our Insurance Expert will call you for hassle free renewal and industry best offers on your coverage
Bajaj Allianz General Insurance Co.Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411006. Reg.No.:113 CIN:U66010PN2000PLC015329

Give a Missed Call on 8080945060, SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com http://www.linkedin.com/company/bajaj-allianz-general-insurance

bagichelp@bajajallianz.co.in Demystify Insurance https://www.bajajallianz.com/blog.html

RECEIPT

THANE BRANCH-Office No 201 To 206, ,2nd Floor, Sun

Policy issuing office and Correspondence address for communication
Magnetica,,Nr Teen Haath Naka,Nr New Rto, Loius Wadi.,
by policyholder for claim, service request, notice, summons, etc.
Thane,Maharashtra,400602,INDIA

Proposer Name Sumit Kumar Verma Policy Number 12-8450-0000066186-03

Receipt Number 54-22-000001220490 Receipt Date 11/03/2023

Business Channel PARTNERPORTAL

Received with thanks from: Sumit Kumar Verma

Customer ID: 114701301 a total sum of Rupees Nine Thousand Five Hundred Fifty-Eight Rupees Only by,

Instrument Type Instrument No Instrument Date Bank Name Branch Name Amount (Rs.)

Online Payment 97735885 11-Mar-2023 BN00000158 BN00000158 9,558.00

Total Amount: 9558

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

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

Give a Missed Call on 8080945060, SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com http://www.linkedin.com/company/bajaj-allianz-general-insurance

bagichelp@bajajallianz.co.in Demystify Insurance https://www.bajajallianz.com/blog.html

 HEALTH & WELLNESS CARD

THANE BRANCH-Office No 201 To 206, ,2nd Floor, Sun Magnetica,,Nr

Policy issuing office and Correspondence address for communication
Teen Haath Naka,Nr New Rto, Loius Wadi.,Thane,Maharashtra,400602,
by policyholder for claim, service request, notice, summons, etc. INDIA

Proposer Name Sumit Kumar Verma Policy Number 12-8450-0000066186-03

Scan QR to view your policy details

Health Card Number: 31-8450-0012899525-0001
Customer ID: 114701301
Policy No: 12-8450-0000066186-03
Inception Date: 15/03/2023
Valid Up to: 14/03/2024
Member Name: Sumit Kumar Verma
Age: 31

HEALTH & WELLNESS CARD

Bajaj Allianz General Insurance Company

(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:

Say Hi on WhatsApp on 7507245858, Give a Missed Call on 8080945060, SMS ‘WORRY’ to
575758, Contact our 24-Hour Call Center at 1800-209-5858
Email: Bagichelp@bajajallianz.co.in, Website www.bajajallianz.com
Corporate Identification Number: U66010PN2000PLC015329

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

Give a Missed Call on 8080945060, SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com http://www.linkedin.com/company/bajaj-allianz-general-insurance

bagichelp@bajajallianz.co.in Demystify Insurance https://www.bajajallianz.com/blog.html

 Certificate for the purpose of deduction under Section 80-D of Income Tax
Amendment Act, 1986

This is to certify that Sumit Kumar Verma has paid Rs. 9558 towards Health Insurance premium for HEALTH GUARD -
INDIVIDUAL for the period from 15/03/2023 to midnight of 14/03/2024 under Policy no 12-8450-0000066186-03

FINANCIAL YEAR AMOUNT(RS)

2022-2023 9558.00

Issue Date: 11/03/2023

Place: THANE BRANCH-Office No 201 To 206, ,2nd Floor, Sun

For & on the behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory
This certificate must be surrendered to the company for issuance of fresh certificate in case of cancellation of the Policy or any alteration
in the insurance affecting premium.

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.

Policy Verification
Claim Registration

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

Give a Missed Call on 8080945060, SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com http://www.linkedin.com/company/bajaj-allianz-general-insurance

bagichelp@bajajallianz.co.in Demystify Insurance https://www.bajajallianz.com/blog.html

TAX INVOICE
(Customer Copy)

Invoice Number 272303I001292995 Customer ID 114701301

Invoice Date 11/03/2023 Policy No. 12-8450-0000066186-03

Recipient/ Details of Insured Supplier/ Details of Insurer

GSTIN Unregistered GSTIN 27AABCB5730G1ZX

PAN NA PAN AABCB5730G

Name (Proposer) Sumit Kumar Verma Name Bajaj Allianz General Insurance Company Ltd.

Address-1 Hpcl Mumbai Refinery B D Patil Marg Address-1 Office No 201 To 206,

Address-2 NA Address-2 2nd Floor, Sun Magnetica,

Address-3 NA Address-3 Nr Teen Haath Naka,Nr New Rto, Loius Wadi.

Pin Code 400074 Pin Code 400602

City MUMBAI City THANE

State MAHARASHTRA State MAHARASHTRA

Client Category NON HNI Place of Supply 27 - MAHARASHTRA

Premium
Description Amount(INR) Description Amount(INR)

Net Premium 8100 State GST/UTGST(9%) 729

Receipt Number: 54-22-000001220490 Date: 11/03/2023
Central GST(9%) 729
Premium Payer ID: 114701301 Float: NA; ** If Premium paid
through Cheque, the Policy is void ab-initio in case of dishonour of 0
IGST(18%)
Cheque
Gross Premium 9558

Total Invoice Value (In figures) : 9558

Total Invoice Value (In Words) : Nine Thousand Five Hundred Fifty-Eight Rupees
Amount of Tax Subject to Reverse Charge: No reverse charge is payable on these services.

Services Accounting Code: 997133 Accident and health insurance services.

Principal Location: Bajaj Allianz House, Airport Road, Yerwada, Pune- 411006 PH-66026666

For & on the behalf

Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory

Important Notes:
* The invoice is issued as per Section 31 of the CGST Act
* 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
* 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
“I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified
under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.”

This is a digitally signed document and hence no physical signature is required

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

Give a Missed Call on 8080945060, SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com http://www.linkedin.com/company/bajaj-allianz-general-insurance

bagichelp@bajajallianz.co.in Demystify Insurance https://www.bajajallianz.com/blog.html