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

[Unique Identification Number (UIN): IRDA/NL-HLT/BAGI/P-P/V.I/280/13-14

Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune

Transcript of Proposal for PERSONAL ACCIDENT

Dear MR MR MUKESH KUMAR JANGID

Policy Number OG-20-1000-9901-00271345

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 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, you shall be reasons for your 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 MR
Middle name MUKESH Last Name KUMAR JANGID
Email Address MUKESHJANGID791@GMAIL.COM Mobile Number 8385944085
Date of Birth 02-FEB-1992 Nationality
Pan No NA Unique Identity (Aadhaar No.) NA
Salary 2000000 Occupation OTHERS
Marital Status NA Family Monthly Income NA
Permanent Address Mailing Address
House No/ Building No/ Flat No SO TULSI RAM JANGID 233KH, KHATIKO House No/ Building No/ Flat No SO TULSI RAM JANGID 233KH, KHATIKO
KA MOHALLA JILIYA NAGAUR KA MOHALLA JILIYA NAGAUR
KUCHAMAN CITY - NEAR WATER TANK, , KUCHAMAN CITY - NEAR WATER TANK, ,
Street/ Locality/ Landmark , Street/ Locality/ Landmark ,
City NAGAUR City NAGAUR
Area , Area ,
Pincode 341508 Pincode 341508

Details of Persons to be insured:

Insured/ Beneficiary Name Gender Date of Birth Relation with Insured Annual Income
MUKESH KUMAR JANGID MALE 02-FEB-92 Proposer 2000000
 


Coverage Details

Insured/ Beneficiary Name Occupation Basic Sum Wider Sum Comprehensive PA add-on: Medical Hospital
Insured Insured Sum Insured Exp. Confinement
MUKESH KUMAR JANGID OTHERS 625000 1875000 0 NO NO

Nominee Details (for member other than proposer 100% assignment will be to the proposer)

Name of Insured Nominee No Name of Nominee DOB / Age Relation % of Sum Insured
MR MUKESH KUMAR JANGID 1 RATAN LAL 26 Others 100

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 : Personal Accident - Individual

2. Period of Insurance : IRDA/NL-HLT/BAGI/P-P/V.I/280/13-14 Year

3. Cumulative Bonus : NA

4. Any existing disability infirmity : NA

5. Previous Insurance Provider : NA

6. Previous Policy number : NA

7. 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 you 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 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.
 


E. 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
as in this transcript 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 as in this transcript will form the basis of the insurance policy, and is subject to the Board approved
underwriting policy of the insurer and that the policy will come into force only after full payment and realisation of the premium chargeable.
3. I further declare that I will notify in writing any change occurring in the occupation or general health of me or other persons to be insured/proposer
after the proposal has been submitted [as in this transcript] 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.I shall be bound by the Privacy Policy of the Company
5. I authorize the company to share information pertaining to my proposal [as in this transcript] 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.

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

Email address: customercare@bajajallianz.co.in

Website: www.bajajallianz.com

Contact our Policy servicing branch at: Bajaj Allianz House, Airport Road, Yerwada, , Pune-411006 Phone No :66026666

** This is print of electronic records maintained by us in accordance with law and hence does not require signature.

Scrutiny No: 142049741

INSURANCE ACT, 1938 SECTION 41 - PROHIBITION OF REBATES

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. ANY PERSON IN BREACH OF COMPLYING WITH THE PROVISIONS OF THIS SECTION
SHALL BE PUNISHABLE WITH FINE WHICH MAY EXTEND TO RUPEES TEN LAKH

For Bajaj Allianz General Insurance Company Limited

Sd/-** (Operations Head)

For & On Behalf of Bajaj Allianz General Insurance Company Ltd.
Authorized signatory Stamp
Duty Rs.
125

Authorized Signatory This document is digitally signed, hence counter signature / stamp is not required
Printed , Signed and Executed at Pune

Regd Office : Bajaj Allianz House,Airport Road, Yerwada Pune-411006 (India), A Company incorporated under Indian Companies Act, 1956 and licensed by
Insurance Regulatory and Development Authority of India [IRDA] vide Reg No.113, Corporate Identification Number U66010PN2000PLC015329.
Consolidated Stamp Duty of Rs.125/- paid towards Insurance Stamps vide Challan No. MH006357478201920M Defaced No. 0003534430201920 ORDER
NO.CSD/169/2019/4519 ORDER DATED 03.10.2019DEFACED DATE dated 03-OCT-19 timing 11:07:41 of General Stamp Office,Mumbai,India.
 

Bajaj Allianz General Insurance Company Ltd.
PERSONAL ACCIDENT POLICY SCHEDULE
UIN: IRDA/NL-HLT/BAGI/P-P/V.I/280/13-14

Policy issuing office and Correspondence address for communication by policyholder Bajaj Allianz House, Airport Road, Yerwada, , Pune-411006 Phone
for claim, service request, notice, summons, etc.: No :66026666
Policy No : OG-20-1000-9901-00271345
First Policy No:
Proposer Name: MR MR MUKESH KUMAR JANGID Partner Id: 172956624
Home Address : SO TULSI RAM JANGID 233KH, KHATIKO KA MOHALLA JILIYA NAGAUR
KUCHAMAN CITY - NEAR WATER TANK, PO Area - -,RAJASTHAN , , NAGAUR
Pincode : 341508
GSTIN / UIN: NA State Code / Name: 08 - Rajasthan
Loan Account No: 6C3GIPFQ617277

SNo NAME RELATION Date OF Birth AGE RISK SUM INSURED ADD ON OPTED CUMULATIVE BONUS(%)
CLASS
(Basic) (Wider) (Comp)
1 MUKESH Proposer 02-FEB-92 27 I 625000 1875000 0
KUMAR
JANGID
Proposer Nominee Details
Nominee Name Dob RelationShip Age Percentage
RATAN LAL 01-JAN-94 Others 26 100
* For Members Other Than Proposer 100% Nomination Will Be To The Proposer
Note - Basic :- Death Only
Wider:- Death + Permanent Disablement(PTD) +Permanent Partial Disablement(PPD)
Comprehenshive :-Death + PTD + PPD + Temperory Disablement
* ME : Add on Medical Cover , HC : Add on Hospital Confinement Allowance Cover.
Base Premium (in Rupees) : 2156
Loading Amount (in Rupees) :
Premium After Loading (in Rupees) :
Family Discount (in Rupees) :
Special Discount (in Rupees) :
Integrated GST (18%) 388
Total Premium (in Rupees) : 2544

Date : 02-JAN-2020
Policy Period :
From : 02-JAN-2020
To : 01-JAN-2021
Information regarding Intimation of Claim : In case of claim, somebody claiming on your behalf must inform us immediately in writing or telephonic intimation to our call centre on 1800-103-2529 (Toll free exclusively for health) or 020-30305858.
Intimation should include details of policy number, name of claimant and details of the accident and type of loss.

Agency Code 10031837 / Subimd 99999999 Channel Name : BA

Agency Name : BAJAJ FINANCE LTD
Contact No : 18002095858/0
Email - BAJAJFINANCELIMITED@GMAIL.COM
In case of any claim, please contact our 24 Hour Call centre at 1800-22-5858, 1800-102-5858 (Toll Free) / 91-020-30305858
(chargeable, add area code before this number in case of mobile call) or email us at 'Bagichelp@bajajallianz.co.in'.
142049741/-/10031837/99999999/-

:= / 142049741/2544 (INR) (If Premium is paid through cheque the policy is void ab-initio in case of dishonor of chq.)
For & On Behalf of Bajaj Allianz General Insurance Company Ltd.
Stamp
Duty Rs.
125

Authorized Signatory This document is digitally signed, hence counter signature / stamp is not required
Printed , Signed and Executed at Pune
Regd Office : Bajaj Allianz House,Airport Road, Yerwada Pune-411006 (India), A Company incorporated under Indian Companies Act, 1956 and licensed by
Insurance Regulatory and Development Authority of India [IRDA] vide Reg No.113, Corporate Identification Number U66010PN2000PLC015329.
Consolidated Stamp Duty of Rs.125/- paid towards Insurance Stamps vide Challan No. MH006357478201920M Defaced No. 0003534430201920 ORDER
NO.CSD/169/2019/4519 ORDER DATED 03.10.2019DEFACED DATE dated 03-OCT-19 timing 11:07:41 of General Stamp Office,Mumbai,India.

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.

Generated by Silent_Printing
 Bajaj Allianz General Insurance Company Limited.
Health & Wellness Card (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)

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
Customer ID : 172956624 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
Policy No : OG-20-1000-9901-00271345 helpline to verify coverage and cashless authorization.

ID Card No : 21-139185303-1
 
  
Valid Upto : 01-Jan-2021 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)
MUKESH KUMAR JANGID ( 27 Yrs) Email us at Bagichelp@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329