Bajaj Allianz General Insurance Company Limited

*88919055*
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)
Welcome to Bajaj Allianz Family

Bajaj Allianz General Insurance CoLtd, 15/54 B 2nd Floor,
Policy issuing office and Correspondence address for communication Virendra Smriti Complex, Civil Lines, KANPUR NAGAR-208001
by policyholder for claim, service request, notice, summons, etc. Phone No :0512-2338277
Proposer Name SATISH KUMAR SRIVASTAVA Policy Number OG-19-1302-8430-00000167
SATISH KUMAR SRIVASTAVA

PLOT NO 540-C FLAT NO 107-A GOPALA
GREEN APPARTMENT, RATANLAL NAGAR,
PO Area - KANPUR,
KANPUR, UTTAR PRADESH,
Pin - 208001
Customer ID : 29873720 *OG-19-1302-8430-00000167*
Dear Customer,
Thank you for choosing Bajaj Allianz General Insurer as your preferred insurer. Bajaj Allianz
General Insurance Company Limited, a consistently profitable insurer enjoys a reputation of
expertise, stability and strength. We are a customer focused market leader present in over 200
locations across India. As an organization we strive to understand the risk management needs of
our consumers and translate it into affordable products and services of global quality that deliver
value for money. Bajaj Allianz has an ISO Certified claims process and has received iAAA rating for
the last three consecutive years from ICRA Limited, an associate of Moody's Investors Service, for
claims paying ability. The rating indicates highest claims paying ability and a fundamentally strong
position in the industry.
We request you to kindly go through the contents of the policy schedule and the terms and
conditions. In case of any clarification or disagreement, please write to us at
Bagichelp@bajajallianz.co.in within fifteen days of receipt of this policy.
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
For help and more information: Page 1 of 8

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

*88919055*

HEALTH GUARD (FLOATER) POLICY SCHEDULE UIN. IRDAI/HLT/BAGI/P-H/V.II/113/16-17

PROPOSER DETAILS POLICY DETAILS

PLOT NO 540-C FLAT NO 107-A Policy Issued on 08-JUN-2018
GOPALA GREEN APPARTMENT, Period of From: 12-JUN-2018 00:01 Hrs.
RATANLAL NAGAR, Insurance
Proposer Address To : 11-JUN-2019 Midnight
PO Area - KANPUR,
KANPUR, UTTAR PRADESH, Customer ID 29873720
Pin - 208001 Policy Status Issued
Previous Policy No. OG-18-1302-8430-00000112 Expiry Date 11-Jun-2018
Insured Member Details
Member Name Customer ID Gender Date Of Birth Age Relation Nominee Name & Relation
SATISH KUMAR SRIVASTAVA 29873720 Male 08-DEC-1968 49 SELF ARTI DEVI SRIVASTAVA SPOUSE
SATISH KUMAR
ARTI DEVI SRIVASTAVA 96738861 Female 01-DEC-1975 42 SPOUSE SPOUSE
SRIVASTAVA
SATISH KUMAR
YASH SRIVASTAVA 96738862 Male 26-OCT-1998 19 SON FATHER
SRIVASTAVA
SATISH KUMAR
SHAURYA SRIVASTAVA 96738863 Male 08-JAN-2011 7 SON FATHER
SRIVASTAVA
GSTIN / UIN STATE CODE /NAME
NA 09 - Uttar Pradesh
Sum Insured & Cover Details
Daily Cash for Accompanying
Inpatient Hospitalization Treatment Convalescence Benefit Maternity Expenses
an Insured Child
Cumulative
Sum Insured Sum Insured Sum Insured Sum Insured
Bonus
1,90,000.00(47.5
4,00,000.00 5,000.00 5,000.00 25,000.00
%)
Premium Details
Description Amount(INR) Description Amount(INR)
Base Premium 18,537.00 Less: Long Term Policy Discount 0.00
Less: Employee Discount 0.00
Premium Payment Zone A Less: Voluntary Co-payment Discount @ 10% / 20% 0.00
Voluntary Co-payment Opted- 10%/20% 0% Net Premium 18,537.00
State GST (9%) 1,668.00
Gross Premium: Rupees Twenty One Thousand Eight Central GST (9%) 1,668.00
Hundred Seventy Three Only
Gross Premium 21,873.00


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HEALTH GUARD (FLOATER) POLICY SCHEDULE UIN. IRDAI/HLT/BAGI/P-H/V.II/113/16-17

Special Terms & Conditions NA

Member Name Special Condition Member level
SATISH KUMAR SRIVASTAVA NA
Special Exclusions ARTI DEVI SRIVASTAVA NA
YASH SRIVASTAVA NA
SHAURYA SRIVASTAVA NA
Maternity benefit is applicable for female member/s only.
Additional Remarks Daily Cash for Accompanying an Insured Child benefit is applicable only for children up to 12 years
This is to certify that SATISH KUMAR SRIVASTAVA has paid RS.21,873.00 towards Health Insurance
80 D Certificate 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
Receipt Number : 1302-00298708 | Date : 08-JUN-18 | Premium Payer ID : 29873720 | 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 10003024/SANJAY KATIYAR
Contact No. 9415484606 E-Mail sanjaykatiyar2004@yahoo.co.in
For & on the behalf
This document is digitally signed, hence counter signature / stamp is not

Authorized Signatory required.
null
BAGIC GST No : 09AABCB5730G1ZV

| Principal Location : Bajaj Allianz
General Insurance Co.Ltd, 15/54 B
2nd Floor, Virendra Smriti Complex,
Civil Lines, KANPUR NAGAR - 208001
PH:0512-2338277 | Services
Accounting Code : 997133 -
Accident and health insurance
services. No reverse charge is
payable on these services. | Invoice
No. : 84684576/2
Schedule (2) | Printed on : 25-AUG-2019 08:23:56|SilentPrint|Web|Sub 10003024 / NA


*88919055*

HEALTH GUARD (FLOATER) ANNEXURE

HEALTH & WELLNESS CARD
Customer ID : 29873720
Policy No : OG-19-1302-8430-00000167
ID Card No : 19-84684576
Valid Up to : 11-JUN-2019
SATISH KUMAR SRIVASTAVA (49Yrs.)
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


*88919055*


Policy No : OG-19-1302-8430-00000167
ID Card No : 19-84684576A
ARTI DEVI SRIVASTAVA (42Yrs.)

hospitalization.


*88919055*


Policy No : OG-19-1302-8430-00000167
ID Card No : 19-84684576B
YASH SRIVASTAVA (19Yrs.)

hospitalization.


*88919055*


Policy No : OG-19-1302-8430-00000167
ID Card No : 19-84684576C
SHAURYA SRIVASTAVA (7Yrs.)

hospitalization.


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HEALTH GUARD (FLOATER) RECEIPT

RECEIPT
Receipt Number 1302-00298708

Receipt Date 08-JUN-18
Business Channel ML
Received with thanks from SATISH KUMAR SRIVASTAVA

(Customer ID : 29873720) a total sum of Rupees Twenty One Thousand Eight Hundred Seventy Three Only by,
Instrument Type Instrument No Instrument Date Bank Name Branch Name Amount
RATANLAL
Cheque 298230 08/06/2018 STATE BANK OF INDIA 21,873.00
NAGAR
Total Amount 21,873.00
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

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


Bajaj Allianz General Insurance Company Limited

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*88919055*