Bajaj Allianz General Insurance Company Ltd.

Corporate Identity Number (CIN): U66010PN2000PLC015329
Unique Identification Number (UIN): IRDAN113RP0012V01200102
Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune-411006
Transcript of Proposal for Standard Fire and Special Perils Policy

Dear KATIKALA PAVAN KUMAR,

We, Bajaj Allianz General Insurance Company Ltd [Company], wish to inform you that the contract under Policy number OG-18-3105-4025-00000002 [Policy]
has been finalized 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 be-
low, we request you to please revert back within a period of 15 days from the date of your receipt of this document [but in case of short term policies, your revert
shall reach us before the activities/risks covered by policies are started]. In case of our non-receipt of your disagreement or objection or any changes [as men-
tioned hereinabove] with respect to information mentioned below, it shall be deemed that you have positively confirmed to us the correctness of the below men-
tioned 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. 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.

Personal Information of Insured

Title Mr First Name KATIKALA
[Mr/Ms/Company/other
entity]
Middle Name Last Name PAVAN KUMAR
Email Address Mobile Number 9030351536
Date of Birth Gender Male
Pan No
Salary Occupation
Marital Status Family Monthly Income
Permanent Address Mailing Address
House No/ Building No/ A/C NO:1391667004201,S/O.SASI House No/ Building No/ A/C NO:1391667004201,S/O.SASI
Flat No KUMAR,PNO:29,SNO:405/5,SRI Flat No KUMAR,PNO:29,SNO:405/5,SRI
LAXMI SAI TOWN LAXMI SAI TOWN
SHIP,VANUKUR,PENAMALURU, SHIP,VANUKUR,PENAMALURU,
Street/ Locality/ Land- Street/ Locality/ Land-
mark mark
State ANDHRA PRADESH State ANDHRA PRADESH
City KRISHNA DIST City KRISHNA
Area Area
Pincode 521151 Pincode 521151

A. Risk Details :

Risk Type Occupation descrip- Risk Location Address/ Location Descrip- FEA Type No of Stories Floor where Sum Insured
tion tion risk is situ-
ated
Simple Dwellings KATIKALA PRAVEEN KUMAR,S/O.SASI KU- 0
MAR,PNO:29,SNO:405/5,SRI LAXMI SAI TOWN
SHIP,VANUKURU,PENAMALURU,KRISHNA
DIST.A P521151

BlockDe- Age of Build- Plinth & Super P&M FFF Stocks SIP Disc For Deleting
scription ing Found.SI(Rs.) St.Bid.SI (Rs.) (Rs.) (Rs.) (Rs.) Others Contents TSI
(Rs.) (Rs.) (Rs.) STFI RSMD
(in mile)
RESIDENTIAL 0.00 50,00,000.00 0.00 0.00 0.00 0.00 0.00 50,00,000.0 0.00 0
BUILDING 0

B. Coverage Details:

1. Period of Insurance : 29-JAN-18 to 28-JAN-23 Month(s)

2. Method Opted : Method B
3. Option II : With same sum insured
4. Do you want to exclude STFI Section : No
[Storm, Cyclone, Typhoon, Tempest, Hurricane,- :Tornado, Flood and Inundation: Section VI of: standard terms and conditions]
5. Do you want to exclude RSMD Section: No [Riot, strike, Malicious Damage: Section V - : of standard terms and conditions] :
6. Do you want to exclude Terrorism clause : Yes
7. Basis of Valuation as in table below : Please tick mark relevant words Yes/No in the table below.
(Buildings, Machinery Furniture, Fixture and Fittings - REINSTATEMENT value basis. Otherwise Market value basis i.e. stock and stock in process.)
Market Value Basis Reinstatement Value
Basis
No No

8. Previous Insurance Provider :

9. Previous Policy number :
10. Previous Policy expiry Date :
11. Is this Hypothecated to the Bank- : Yes
and if so the details: Name of Pledgee : CANARA BANK VENIGANDLA

12. Add on Cover(s) opted :

Addon Cover Code Addon Cover Description Addon Cover SI
EQP Earthquake With Plinth and Foundation 50,00,000.00
13. Whether you have insured the same property with any other insurance company with identical coverage (If so, give details)
________________________________________________________ No provision on TAB

14. Whether Insurance cover was declined by any other company or imposed any special conditions (If is, give details)
______________________________________________________________________________ No provision on TAB

C. EXCLUSIONS AND TERMS AND CONDITIONS:

The detailed list of exclusions, Standard Terms and Conditions of the Company, were fully explained to you and for full details thereof please refer to the
Policy wordings of the Company.
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.
In case of Disagreement or objection or any changes with respect to information, declarations, Standard Terms and Conditions, exclusions and contents
mentioned hereinabove, please contact our toll free number and register your objections / changes / disagreement to the contents of this transcript or
you may also send us an email or written correspondence at the following details within a period of 15 days from date of your receipt of this transcript
along with the Policy.

DECLARATION:

If additions or alterations are carried out in the risk proposed after the submission of this form, then the same would be conveyed by me/us to the Com-
pany immediately.

I authorize the Company to share information pertaining to my proposal for the sole purpose of underwriting the proposal and/or claims settlement and
with any Governmental and/or Regulatory authority, reinsurers, group companies, auditors/legal counsel, service providers etc.,.

I agree and hereby declare that there are no losses/claims at the proposed risk locations in past 3 years to the best of my knowledge. I agree that the
Standard Terms and Conditions sent to me for the Policy taken by me for the first time shall be applicable to the renewal Policy and the Company need
not sent the Standard Terms and Conditions at the time of renewal and if I/we require the same I/We will seek the same from the Company.

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: D No 6-9-10/A, First Floor, , Shri Teja House, Above Syndicate Bank, , 9/2, Arundel Pet, Guntur, , GUNTUR-
522002,Phone No: 08666632031

** This is print of electronic records maintained by us in accordance with law and hence does not require signature.
Scrutiny No: 81340658

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 re-
spect 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 ac-
cordance with the published prospectus or tables of the insurer. Any person making default in complying with the provisions of this section shall be liable
for a penalty which may extend to ten lakh rupees.
 


POLICY SCHEDULE
Standard Fire and Special Perils Policy
UIN: IRDAN113RP0012V01200102
Policy issuing office and Correspondence address for communication D No 6-9-10/A, First Floor, , Shri Teja House, Above Syndicate Bank, ,
by policyholder for claim, service request, notice, summons, etc. 9/2, Arundel Pet, Guntur, , GUNTUR-522002 Tel No:08666632031,
0866-66632021

INSURED DETAILS POLICY DETAILS

Insured Name KATIKALA PAVAN KUMAR Current Policy No OG-18-3105-4025-00000002
Insured Address A/C NO:1391667004201,S/O.SASI KU- Expiring Policy No
MAR,PNO:29,SNO:405/5,SRI LAXMI SAI Product Standard Fire and Special Perils Policy
TOWN SHIP,VANUKUR,PENAMALURU, Policy Issued on 01-FEB-18
ANDHRA PRADESH, KRISHNA DIST-521151 Period of Insurance 29-JAN-18 to 28-JAN-23
Partner ID 112637476 Coinsurance Details N/A
GSTIN / UIN NA
Place Of Supply/ 37 - Andhra Pradesh Policy Status Issued
State Code/Name Invoice No : 93164172/1
Bank Details Various Financial Institutes as listed in Annexure
II
Bank Reference No. 1391667004201
Bank Emp. Code
Company GST No : 37AABCB5730G1ZW
Company PAN : AABCB5730G

Description Sum Insured (Rs)

Sum Insured (Only Fire) 50,00,000.00

Premium Details Amount (Currency) Premium Details Amount (Currency)

Net Fire Premium (A) 3,345.75 State GST (9%) 381
Net Add On Cover (B) 892.25 Central GST (9%) 381
Terrorism Surcharge (C) 0.00 Final Premium (A+B+C+D+E) 5,000.00

Premium Collection Details 1815-00082538 / 81340658 / RS. 5000 ,

Agency Code 10045514 Channel Name : BA

Agency Name : CANARA BANK
Contact No : -/-
Email - CB4148@CANARABANK.COM

Risk covered Standard Fire & Special Perils and Addons as detailed under Annexure I

Add on Cover Earthquake With Plinth and Foundation

Exclusions Standard Fire and Special Perils wordings, clauses and warranties as attached

Subject to clauses Agreed Bank Clause

Annexure1-Terrorism Damage Exclusion Warranty

Warranties Construction (Applicable Other THAN FOR OPEN STORAGE)

Fea Warranty

Option II : With same sum insured

Special conditions / Deduct- This policy excludes direct and indirect loss as a result of infectious diseases or contagious disease; including but not
ibles (if applicable) limited to diseases arising out of coronaviruses.

Higher Excess

81340658/-/10045514/4000/Y
NOTE: If Premium paid through Cheque, the Policy is void ab-initio in case of dishonor of Cheque.
This policy is subject to the standard policy wordings, warranties and conditions applicable for this product in addition to any specific warranty or condition attached.

In Case of any claim, please contact our 24 Hour Call Centre at 1800-22-5858, 1800-102-5858, 1800-209-5959 Toll Free / 30305858 (Chargeable, add area code before this number in case of mobile
call) or email us at Bagichelp@bajajallianz.co.in
Regd Office: Bajaj Allianz House, Airport Road, Yerwada Pune-411006 (India) Latest Schedule-11-Sep-2020:08:14:53 PM Generated by Silent_Printing
 In witness whereof undersigned being authorized by and on behalf of the company has/have herein to set his/her their
name...........................................................(Date) at............................................................ (Place)................................
null
For & On Behalf of Bajaj Allianz General Insurance Company Ltd.
Stamp
Duty
Rs. 0.5

Authorized Signatory This document is digitally signed, hence counter

signature / stamp is not required
Printed , Signed and Executed at null Consolidated Stamp Duty of Rs.0.5/- paid towards
Pune Insurance Stamps vide Challan No.
MH008554577201718M Defaced No.
0004919688201718 dated 30-DEC-17 timing 16:10:44
of General Stamp Office,Mumbai,India.
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 Devel-
opment Authority of India [IRDA] vide Reg No.113, Corporate Identification Number U66010PN2000PLC015329.
Principal Location : D.No.40-1-10, Upsatirs of Kusalava Hyundai Showroom, 2nd Floor, MG Road, Labbipet, Vijayawada - 520010 PH:0866-6632031 | Services Accounting Code : 997137 -
Other property insurance services. No reverse charge is payable on these services.

In Case of any claim, please contact our 24 Hour Call Centre at 1800-22-5858, 1800-102-5858, 1800-209-5959 Toll Free / 30305858 (Chargeable, add area code before this number in case of mobile
call) or email us at Bagichelp@bajajallianz.co.in
Regd Office: Bajaj Allianz House, Airport Road, Yerwada Pune-411006 (India) Latest Schedule-11-Sep-2020:08:14:53 PM Generated by Silent_Printing
 


Policy issuing office and Correspondence address for communication D No 6-9-10/A, First Floor, , Shri Teja House, Above Syndicate Bank, ,
by policyholder for claim, service request, notice, summons, etc. 9/2, Arundel Pet, Guntur, , GUNTUR-522002 Tel No:08666632031,
0866-66632021

INSURED DETAILS POLICY DETAILS

Insured Name KATIKALA PAVAN KUMAR Current Policy No OG-18-3105-4025-00000002

Standard Fire And Special Perils Policy

Annexure I

Policy No OG-18-3105-4025-00000002
Policy Period 29-JAN-18 to 28-JAN-23

Location Description: RESIDENTIAL BUILDING

Location Address : KATIKALA PRAVEEN KUMAR,S/O.SASI KU-
MAR,PNO:29,SNO:405/5,SRI LAXMI SAI TOWN
SHIP,VANUKURU,PENAMALURU,KRISHNA DIST. A P
521151
Occupation Description : Dwellings

Sr.No. BlockDescription Plinth & Super P&M FFF Stocks SIP Disc For Deleting CED Fea Spr Net Net Fire
Found.SI(Rs.) St.Bid.SI (Rs.) (Rs.) (Rs.) (Rs.) Others TSI Disc Disc Disc. Rate Rate Premium
(Rs.) (Rs.) STFI RSMD (ln%) Bidg. Cont (Rs)
(in mile)
1 RESIDENTIAL BUILDING 0.00 50,00,000.00 0.00 0.00 0.00 0.00 0.00 50,00,000.0 0.00 0 0 0 0 .5 .5 9,375.00
0

Addon Covers Details(Location Level):

Sr.No Addon Cover Code Addon Cover Description Addon Cover SI Addon Cover Premium
1 EQP Earthquake With Plinth and Foundation 50,00,000.00 2,500.00

For and on behalf of

Bajaj Allianz General Insurance Company Ltd

Authorized Signatory
In Case of any claim, please contact our 24 Hour Call Centre at 1800-22-5858, 1800-102-5858, 1800-209-5959 Toll Free / 30305858 (Chargeable, add area code before this number in case of mobile
call) or email us at Bagichelp@bajajallianz.co.in
Principal Location : D.No.40-1-10, Upsatirs of Kusalava Hyundai Showroom, 2nd Floor, MG Road, Labbipet, Vijayawada - 520010 PH:0866-6632031 | Services Accounting Code : 997137 - Other prop-
erty insurance services. No reverse charge is payable on these services.
Regd Office: Bajaj Allianz House, Airport Road, Yerwada Pune-411006 (India) Latest Schedule-11-Sep-2020:08:14:53 PM

Generated by Silent_Printing
 


Policy issuing office and Correspondence address for communication D No 6-9-10/A, First Floor, , Shri Teja House, Above Syndicate Bank, ,
by policyholder for claim, service request, notice, summons, etc. 9/2, Arundel Pet, Guntur, , GUNTUR-522002 Tel No:08666632031,
0866-66632021

INSURED DETAILS POLICY DETAILS

Insured Name KATIKALA PAVAN KUMAR Current Policy No OG-18-3105-4025-00000002

Standard Fire And Special Perils Policy

Annexure ||

Policy No. : OG-18-3105-4025-00000002

Location : RESIDENTIAL BUILDING
Address : KATIKALA PRAVEEN KUMAR,S/O.SASI KU-
MAR,PNO:29,SNO:405/5,SRI LAXMI SAI TOWN
SHIP,VANUKURU,PENAMALURU,KRISHNA DIST. A
P 521151
Block Desc : RESIDENTIAL BUILDING
Item Code Item Details Item Description
I002 RESIDENTIAL BUILDING Super Structure(Building)
This Policy Covers The Respective Rights And Interests Of following Banks/Financial Institutions:-
Sr.No. Financial Institute Name
1 CANARA BANK VENIGANDLA

For and on behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory
In Case of any claim, please contact our 24 Hour Call Centre at 1800-22-5858, 1800-102-5858, 1800-209-5959 Toll Free / 30305858 (Chargeable, add area code before this number in case of mobile
call) or email us at Bagichelp@bajajallianz.co.in
Principal Location : D.No.40-1-10, Upsatirs of Kusalava Hyundai Showroom, 2nd Floor, MG Road, Labbipet, Vijayawada - 520010 PH:0866-6632031 | Services Accounting Code : 997137 - Other prop-
erty insurance services. No reverse charge is payable on these services.
Regd Office: Bajaj Allianz House, Airport Road, Yerwada Pune-411006 (India) Latest Schedule-11-Sep-2020:08:14:53 PM
 


Policy issuing office and Correspondence address for communication D No 6-9-10/A, First Floor, , Shri Teja House, Above Syndicate Bank, ,
by policyholder for claim, service request, notice, summons, etc. 9/2, Arundel Pet, Guntur, , GUNTUR-522002 Tel No:08666632031,
0866-66632021

INSURED DETAILS POLICY DETAILS

Insured Name KATIKALA PAVAN KUMAR Current Policy No OG-18-3105-4025-00000002

Standard Fire And Special Perils Policy

Annexure III

This Following Addon Covers/Clauses/Warrantiesare attached to and form that of policy No : OG-18-3105-4025-00000002

Addon-cover

EarthQuake : Extension cover shall be granted only if the entire property in one Complex / Compound/ location covered under the policy is extended to cover
this risk and sum insured for this extension is identical to the sum insured against the risk covered under main policy except for the value of the plinth and foundation
of the building(s). If option to delete STFI peril is not exercised "In consideration of the payment by the Insured to the Company of the sum of ____________ addition-
al premium, it is hereby agreed and declared that notwithstanding anything stated in the printed exclusions of this policy to the contrary, this Insurance is extended to
cover loss or damage (including loss or damage by fire) to any of the property Insured by this policy occasioned by or through or in consequence of earthquake includ-
ing flood or overflow of the sea, lakes, reservoirs and rivers and/or Landslide /Rockslide resulting therefrom. Provided always that all the conditions of this policy shall
apply (except in so far as they may be hereby expressly varied) and that any reference therein to loss or damage by fire shall be deemed to apply also to loss or damage
directly caused by any of the perils which this insurance extends to include by virtue of this endorsement." Special conditions 1) Excess clause 5% of each and every
claim subject to a minimum of Rs.10,000/. 2) Extension cover shall be granted only if the entire property in one complex / compound /location covered under the
policy is extended to cover this risk and the Sum Insured for this extension is identical to the Sum Insured against the risk covered under main policy except for the
value of the plinth and foundations of the building(s).. 3) Onus of proof In the event of the Insured making any claim for loss or damage under this policy he must (if so
required by the Company) prove that the loss or damage was occasioned by or through or in consequence of earthquake."

CLAUSE

Agreed Bank Clause : "`It is hereby declared and agreed:- i. That upon any monies becoming payable under this policy the same shall be paid by the
Company to the Bank and such part of any monies so paid as may relate to the interests of other parties insured hereunder shall be received by the Bank as Agents for
such other parties. ii. That the receipts of the Bank shall be complete discharge of the Company therefore and shall be binding on all the parties insured hereun-
der.N.B: The Bank shall mean the first named Financial Institution/ Bank named in the policy.iii. That if and whenever any notice shall be required to be given or
other communication shall be required to be made by the Company to the insured or any of them in any manner arising under or in connection with this policy such no-
tice or other communication shall be deemed to have been sufficiently given or made if given or made to the Bank.iv. That any adjustment, settlement, compromise
or reference to arbitration in connection with any dispute between the Company and the insured or any of them arising under or in connection with this policy if made
by the Bank shall be valid and binding on all parties insured hereunder but not so as to impair rights of the Bank to recover the full amount of any claim it may have on
other parties insured hereunder. v. That this insurance so far only as it relates to the interest of the Bank therein shall not cease to attach to any of the insured prop-
erty by reason of operation of condition 3 of the Policy except where a breach of the condition has been committed by the Bank or its duly authorised agents or servants
and this insurance shall not be invalidated by any act or omission on the part of any other party insured hereunder whereby the risk is increased or by anything being
done to upon or any building hereby insured or any building in which the goods insured under the policy are stored without the knowledge of the Bank provided always
that the Bank shall notify the Company of any change of ownership or alterations or increase of hazards not permitted by this insurance as soon as the same shall come
to its knowledge and shall on demand pay to the Company necessary additional premium from the time when such increase of risks first took place andvi. It is fur-
ther agreed that whenever the Company shall pay the Bank any sum in respect of loss or damage under this policy and shall claim that as to the Mortgagor or owner no
liability therefore existed, the Company shall become legally subrogated to all the rights of the Bank to the extent of such payments but not so as to impair the right of
the Bank to recover the full amount of any claim it may have on such Mortgagor or Owner or any other party or parties insured hereunder or from any securities or
funds available.N.B: In cases where the name of any Central Government or State Government owned and / or sponsored Industrial Financing or Rehabilitation Finan-
cing Corporations and /or Unit Trust of India or General Insurance Corporation of India and/or its subsidiaries or LIC of India/ any Financial Institution is included in
the title of the Fire Policy as mortgages, the above Agreed Bank Clause may be incorporated in the Policy substituting the name of such institution in place of the word
'Bank' in the said clause.

Annexure1-Terrorism Damage Exclusion Warranty : This Policy excludes loss, damage, cost or expense of whatsoever nature directly or indir-
ectly caused by, resulting from or in connection with any act of terrorism regardless of any other cause or event contributing concurrently or in any other sequence to
the loss. For the purpose of this exclusion, an act of terrorism means an act or series of acts, including but not limited to the use of force or violence and/or the threat
thereof, of any person or group(s) of persons, whether acting alone or on behalf of or in connection with any organisation(s) or government(s), or unlawful associations,
recognized under Unlawful Activities (Prevention) Amendment Act, 2008 or any other related and applicable national or state legislation formulated to combat unlaw-
ful and terrorist activities in the nation for the time being in force, committed for political, religious, ideological or similar purposes including the intention to influence
any government and/or to put the public or any section of the public in fear for such purposes. This exclusion also includes loss, damage, cost or expense of whatsoever
nature directly or indirectly caused by, resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to the above.

WARRANTY

Construction (Applicable Other THAN FOR OPEN STORAGE) : Warranted that the building covered under the policy/ in which the contents
covered under this policy is present is not kutcha construction as described below. Kutcha construction: Building (s) having walls and / or roofs of wooden planks /
thatched leaves and / or grass/ hay of any kind / bamboo/ plastic cloth/ asphalt cloth/ canvas/ tarpaulin and the like.

Fea Warranty : Warranted that any claim under the policy shall be admissible only if: a) All Fire Extinguishing Appliances ( available at the time of policy in-
ception) shall be installed throughout the premises at accessible locations and to be maintained in efficient working condition through the policy period) b) Hydrant
system / smoke detectors / Heat detectors / Fire alarms / sprinklers if available at the time of commencement of risk or agreed to be installed before acceptance of risk
shall be maintained in efficient working condition. It is also warranted that a team of trained employees shall remain available inside the plant premises during the
working hours of plant

For and on behalf of

Bajaj Allianz General Insurance Company Ltd.
Authorized Signatory
In Case of any claim, please contact our 24 Hour Call Centre at 1800-22-5858, 1800-102-5858, 1800-209-5959 Toll Free / 30305858 (Chargeable, add area code before this number in case of mobile
call) or email us at Bagichelp@bajajallianz.co.in

Principal Location : D.No.40-1-10, Upsatirs of Kusalava Hyundai Showroom, 2nd Floor, MG Road, Labbipet, Vijayawada - 520010 PH:0866-6632031 | Services Accounting Code : 997137 - Other prop-
erty insurance services. No reverse charge is payable on these services.
Regd Office: Bajaj Allianz House, Airport Road, Yerwada Pune-411006 (India) Latest Schedule-11-Sep-2020:08:14:53 PM
 Bajaj Allianz General Insurance Company Ltd.
Door no: 6-9-10/A, Teja House, Above Syndicate Bank, 9/2, Arundel Pet, GUNTUR - 522002
Contact No:Contact No: 0863 - 6632051; Fax No: 0863 - 6632041

RECEIPT

Receipt Number 1815-00082538

Receipt Date 01/02/2018
Business Channel BA

Received with thanks from KATIKALA PAVAN KUMAR

(Customer ID : 112637476 ) a total sum of Rupees Five Thousand Only by,

Instrument Instrument No. Instrument Bank Name Branch Name Amount

Type Date
DD/PO 412865 29/01/2018 CANARA BANK PAYABLE AT PAR 5,000

Total Amount Rs. 5,000.00

Note : SC NO: 81340658
Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General In-
surance Company Limited. The insurance cover for the risk shall be as per the terms and con-
ditions of the Insurance Policy if and when issued.
* Cheque/DD/PO receipt is valid subject to realisation of the instrument.

For & on behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory

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