Bajaj Allianz General Insurance Company Ltd

[Corporate Identity Number (CIN) : U66010PN2000PLC015329]

Unique Identification Number (UIN) : BAJHLGP20109V011920
Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune-411006
Transcript of Proposal for Group Guard Policy Schedule
Dear MR. AYAN ROY,
We, Bajaj Allianz General Insurance Company Limited [âCompanyâ] 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 [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 mentioned hereinabove] with respect to information mentioned
below, it shall be deemed that you have positively confirmed to us 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, 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

First Name AYAN
Middle Name Last Name ROY
Email Address GODDEMI868@GMAIL.COM Mobile Number 0
Date of Birth 05-FEB-97 Nationality INDIAN
Unique Identity (Aadhaar
Pan No No.)
Salary Occupation NA
Marital Status NA Family Monthly Income
Permanent Address Mailing Address
House No/ Building No/ House No/ Building No/
835BTROADBARANAGAR -M-
Flat No Flat No
Street/ Locality/ Street/ Locality/
835BTROADBARANAGAR -M-
Landmark Landmark
State WEST BENGAL State
City KOLKATA City
Area Area
Pincode 700090 Pincode

Q1. Do you or any of the family members to be covered have/had any health complaints/disability/met with any accident in the past and/or have been taking treatment/
hospitalization? Please provide the details & duration of illness along with treatment taken in below table. NO
Total Pre
Insured/Beneficiar Relation with Sum insured Nominee Relation Add On Cover
Gender Date of Birth Nominee Name Monthly Existing
y Name Insured (Individual Basis) with Beneficiary Details INcome Diseases
MR. AYAN ROY Self Male 05-FEB-1997 500 Ayan Roy Self NA NO

Kindly note that as the information/contents and declarations/confirmations provided by you as contained in this transcript is the basis on which we are issuing / 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 : GROUP GUARD FOR SAVING ACCOUNT HOLDERS OF UJJIVAN SMALL FINANCE BANK
2. Period of Insurance : 30-MAY-24 to 29-MAY-25
3. Previous Insurance Provider : NA
4. Previous Policy number : NA
5. Previous Policy expiry Date : NA
6. Health Prime Rider : Individual Option 2

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 him 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 & register 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.
DECLARATION:

For help and more information: Page 1 of 6

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

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 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 will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurer and that the policy
will come into force only after full payment of the premium chargeable.
3. I further declare that I will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been submitted 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.
5. I authorize the company to share information pertaining to my proposal 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.
PROHIBITION OF REBATES
Section 41, of Insurance Act, 1938: 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 making default in complying with the provisions of this section shall be punishable with a penalty which may extend to ten lakh rupees.
Toll free Number: 1800-103-2529, 1800-102-5858 and 1800-209-5858
Email address: Bagichelp@bajajallianz.co.in
Website: www.bajajallianz.com
Contact our Policy servicing branch at: Golden Heights,4th Floor,No.1/2,59th C Cross,4th M Block,Rajajinagar,BANGALORE-560010,Phone No :080-67195000
** This is print of electronic records maintained by us in accordance with law and hence does not require signature.
Scrutiny No: 405664996

For help and more information: Page 2 of 6

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

 *405664996*

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 â 411006 (India)

GROUP GUARD POLICY SCHEDULE UIN : BAJHLGP20109V011920

Policy issuing office and Correspondence address for communication by policyholder for Golden Heights,4th Floor,No.1/2,59th C Cross,4th M Block,Rajajinagar,BANGALORE-
claim, service request, notice, summons, etc. : 560010,Phone No :080-67195000
Insured Name MR. AYAN ROY Child Certificate Number OG-25-1701-6035-00070569

INSURED DETAILS POLICY DETAILS

Policy Issued on 30-MAY-2024
835BTROADBARANAGAR -M-,
835BTROADBARANAGAR -M-, From: 30-MAY-2024 00:00
Insured Address Period of Insurance
KOLKATA - 700090, To : 29-MAY-2025 Midnight
WEST BENGAL
Endorsement NA
Customer ID 437479162 Previous Policy Number NA
GSTIN / UIN NA
Policy Status ISSUED STATE CODE / NAME 19 - West Bengal
Company GST No : 29AABCB5730G1ZT
Invoice No : 423783789/0 Company PAN : AABCB5730G
Master Policy Number OG-23-9999-9960-00000039 Plan Chosen GROUP GUARD FOR SAVING ACCOUNT HOLDERS OF UJJIVAN
SMALL FINANCE BANK
Cover Details
PLAN RISK COVERED RATES/SUM INSURED
Per Day Benefit :- 500
Option 1 Hospital Cash Benefit NO_OF_DAYS :- 10
AGE :- 27
Rider Selected Health Prime Rider Individual Option 2 COVER :- Option 2
Premium Details
Discounts ( if Any ) Rs.0
Net Premium. Rs.384
Final Premium Rupees Four Hundred Fifty Three only.
Integrated GST (18%) Rs.69
Gross Premium. Rs.453

Family Member Details

Insured Name Relation Gender DOB Rate(%) Nominee Name Nominee Relation Pre Existing Diseases
AYAN ROY Self Male 05-FEB-1997 Ayan Roy Self N
Other Details
Scope of coverage 1 PER DAY BENEFIT -500 PER DAY IN CASE OF MINIMUM 24 HOURS OF HOSPITALIZATION DUE TO SICKNESS OR ACCIDENTAL.
Scope of coverage 2 DAY CARE PROCEDURES ARE COVERED AS PER THE STANDARD DEFINITION OF DAY CARE.
Scope of coverage 3 PED AND SPECIFIC DISEASE WAITING PERIOD IS 12 MONTHS.
Scope of coverage 4 MATERNITY IS NOT COVERED
Scope of coverage 5 NUMBER OF DAYS BENEFIT IS 10 DAYS
Scope of coverage 6 DOUBLE ICU BENEFIT.
HEALTH PRIME RIDER TELE CONSULTATION COVER = UNLIMITED (ALL SPECIALITIES) INVESTIGATIONS COVER PATHOLOGY AND RADIOLOGY
Scope of coverage 7 EXPENSES = 1500 ANNUAL PREVENTIVE HEALTH CHECK -UP COVER = 1 VOUCHER
Scope of Coverage 8 INITIAL WAITING PERIOD OF 30 DAYS WILL BE APPLICABLE.
Scope of Coverage 9 REST OF THE TERMS AND CONDITIONS AS PER GROUP GUARD AND HEALTH PRIME RIDER (GROUP) POLICY WORDING.
Gross Monthly Income 66666
Pre-Existing Disease N
Bank Reference No. 2 3325218609
BAGIC. RM. Code NA
BAGIC RM Name NA
IMD RM. Code NA
IMD RM Name NA
UW Remarks NA
First Policy Inception Date NA
Previous Policy Expiry Date NA
Special Terms and Conditions NA
Smoking N
Customer Consent YES
Electronic Insurance Account
Number (EIA No)
Remarks NA
S P Code
GSTN No
This is to certify that MR. AYAN ROY has Paid Rs.453 towards Health Insurance for Period and Policy Number as mentioned on the Policy Schedule
80 D Certificate and is eligible for Deduction under Section 80-D of Income Tax (Amendment) Act, 1986 .

Receipt Number:1701-05149125 | Date:30-MAY-24 | Premium Payer ID:10050945 | Float: AF

Premium Details ** If Premium paid through Cheque, the Policy is void ab-initio in case of dishonour of Cheque.
Financial Institution Ref. No. 3325110250052405

For help and more information: Page 3 of 6

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

 *405664996*

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 â 411006 (India)

GROUP GUARD POLICY SCHEDULE UIN : BAJHLGP20109V011920

Policy issuing office and Correspondence address for communication by policyholder for Golden Heights,4th Floor,No.1/2,59th C Cross,4th M Block,Rajajinagar,BANGALORE-
claim, service request, notice, summons, etc. : 560010,Phone No :080-67195000
Insured Name MR. AYAN ROY Child Certificate Number OG-25-1701-6035-00070569

Agency Code 10050945,UJJIVAN SMALL Contact No. 07774999823,00

& Name FINANCE BANK E-Mail ID. sai@gmail.com
LIMITED
For & on the behalf
Bajaj Allianz General Insurance Company Ltd. QR Code

Authorized Signatory
(It is mandatory to keep your policy with updated contact (Mobile No., Email ID and PAN Card) and bank account details, to process any of your service requests faster and hassle-free
in future.You can update the same through Caringly yours App {Link}, WhatsApp Service { Say Hi on WhatsApp - +91 75072 45858}, Contact our 24-Hour Call Center at 1800-209-5858,
1800-102-5858, Give a Missed Call on 8080945060, SMS WORRY to 575758, Email bagichelp@bajajallianz.co.in, website {Link}, contact your agent or nearest branch.)
(This is system generated document and need not be countersigned.)
Consolidated Stamp Duty of Rs. 0.50/- paid for insurance policy stamps vide Order No. CSD/17/2023/4571 dated 10-NOV-23 of General Stamp Office, Mumbai, India.
BAGIC GST No : 29AABCB5730G1ZT | Principal Location : Golden Heights, 4th Floor, No.1/2, 59th C Cross, 4th M Block, Rajajinagar, BANGALORE - 560010 PH:080-67195000 |
Services Accounting Code : NA. No reverse charge is payable on these services. | Invoice No. : 423783789/1
Schedule (1) | Printed on : 15-Oct-2024 10:01:48 pm |Silent Print|WEB|094500000100

For help and more information: Page 4 of 6

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

 *405664996*

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 â 411006 (India)

HEALTH PRIME RIDER COVER UIN : BAJHLGA22166V012122

Policy issuing office and Correspondence address for communication by policyholder for Golden Heights,4th Floor,No.1/2,59th C Cross,4th M Block,Rajajinagar,BANGALORE-
claim, service request, notice, summons, etc. : 560010,Phone No :080-67195000
Insured Name MR. AYAN ROY Child Certificate Number OG-25-1701-6035-00070569

HEALTH PRIME RIDER COVER DETAILS

HEALTH PRIME RIDER PLAN HEALTH PRIME RIDER PREMIUM(Excl. GST)
Health Prime Rider Individual Option 2 178

SCOPE OF COVERAGES
HEALTH PRIME RIDER PLAN COVERAGE
Tele Consultation Cover = Unlimited (All Specialities) + Investigations
Health Prime Rider Individual Option 2 Cover - Pathology & Radiology Expenses = 1500 + Annual Preventive
Health Check -up cover = 1 Voucher

For help and more information: Page 5 of 6

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

 *405664996*

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 â 411006 (India)

HEALTH PRIME RIDER COVER UIN : BAJHLGA22166V012122

Policy issuing office and Correspondence address for communication by policyholder for Golden Heights,4th Floor,No.1/2,59th C Cross,4th M Block,Rajajinagar,BANGALORE-
claim, service request, notice, summons, etc. : 560010,Phone No :080-67195000
Insured Name MR. AYAN ROY Child Certificate Number OG-25-1701-6035-00070569

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)

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.
HEALTH & WELLNESS CARD 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.

For help and more information:
Contact our 24 Hour Call Center at 1800-102-5858,1800-209-5858,
Customer ID:437479162 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-25-1701-6035-00070569
ID Card No : 25-423783789
Valid Upto : 29-May-2025
AYAN ROY (27 Yrs)

For help and more information: Page 6 of 6

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