*136393822*

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)

MEDICLAIM INSURANCE POLICY - (FOR BFL CUSTOMERS) POLICY SCHEDULE UIN : IRDA/NL-
HLT/BAGI/P-H/47/13-14

Policy issuing office and Correspondence address for communication by policyholder for Bajaj Allianz House,Airport Road,Yerwada,Pune-411006,Phone No :66026666
claim, service request, notice, summons, etc. :
Insured Name MS SHAMPA DEY Child Certificate Number OG-20-1000-6021-00119576
INSURED DETAILS POLICY DETAILS
Policy Issued on 11-NOV-2019
45 REGENT COLONY 1ST FLOOR TOLLY GUNJ NSC BOSE ROAD,
KOLKATA, From: 09-NOV-2019 00:00
Insured Address Period of Insurance
KOLKATA - 700040, To : 08-NOV-2020 Midnight
WEST BENGAL
Endorsement NA
Customer ID 167385618 Previous Policy Number NA
GSTIN / UIN NA
STATE CODE / NAME 19 - West Bengal
Policy Status ISSUED
Company GST No : 27AABCB5730G1ZX
Invoice No : 134895229/0
Company PAN : AABCB5730G
Master Policy Number OG-20-9999-9960-00000060 Phone No. 9830281234
Cover Details
PLAN RISK COVERED RATES/SUM INSURED
NO OF PERSONS :- Self + 1 Child
Group Health Inpatient Hospitalisation SUM_INSURED:-Rs.5,00,000
AGE :- 43
Premium Details
Discounts ( if Any ) Rs.0
Net Premium. Rs.8,482
Final Premium Rupees Ten Thousand and Nine only.
Integrated GST (18%) Rs.1527
Gross Premium. Rs.10,009

Family Member Details

Insured Name Relation Gender DOB Rate(%) Nominee Name Nominee Relation Pre Existing Diseases
SAPTARISHI
SHAMPA DEY Self FEMALE 12-OCT-1976 Mother N
PRAMANIK
SAPTARISHI Child MALE 20-SEP-2001 SHAMPA DEY Son N
PRAMANIK
Other Details
Scope of Cover 1 ALL OTHER TERMS CONDITIONS DEDUCTIBLES AND EXCLUSIONS ARE AS PER STANDARD MEDICLAIM INSURANCE POLICY WORDINGS
IN CASE OF DIAGNOSIS WITH ANY OF THE LISTED CRITICAL ILLNESS;THE SUM INSURED WOULD BECOME 3 TIMES OF THE BASE SUM INSURED
Scope of Cover 2 FORTHAT CRITICAL ILLNESS.
Pre-Existing Disease N
Special Terms and conditions ALL TERMS; CONDITIONS; AND EXCLUSIONS ARE AS PER POLICY WORDINGS.
Bank Reference No. 2 IN4330837
BAGIC. RM. Code 8578
BAGIC RM Name SANTOSH RASKAR
IMD RM. Code 10774
IMD RM Name ANIKET GADE
Customer Consent YES
Electronic Insurance Account
Number (EIA No)
Remarks
S P Code
Previous Policy Number
This is to certify that MS SHAMPA DEY has Paid Rs.10,009 towards Health Insurance for Period and Policy Number as mentioned on the Policy
80 D Certificate Schedule and is eligible for Deduction under Section 80-D of Income Tax (Amendment) Act, 1986 .

Receipt Number:0 | Date:11-NOV-19 | Premium Payer ID:33875185 | Float: BG

Premium Details ** If Premium paid through Cheque, the Policy is void ab-initio in case of dishonour of Cheque.
Financial Institution Ref. No. IN4330837

Agency Code 10031837,BAJAJ FINANCE Contact No. 18002095858

& Name LIMITED E-Mail ID. BAJAJFINANCELIMIT
[email protected]
For & on the behalf
Bajaj Allianz General Insurance Company Ltd. QR Code

For help and more information: Page 1 of 3

Contact our 24 Hour Call Centre at 1800-209-5858, 1800-102-5858 (Toll Free)
Email: [email protected] , 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

 *136393822*

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)

MEDICLAIM INSURANCE POLICY - (FOR BFL CUSTOMERS) POLICY SCHEDULE UIN : IRDA/NL-
HLT/BAGI/P-H/47/13-14

Policy issuing office and Correspondence address for communication by policyholder for Bajaj Allianz House,Airport Road,Yerwada,Pune-411006,Phone No :66026666
claim, service request, notice, summons, etc. :
Insured Name MS SHAMPA DEY Child Certificate Number OG-20-1000-6021-00119576

Authorized Signatory
(This is system generated document and need not be countersigned.)
Consolidated Stamp Duty of Rs.0.5/- 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.
BAGIC GST No : 27AABCB5730G1ZX | 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. | Invoice No. : 134895229/1
Schedule (1) | Printed on : 11-Nov-2019 03:24:55 pm |Silent Print|WEB|2016

For help and more information: Page 2 of 3

Contact our 24 Hour Call Centre at 1800-209-5858, 1800-102-5858 (Toll Free)
Email: [email protected] , 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

 *136393822*

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)

MEDICLAIM INSURANCE POLICY - (FOR BFL CUSTOMERS) POLICY SCHEDULE UIN : IRDA/NL-
HLT/BAGI/P-H/47/13-14

Policy issuing office and Correspondence address for communication by policyholder for Bajaj Allianz House,Airport Road,Yerwada,Pune-411006,Phone No :66026666
claim, service request, notice, summons, etc. :
Insured Name MS SHAMPA DEY Child Certificate Number OG-20-1000-6021-00119576

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)
HEALTH & WELLNESS CARD 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.
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.

Customer ID:167385618 For help and more information:
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
Email us at [email protected] or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329

Policy No : OG-20-1000-6021-00119576
ID Card No : 20-134895229
Valid Upto : 08-Nov-2020
SHAMPA DEY (43 Yrs)

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)
HEALTH & WELLNESS CARD 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.
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.

Customer ID:167385619 For help and more information:
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
Email us at [email protected] or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329

Policy No : OG-20-1000-6021-00119576
ID Card No : 20-134895229-2
Valid Upto : 08-Nov-2020
SAPTARISHI PRAMANIK (18 Yrs)

For help and more information: Page 3 of 3

Contact our 24 Hour Call Centre at 1800-209-5858, 1800-102-5858 (Toll Free)
Email: [email protected] , 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