Bajaj Allianz General Insurance Company Ltd

[Corporate Identity Number (CIN) : U66010PN2000PLC015329]

Unique Identification Number (UIN) : IRDAN113CP0004V03201819
Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune-411006
Transcript of Proposal for GROUP AFFINITY INSURANCE POLICY
Dear OM SINGH ,
Child Certificate Number OG-25-9915-6616-00339573
Master Policy Number OG-25-9999-9960-00000092
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 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.to verify if this decoration takes care of the PPI
regulations.
Personal Information of Insured
First Name OM SINGH
Middle Name Last Name
Email Address [email protected] Mobile Number 0
Date of Birth 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/ ABHISKEK SINGH (PRINCE) TILAK NAGAR COLONY MAHUABAGH House No/ Building No/
Flat No Flat No
Street/ Locality/ Street/ Locality/
GHAZIPUR, GHAZIPUR,
Landmark Landmark
State UTTAR PRADESH State
City City
Area Area
Pincode 233001 Pincode

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 Affinity Insurance Policy - Flipkart AD/LD
2. Premium Payment Zone : UTTAR PRADESH
3. Period of Insurance :
4. Is Voluntary Co-payment Opted : Yes/No
Amount of Voluntary Co-payment opted :
5. Cumulative Bonus :
6. Add On Cover Opted : Yes/No
7. Previous Insurance Provider :
8. Previous Policy number : NA
9. 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 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:
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.

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Email: [email protected] , Website www.bajajallianz.com Corporate Identification Number: U66010PN2000PLC015329

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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.
NOTE: 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.
Toll free Number: 1800-103-2529, 1800-22-5858, 1800-102-5858 and 1800-209-5858
Email address: [email protected]
Website: www.bajajallianz.com
Contact our Policy servicing branch at: 1st Floor,Behind Weikfield IT-Park,Viman Nagar,PUNE-411014,Phone No :1800-209-0144
** This is print of electronic records maintained by us in accordance with law and hence does not require signature.
Scrutiny No: 437865707

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Email: [email protected] , Website www.bajajallianz.com Corporate Identification Number: U66010PN2000PLC015329

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 *437865707*

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 AFFINITY INSURANCE POLICY UIN : IRDAN113CP0004V03201819

Policy issuing office and Correspondence address for communication by policyholder for 1st Floor,Behind Weikfield IT-Park,Viman Nagar,PUNE-411014,Phone No :1800-209-0144
claim, service request, notice, summons, etc. :
Insured Name OM SINGH Child Certificate Number OG-25-9915-6616-00339573

INSURED DETAILS POLICY DETAILS

ABHISKEK SINGH (PRINCE) TILAK NAGAR COLONY Policy Issued on 02-FEB-2025
MAHUABAGH, From: 02-FEB-2025 00:00
Insured Address GHAZIPUR, Period of Insurance To : 01-FEB-2026 Midnight
- 233001,
UTTAR PRADESH Endorsement NA
Customer ID 459329647 Previous Policy Number NA
GSTIN / UIN NA
Policy Status ISSUED STATE CODE / NAME 09 - Uttar Pradesh
Company GST No : 27AABCB5730G1ZX
Invoice No : 446431864/0 Company PAN : AABCB5730G
Master Policy Number OG-25-9999-9960-00000092 Plan Chosen Group Affinity Insurance Policy - Flipkart AD/LD
Cover Details
PLAN RISK COVERED RATES/SUM INSURED
INVOICE VALUE :- 6,999
Group Affinity Accidental / Liquid Damage POLICY PERIOD :- 12
Premium Details
Discounts ( if Any ) Rs.0
Net Premium. Rs.44
Final Premium Rupees Fifty Two only.
Integrated GST (18%) Rs.8
Gross Premium. Rs.52

Other Details
Scope of coverage 1 REST ALL THE TERMS AND CONDITIONS ARE AS PER THE STANDARD POLICY WORDINGS
IMEI / Serial Number 353992430502568
Bank Reference No. 2
BAGIC. RM. Code BAGICFLIPKART
BAGIC RM Name BAGIC FLIPKART
Customer Consent YES
Electronic Insurance Account
Number (EIA No)
Remarks
S P Code

Receipt Number:0 | Date:02-FEB-25 | Premium Payer ID:133644404 | 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. PCMFLK0V354453481910718

Agency Code 55555557,WEB SALES Contact No. 18002095858,1800209585

& Name 8
E-Mail ID. [email protected]
o.in
On specific request and subject to terms and conditions, record of information exchange will be made available.
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 [email protected], 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/36/2024-25/2886 dated 01-AUG-24 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 : NA. No reverse
charge is payable on these services. | Invoice No. : 446431864/1
Schedule (1) | Printed on : 03-Feb-2025 09:35:09 am |Silent Print|WEB|99060019

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

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