Welcome to Bajaj Allianz Family

GHATKOPAR-Bajaj Allianz General Insurance Company Limited,,

Policy issuing office and Correspondence address for communication Unit No.301 And 302,3rd Floor,,Silver Point, Plot No.17/18, Cts
by policyholder for claim, service request, notice, summons, etc. No.501/1,New Maneklal Estate, Ghatkopar (W),Mumbai,
Maharashtra,400086,INDIA

Insured Name Satish Morarjibhai Gokani Policy number 12-8428-0000377236-00

Name: Satish Morarjibhai Gokani

Address:
Line1: 901-A, Chembur Heights, Road No 8, Behind Sindhi, Society, Chembur, Mumbai 400071
Line2: Chembur
City: Mumbai State: 27 - MAHARASHTRA
Post Code: 400071
Mobile Number: 9324537474
Customer ID: PI25434989

Dear Satish Morarjibhai Gokani,

It is our privilege to welcome you to the Bajaj Allianz General Insurance family.

We thank you for choosing Bajaj Allianz for your Insurance needs. We are one of India's leading general insurance companies with iAAA
rating from ICRA for the last ten consecutive years indicating the company's high claims paying ability and fundamentally strong
position in the industry. Please be assured that you have made right choice by choosing us and we will stand by you in your hour of
need.

Please find enclosed the policy schedule. We wish to inform you that the policy issued is based on the information submitted in the
proposal form as well as the acceptance of the terms and conditions, and this will be verified at the time of filing of claim. Request you
to kindly go through the same once again and in case of any disagreement, discrepancy or clarifications – write to us at
[email protected] within 15 days of the letter date.For policy wordings containing detailed terms, conditions and exclusions
of your insurance coverage follow below link
https://www.bajajallianz.com/download-documents/health-insurance/global-personal-guard/GPGP_PW.pdf
Once again, we welcome you to the Bajaj Allianz family and look forward to a long association with you.

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

Signature Not Verified

Digitally signed by DS BAJAJ ALLIANZ GENERAL
INSURANCE COMPANY LIMITED 01
Date: 2023.04.11 21:03:15 IST

Bajaj Allianz General Insurance Co. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. Reg. No.: 113 CIN: U66010PN2000PLC015329

Give a Missed Call on 808094506 SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com http://www.linkedin.com/company/bajaj-allianz-general-insurance

[email protected] Demystify Insurance https://www.bajajallianz.com/blog.html

GLOBAL PERSONAL GUARD POLICY (INDIVIDUAL)- POLICY SCHEDULE
UIN: IRDAI/HLT/BAGI/P-P/V.I/30/14-15

GHATKOPAR-Bajaj Allianz General Insurance Company Limited,,Unit No.

Policy issuing office and Correspondence address for communication
301 And 302,3rd Floor,,Silver Point, Plot No.17/18, Cts No.501/1,New
by policyholder for claim, service request, notice, summons, etc. Maneklal Estate, Ghatkopar (W),Mumbai,Maharashtra,400086,INDIA

Proposer Details
Proposer Name Satish Morarjibhai Gokani

901-A, CHEMBUR HEIGHTS, ROAD NO 8, BEHIND SINDHI, SOCIETY, CHEMBUR, MUMBAI 400071, CHEMBUR,
Proposer Address
MUMBAI, MAHARASHTRA, 400071, INDIA

Phone No 9324537474 Email ID [email protected]

Customer ID PI25434989

Previous Policy No NA Previous Policy Expiry Date NA

Policy Details
Policy Number 12-8428-0000377236-00 Endorsement No NA

Policy Issued on 11/04/2023 Policy Status ACTIVE

Period of Insurance From 11/04/2023 00:00 Hrs To 10/04/2024 Midnight Expiry Date 10/04/2024

GSTIN / UIN Unregistered

Place of Supply/State
27 - MAHARASHTRA
Code/Name
Company GST No: 27AABCB5730G1ZX

Company PAN AABCB5730G Invoice No: 272304I001360535

Insured Member Details

Nominee Name & First Policy
Member Name Customer ID Gender Date of Birth Age Relation Occupation
Relation Inception Date
Satish Morarjibhai Other Class 1. Beena S Gokani
PI25434989 Male 14/06/1963 59.0 Self 10/04/2023
Gokani 1 - Spouse
901-A, CHEMBUR HEIGHTS, ROAD NO 8, BEHIND SINDHI, SOCIETY, CHEMBUR, MUMBAI 400071, CHEMBUR,
Insured Address
MUMBAI, MAHARASHTRA, 400071, INDIA

Cover Details
Death Permanent Total Disability Permanent Partial Disability
Member Name Premium
Cumulative Cumulative Cumulative
Sum Insured Sum Insured Sum Insured
Bonus ( %) Bonus ( %) Bonus ( %)
Satish Morarjibhai
4548 5000000 0 (0%) 3000000 0 (0%) 3000000 0 (0%)
Gokani

Optional Cover
Accidental Adventure Sports Benefit Air Coma Due to
Children's EMI
Hospitalization Ambulance Accidental
Education Benefit Payment Cover
Expenses Death PTD Cover Bodily Injury
Member Name

Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured

Satish
Morarjibhai NA NA NA NA 0 1000000 0
Gokani

Loan Road Travel

Loss of Income due to
Fracture Care Hospital Cash Benefit Protector Ambulance Expenses
Member Disability from Accident
Cover Cover Benefit
Name
Per Day Number of Weekly
Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured
Benefit Days Benefit Amt.
GLOBAL PERSONAL GUARD POLICY (INDIVIDUAL)- POLICY SCHEDULE
UIN: IRDAI/HLT/BAGI/P-P/V.I/30/14-15

Per Day Number of Weekly

Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured
Benefit Days Benefit Amt.
Satish
Morarjibh NA NA NA 0 NA 0 NA 0
ai Gokani

Add on Cover
Health Prime Rider
Member Name
UIN: BAJHLIA22169V012122
Individual Option 6
SATISH MORARJIBHAI GOKANI Telconsultation:- Unlimited (All Specialities),Investigations &
Doctor consultaion:- 15000, Annual preventive health check-up:
- Yes (1 Voucher)

Premium Details
Description Amount(INR) Description Amount(INR)

Base Premium 2510 Family Discount 0

Premium on Add-on Cover 1344 Long Term Policy Discount 0

Premium on Health Prime Rider 1084 Employee Discount 0

Discount on Health Prime Rider 0 Online Discount/Direct Customer 0

Gross Premium: Four Thousand Five Hundred Forty-Eight Net Premium 3854
Rupees
State GST(9%) 347

Central GST(9%) 347

IGST 0

UTGST 0

CESS 0

Gross Premium 4548

"As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th September of the next
financial year E. & O.E"

"In case no GSTIN or incorrect GSTIN is provided by the Proposer at Proposal stage, Bajaj Allianz General Insurance Company Ltd shall not be
responsible for any Input Tax Credit losses and no subsequent revision of invoice will be undertaken."

“I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover
notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.”

Exclusions
Member Name Exclusion
Satish Morarjibhai
NA
Gokani
GLOBAL PERSONAL GUARD POLICY (INDIVIDUAL)- POLICY SCHEDULE
UIN: IRDAI/HLT/BAGI/P-P/V.I/30/14-15
Special Exclusion at Policy
Level NA

Loan Details NA

Assignment Details NA

Type of Assignment NA

Assignment Wordings NA

Additional Remarks NA
This is to certify that Satish Morarjibhai Gokani has paid Rs.1279 towards Health Insurance premium 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
Notes:
80 D Certificate 1. This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended
from time to time.
2. This certificate must be surrendered to the company in case of cancellation of this policy.
3. In event of incorrect representation of this declaration the liability shall be upon the policy holder.
4. This certificate will not be valid if premium payment has been made in cash.
Receipt Number: 54-23-000000033761 Date: 11/04/2023 Premium Payer ID: PI25434989 Float: NA;
Premium Details Payment Frequency: Single Premium ** If Premium paid through Cheque, the Policy is void ab-initio in
case of dishonour of Cheque
Financial Institution Ref. No. NA

AGENCY CODE 10044908 CONTACT NO 09702555550

AGENCY NAME Shift Risk Insurance Brokers Limited EMAIL ID [email protected]

For & on the behalf

Bajaj Allianz General Insurance Company Ltd. Consolidated Stamp Duty of Rs. 600/- paid towards Insurance Premium Stamps Vide Challan
No MH002405964202122M defaced number 0001482221202122/order no. CSD/82/2021/2306
dated 12-APR-21 timing 13:29:05 of General Stamp of India.

Stamp Duty
This document is digitally signed,hence counter signature / stamp is not required
Rs.600/- 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.
Authorized Signatory

SUB 10044908 / NA
GLOBAL PERSONAL GUARD POLICY (INDIVIDUAL)- POLICY SCHEDULE
UIN: IRDAI/HLT/BAGI/P-P/V.I/30/14-15

Policy Verification Claim Registration

Our Insurance Expert will call you for hassle free renewal and industry best offers on your coverage
Bajaj Allianz General Insurance Co.Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411006. Reg.No.:113 CIN:U66010PN2000PLC015329

Give a Missed Call on 8080945060, SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com http://www.linkedin.com/company/bajaj-allianz-general-insurance

[email protected] Demystify Insurance https://www.bajajallianz.com/blog.html

RECEIPT

GHATKOPAR-Bajaj Allianz General Insurance Company

Policy issuing office and Correspondence address for communication Limited,,Unit No.301 And 302,3rd Floor,,Silver Point, Plot No.
by policyholder for claim, service request, notice, summons, etc. 17/18, Cts No.501/1,New Maneklal Estate, Ghatkopar (W),
Mumbai,Maharashtra,400086,INDIA

Proposer Name Satish Morarjibhai Gokani Policy Number 12-8428-0000377236-00

Receipt Number 54-23-000000033761 Receipt Date 11/04/2023

Business Channel PARTNERPORTAL

Received with thanks from: Satish Morarjibhai Gokani

Customer ID: PI25434989 a total sum of Rupees Four Thousand Five Hundred Forty-Eight Rupees Only by,

Instrument Type Instrument No Instrument Date Bank Name Branch Name Amount (Rs.)

Online Payment 98252122 11-Apr-2023 BN00000158 BN00000158 4,548.00

Total Amount: 4548

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

Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory

Bajaj Allianz General Insurance Co.Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411006. Reg.No.:113 CIN:U66010PN2000PLC015329

Give a Missed Call on 8080945060, SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com http://www.linkedin.com/company/bajaj-allianz-general-insurance

[email protected] Demystify Insurance https://www.bajajallianz.com/blog.html

Transcript of Proposal for ([11-8428-0002125650-00] GLOBAL PERSONAL GUARD
POLICY (INDIVIDUAL)) [(UIN):IRDAI/HLT/BAGI/P-P/V.I/30/14-15]

Dear Satish Morarjibhai Gokani,

We wish to inform you that your contract will be based on the information and declaration given by you through telephonic conversation / email / web-
inputs / TAB /CSC Centers 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 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, you 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.

Proposer Details
Proposer Name Satish Morarjibhai Gokani

Are you an Existing Bajaj Allianz Customer: Yes/No If Yes, please mention the policy No

Gender Male Date of Birth 14/06/1963

PAN No AABPG8471C UID/Unique ID 946897050846

Bajaj Allianz Employee Code, if Proposer is BAGIC/BALIC Employee NA

Marital Status Married No of children NA

Occupation Other Class 1

Address
Permanent/ Residential Address Correspondence Address
(All the communications will be sent to the below address)

901-A, Chembur Heights, Road No 8, Behind 901-A, Chembur Heights, Road No 8, Behind
Address Line 1 Address Line 1
Sindhi, Society, Chembur, Mumbai 400071 Sindhi, Society, Chembur, Mumbai 400071

Address Line 2 CHEMBUR Address Line 2 Chembur

Address Line 3 NA Address Line 3 NA

City/District Mumbai City/District Mumbai

State Maharashtra State Maharashtra

Pin Code 400071 Pin Code 400071

Telephone 9324537474 Telephone 9324537474

Mobile 9324537474 Mobile 9324537474

Email [email protected] Email [email protected]

Educational Qualification Ug

Family Monthly Income 50000

In case of any offer, you would prefer to be contacted by 9324537474,[email protected]

Nationality Indian

Policy Period 1 Year

Details of the Persons to be Insured

Relationship of
Sr Relationship DOB Gender Gross Monthly
Name Age Nominee Nominee with
No with Proposer (dd/mm/yy) (M/F) Income
Insured
Satish Morarjibhai 1. Beena S
1 Self 14/06/1963 59.0 Male 50000 1. Spouse
Gokani Gokani
Transcript of Proposal for ([11-8428-0002125650-00] GLOBAL PERSONAL GUARD
POLICY (INDIVIDUAL)) [(UIN):IRDAI/HLT/BAGI/P-P/V.I/30/14-15]

Base Cover Details

Any Existing Death Permanent Total Disability Permanent Partial
Member Name Occupation
Disability/ Infirmity Sum Insured Sum Insured Sum Insured
Satish Morarjibhai
Other Class 1 No 5000000 3000000 3000000
Gokani

Optional Cover Details

Accidental Adventure Sports Benefit Air Coma Due to
Children's EMI
Hospitalization Ambulance Accidental
Education Benefit Payment Cover
Expenses Death PTD Cover Bodily Injury
Member Name
Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured Sum Insured
Satish
Morarjibhai NA NA NA NA NA 1000000 NA
Gokani

Loss of Income due to Travel

Hospital Cash Loan Protector Road Ambulance
Fracture Care Disability from Expenses
Benefit Cover**** Cover
Member Name Accident Benefit

Sum Insured Per Day Benefit Sum Insured Sum Insured Sum Insured Sum Insured

Satish Morarjibhai
NA NA(NA days) NA NA NA NA
Gokani

Add on Cover
Health Prime Rider
Member Name
UIN: BAJHLIA22169V012122
Individual Option 6
SATISH MORARJIBHAI GOKANI Telconsultation:- Unlimited (All Specialities),Investigations &
Doctor consultaion:- 15000, Annual preventive health check-up:
- Yes (1 Voucher)

Loan Account Details (Please fill in details in case of Loan Protector cover and EMI Payment
Bank Name NA

Address NA

Type of Loan NA Loan Account Number NA

Sanctioned Loan
0 Loan Period NA
Amount
EMI (Rs) 0

Note:
*"Adventure Sports Benefit” can be opted only if the proposer has opted for Section I: Death Cover AND/ OR Section II: Permanent Total
Disability

**"Children’s Education Benefit” can be opted only if the proposer has opted for Section I: Death Cover AND/ OR Section II: Permanent
Total Disability
***"EMI Payment Cover” can be opted only if the proposer has opted for Sectio3- Permanent Partial Disability (Loan sanction letter to be
submitted mandatorily)

****"Loan Protector Cover” can be opted only if the proposer has opted for Section I: Death Cover AND/ OR Section II: Permanent Total
Disability (Loan sanction letter to be submitted mandatorily)

*****"Travel Expenses Benefit” can be opted only if the Proposer has opted for Accidental Hospitalization under optional Covers.
Transcript of Proposal for ([11-8428-0002125650-00] GLOBAL PERSONAL GUARD
POLICY (INDIVIDUAL)) [(UIN):IRDAI/HLT/BAGI/P-P/V.I/30/14-15]

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.

Disclaimer

A. 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.

B. 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.

C. 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.

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 prospectuses 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.

Contact our Policy servicing branch at: GHATKOPAR-Bajaj Allianz General Insurance Company Limited,,Unit No.301 And 302,3rd Floor,,Silver Point,
Plot No.17/18, Cts No.501/1,New Maneklal Estate, Ghatkopar (W),Mumbai,Maharashtra,INDIA,400086
** This is print of electronic records maintained by us in accordance with law and hence does not require signature.

Bajaj Allianz General Insurance Co.Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411006. Reg.No.:113 CIN:U66010PN2000PLC015329

Give a Missed Call on 8080945060, SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com http://www.linkedin.com/company/bajaj-allianz-general-insurance

[email protected] Demystify Insurance https://www.bajajallianz.com/blog.html

 HEALTH & WELLNESS CARD

GHATKOPAR-Bajaj Allianz General Insurance Company Limited,,Unit No.

Policy issuing office and Correspondence address for communication
301 And 302,3rd Floor,,Silver Point, Plot No.17/18, Cts No.501/1,New
by policyholder for claim, service request, notice, summons, etc. Maneklal Estate, Ghatkopar (W),Mumbai,Maharashtra,400086,INDIA

Proposer Name Satish Morarjibhai Gokani Policy Number 12-8428-0000377236-00

Scan QR to view your policy details

Health Card Number: 31-8428-0014829414-0001
Customer ID: PI25434989
Policy No: 12-8428-0000377236-00
Inception Date: 11/04/2023
Valid Up to: 10/04/2024
Member Name: Satish Morarjibhai Gokani
Age: 59

HEALTH & WELLNESS CARD

Bajaj Allianz General Insurance Company

(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:

Say Hi on WhatsApp on 7507245858, Give a Missed Call on 8080945060, SMS ‘WORRY’ to
575758, Contact our 24-Hour Call Center at 1800-209-5858
Email: [email protected], Website www.bajajallianz.com
Corporate Identification Number: U66010PN2000PLC015329

Bajaj Allianz General Insurance Co.Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411006. Reg.No.: 113 CIN: U66010PN2000PLC015329

Give a Missed Call on 8080945060, SMS 'WORRY' to 575758 http://www.facebook.com/BajajAllianz

Contact our 24-Hour Call Center at 1800-209-5858 http://twitter.com/BajajAllianz

www.bajajallianz.com http://www.linkedin.com/company/bajaj-allianz-general-insurance

[email protected] Demystify Insurance https://www.bajajallianz.com/blog.html

TAX INVOICE
(Customer Copy)

Invoice Number 272304I001360535 Customer ID PI25434989

Invoice Date 11/04/2023 Policy No. 12-8428-0000377236-00

Recipient/ Details of Insured Supplier/ Details of Insurer

GSTIN Unregistered GSTIN 27AABCB5730G1ZX

PAN AABPG8471C PAN AABCB5730G

Name (Proposer) Satish Morarjibhai Gokani Name Bajaj Allianz General Insurance Company Ltd.

901-A, Chembur Heights, Road No 8, Behind

Address-1 Address-1 Bajaj Allianz General Insurance Company Limited,
Sindhi, Society, Chembur, Mumbai 400071

Address-2 Chembur Address-2 Unit No.301 And 302,3rd Floor,

Address-3 NA Address-3 Silver Point, Plot No.17/18, Cts No.501/1,New

Pin Code 400071 Pin Code 400086

City MUMBAI City MUMBAI

State MAHARASHTRA State MAHARASHTRA

Client Category NON HNI Place of Supply 27 - MAHARASHTRA

Premium
Description Amount(INR) Description Amount(INR)

Net Premium 3854 State GST/UTGST(9%) 347

Receipt Number: 54-23-000000033761 Date: 11/04/2023
Central GST(9%) 347
Premium Payer ID: PI25434989 Float: NA; ** If Premium paid
through Cheque, the Policy is void ab-initio in case of dishonour of 0
IGST(18%)
Cheque
Gross Premium 4548

Total Invoice Value (In figures) : 4548

Total Invoice Value (In Words) : Four Thousand Five Hundred Forty-Eight Rupees
Amount of Tax Subject to Reverse Charge: No reverse charge is payable on these services.

Services Accounting Code: 997133 Accident and health insurance services.

Principal Location: Bajaj Allianz House, Airport Road, Yerwada, Pune- 411006 PH-66026666

For & on the behalf

Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory

Important Notes:
* The invoice is issued as per Section 31 of the CGST Act
* In case no GSTIN or incorrect GSTIN is provided by the Proposer at Proposal stage, Bajaj Allianz General Insurance Company Ltd shall not be responsible for
any Input Tax Credit losses and no subsequent revision of invoice will be undertaken
* As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th September of the next financial year E.
& O.E
“I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified
under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.”

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Bajaj Allianz General Insurance Co. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411006. Reg.No.:113 CIN:U66010PN2000PLC015329

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