Welcome to Bajaj Allianz Family

Policy issuing office and Correspondence address for communication BALASORE-2nd Flr, Mittal Tower,O.T Road,Iti Chawk,Balasore,
by policyholder for claim, service request, notice, summons, etc. Odisha,756001,INDIA

Insured Name Jayasmita Malik Policy number 12-8435-0000107784-00

Name: Jayasmita Malik

Address:
Line1: Nilgiri
Line2:
City: BALESWAR State: 21 - ODISHA
Post Code: 756040
Email ID: [email protected]
Mobile Number: 6371909459
Customer ID: PI32691240

Dear Jayasmita Malik,

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/health-ensure/Health_EnSure_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.

Signature Not Verified

Digitally signed by DS BAJAJ
ALLIANZ GENERAL INSURANCE
COMPANY LIMITED
Date: 2025.01.09 18:09:48
18:09:36 IST
Authorized Signatory

Bajaj Allianz General Insurance Co. Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. 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 www.bit.do/bjazgi

[email protected] Demystify Insurance http://support.bajajallianz.com

HEALTH ENSURE - INDIVIDUAL- POLICY SCHEDULE
UIN: BAJHLIP24149V062324

Policy issuing office and Correspondence address for communication BALASORE-2nd Flr, Mittal Tower,O.T Road,Iti Chawk,Balasore,Odisha,
by policyholder for claim, service request, notice, summons, etc. 756001,INDIA

Proposer Details
Proposer Name Jayasmita Malik

Proposer Address NILGIRI, BALESWAR, ODISHA, 756040, INDIA

Phone No 06371909459 Email ID [email protected]

Customer ID PI32691240

Previous Policy No NA Previous Policy Expiry Date NA

Policy Details
Policy Number 12-8435-0000107784-00 Endorsement No NA

Policy Issued on 09/01/2025 Policy Status ACTIVE

From 08/01/2025 00:00 Hrs To

Period of Insurance Expiry Date 07/01/2026
07/01/2026 Midnight

GSTIN / UIN Unregistered

Place of Supply/State
21 - ODISHA
Code/Name
Company GST No: 21AABCB5730G1Z9

Company PAN AABCB5730G Invoice No: 212501I000030283

Insured Member Details

Nominee Name & First Policy
Member Name Customer ID Gender Date of Birth Age Relation
Relation Inception Date
1. K C Malik -
Jayasmita Malik PI32691240 Male 03/05/1992 32 Self 08/01/2025
Father
Insured Address NILGIRI, BALESWAR, ODISHA, 756040, INDIA

Cover Details
Inpatient Hospitalization Treatment (SI)
Member Name Premium Loading

Cumulative Cumulative
Sum Insured
Amount Bonus (%)

Jayasmita Malik 6037 0 300000 0 0%

Optional Covers (All figures in Rupees) –

Cumulative Bonus SI Personal Accident
Room rent Double Sum Insured
Member name Enhancement Reinstatement (For Self Only)
Upgradation for Cancer
Benefit
Jayasmita Malik Not Opted Not Opted Not Opted Not Opted Not Opted

Add On Cover
Non-Medical Expenses Cover Health Prime Rider
Member Name
UIN: BAJHLAP21586V012021 BAJHLIA24087V022324

JAYASMITA MALIK No No
HEALTH ENSURE - INDIVIDUAL- POLICY SCHEDULE
UIN: BAJHLIP24149V062324

Premium Details
Description Amount Description Amount

Long Term Policy Discount 0

Base Premium 5116 Employee Discount 0

Online Discount/Direct Customer
0
Discount

Premium Payment Zone Zone B Voluntary Co-payment Discount 0

Total Discount 0
Voluntary Co-payment Option 0

Net Premium 5116

Premium of Optional Cover 0
Premium on Add-on/Rider State GST(9%) 460
0
Covers
Central GST(9%) 460

IGST 0
Gross Premiumin words: Six Thousand Thirty-Six Rupees UTGST 0

CESS 0

Gross Premium 6036

"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.”

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 – {https://play.google.com/store/apps/details?id=com.ba.cp.controller&hl=en_IN},
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 – {www.bajajallianz.com}, contact your agent or
nearest branch.

Exclusions
Member Name Exclusion

Jayasmita Malik NA

Special Exclusion at Policy

NA
Level

Additional Remarks NA

This is to certify that Jayasmita Malik has paid Rs.6036 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.
HEALTH ENSURE - INDIVIDUAL- POLICY SCHEDULE
UIN: BAJHLIP24149V062324

Receipt Number: SYS-24-000011555857 Date: 09/01/2025 Premium Payer ID: PI32691240 Float: NA;
Premium Payment 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. NA

AGENCY CODE 10091374 CONTACT NO 9748758924

AGENCY NAME Axis Bank Limited EMAIL ID [email protected]

For & on the behalf

Bajaj Allianz General Insurance Company Ltd. Consolidated Stamp Duty of Rs. 0.50/- paid towards insurance policy stamps vide
Challan No. MH003479644202425M Defaced No. 0002709637202425 Order No. LOA/ENF-
Signature Not Verified 1/CSD/36/2024-25 Order Dated 15/07/2024 Defaced Dated 10/07/2024 timing 15:00:00 of
Digitally signed by DS BAJAJ General Stamp Office, Mumbai, India.
Stamp Duty
ALLIANZ GENERAL INSURANCE
COMPANY LIMITED Rs.0.50/- This document is digitally signed,hence counter signature / stamp is not required
Date: 2025.01.09 18:09:48
18:09:35 IST
Principal Location : Bajaj Allianz House, Airport Road, Yerwada, Pune- 411006 PH-
66026666 | Services Accounting Code : 997133 Accident and health insurance services.
Authorized Signatory

SUB 10091374 / 137400001075

“The amounts present in the document are calculated with INR currency if not mentioned otherwise.”

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
RECEIPT

Policy issuing office and Correspondence address for communication BALASORE-2nd Flr, Mittal Tower,O.T Road,Iti Chawk,Balasore,
by policyholder for claim, service request, notice, summons, etc. Odisha,756001,INDIA

Proposer Name Jayasmita Malik Policy Number 12-8435-0000107784-00

Receipt Number SYS-24-000011555857 Receipt Date 09/01/2025

Business Channel OLADANGA-2324(137400001075)

Received with thanks from: Jayasmita Malik

Customer ID: PI32691240 a total sum of Six Thousand Thirty-Six Rupees Only by,

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

CD-Customer NA NA NA NA 6,036.00

Total Amount: 6036

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.

Signature Not Verified

Digitally signed by DS BAJAJ
ALLIANZ GENERAL INSURANCE
COMPANY LIMITED
Date: 2025.01.09 18:09:48
18:09:37 IST

Authorized Signatory

Bajaj Allianz General Insurance Co. Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. 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 www.bit.do/bjazgi

[email protected] Demystify Insurance http://support.bajajallianz.com

Transcript of Proposal for ([11-8435-0000899132-00] HEALTH ENSURE -
INDIVIDUAL) [(UIN):BAJHLIP24149V062324]

Dear Jayasmita Malik,

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 Jayasmita Malik

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

Gender Male Date of Birth 03/05/1992

PAN No NA

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

Marital Status Unknown No of children NA

Occupation Other Class 2

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

Address Line 1 Nilgiri Address Line 1 Nilgiri

Address Line 2 NA Address Line 2 NA

Address Line 3 NA Address Line 3 Baleswar

City/District BALESWAR City/District BALESWAR

State 21 - ODISHA State ODISHA

Pin Code 756040 Pin Code 756040

Telephone 06371909459 Telephone 06371909459

Mobile 6371909459 Mobile 6371909459

Email [email protected] Email [email protected]

Educational Qualification NA

Family Monthly Income 50000

In case of any offer, you would prefer to be contacted by 6371909459 / [email protected]

Nationality Indian

Policy Term 1 Year

Premium Payment Zone to be opted Zone B

There are Three Zones for Premium payment-

Zone A
Delhi/NCR, Mumbai including (Navi Mumbai, Thane and Kalyan), Hyderabad and Secunderabad, Kolkata, Ahmedabad, Vadodara and Surat.
No Co-Payment
Zone B
Rest of India apart from Zone A & Zone C
* 15% Co-Payment Applicable if treatment availed in Zone A locations
Zone C
Goa,Chhattisgarh,Punjab,Chandigarh,Jammu & Kashmir,Jharkhand,Arunachal Pradesh, Bihar, Himachal Pradesh,Nagaland, Odisha,
Sikkim,
Tripura, Uttarakhand, Manipur, Meghalaya,Mizoram,Andaman & Nicobar islands
*20% & 5% Co-Payment Applicable if treatment availed in Zone A and Zone B locations respectively
Transcript of Proposal for ([11-8435-0000899132-00] HEALTH ENSURE -
INDIVIDUAL) [(UIN):BAJHLIP24149V062324]

Sum Insured Options :

Note:-
Policyholder residing in Zone B and Zone C can choose to pay premium of Zone A and avail treatment all over India without any co-
Policyholders paying Zone A premium rates can avail treatment allover India without any co-payment.
But, those, who pay zone B premium rates and avail treatment in zone A city will have to pay 20% co-payment on admissible claim
Co - payment will not be applicable for Accidental Hospitalization cases."
Policyholder residing in Zone B can choose to pay premium for zone A and avail treatment all over India without any co-payment.
a. Individual Sum Insured Options (please mention the member wise sum insured in the member details table)
b. Family Floater Sum Insured in INR: Rs. NA

Details of the Persons to be Insured

Cumulativ
Individual Nominee First policy
Member Date of e
Sum Customer ID Gender Age Height Weight Relation Name & inception
Name Birth Bonus (%)
insured Relation date

Jayasmita 03/05/199 1. K C Malik

300000 PI32691240 Male 32 150 50 Self 08/01/2025
Malik 2 - Father
Inpatient Hospitalization Treatment

Insured Address NILGIRI, BALESWAR, ODISHA, 756040, INDIA

Coverages Details –
Inpatient Hospitalization
Treatment (SI)
Insured Member Details
Member name
Cumulative Bonus Amount
Sum Insured Cumulative Bonus (%)

JAYASMITA MALIK 300000 0 0%

Optional Covers (All figures in Rupees) –

Cumulative Bonus SI Personal Accident
Room rent Double Sum Insured
Member name Enhancement Reinstatement (For Self Only)
Upgradation for Cancer
Benefit
Jayasmita Malik Not Opted Not Opted Not Opted Not Opted Not Opted

Add On Cover
Non-Medical Expenses Cover Health Prime Rider
Member Name
UIN: BAJHLAP21586V012021 BAJHLIA24087V022324

JAYASMITA MALIK No No

Member Name Health Questionnaire Yes/No Details

Jayasmita Malik Has any of the persons to be insured suffer from/or No NA

investigated for any of the following?Disorder of the heart,
or circulatory system, chest pain, high blood pressure,
stroke, asthma any respiratory conditions, cancer tumor
lump of any kind, diabetes, hepatitis, disorder of urinary
tract or kidneys, blood disorder, any mental or psychiatric
conditions, any disease of brain or nervous system, fits
(epilepsy) slipped disc, backache, any congenital/ birth
defects/ urinary diseases, AIDS or positive HIV, If yes,
indicate in the table given below.If yes please provide
details.
Jayasmita Malik Diabetes NA NA

Jayasmita Malik Hypertension NA NA

Jayasmita Malik Cholesterol Disorder NA NA

Jayasmita Malik Obesity NA NA

Jayasmita Malik Cardiovascular diseases NA NA

Transcript of Proposal for ([11-8435-0000899132-00] HEALTH ENSURE -
INDIVIDUAL) [(UIN):BAJHLIP24149V062324]

Member Name Health Questionnaire Yes/No Details

Jayasmita Malik Do you or any of the family members to be covered No NA

have/had any health complaints/met with any accident in
the past 4 years and prior to 4 years and have been taking
treatment, regular medication (self/ prescribed)or planned
for any treatment / surgery / hospitalization?
Jayasmita Malik Do you smoke cigarettes or consume tobacco (chewing No NA
paste) / alcohol, nicotine or marijuana in any form? Please
give duration and daily consumption
Jayasmita Malik Have any of your immediate family members (father, No NA
mother, brother, or sister) have/had cancer, heart attack, or
stroke and at what age? Prior to age 60?
Jayasmita Malik Has any proposal for life, critical illness or health related No NA
insurance on your life or lives ever been postponed,
declined or accepted on special terms? If yes, give details
Jayasmita Malik Are you vaccinated against Covid 19? (If yes, Give No NA
Vaccination Details.)
Jayasmita Malik Have you or any of the persons proposed to be insured No NA
were/are detected as Covid positive (If Yes, Give Date of
Detection and Treatment Details.)

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.

I/We hereby give voluntary consent to BAGIC/Company to share my/our personal information and data provided in this proposal form with its group
companies or any other person in connection with the Insurance Policy or otherwise, including for providing products and services of group
companies that may be of interest to me/us, to be used in accordance with their respective privacy policies and subject to appropriate measures
being in place to safeguard my/our personal information.

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.
Transcript of Proposal for ([11-8435-0000899132-00] HEALTH ENSURE -
INDIVIDUAL) [(UIN):BAJHLIP24149V062324]

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: BALASORE-2nd Flr, Mittal Tower,O.T Road,Iti Chawk,Balasore,Odisha,INDIA,756001
** 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

Policy issuing office and Correspondence address for communication BALASORE-2nd Flr, Mittal Tower,O.T Road,Iti Chawk,Balasore,Odisha,
by policyholder for claim, service request, notice, summons, etc. 756001,INDIA

Proposer Name Jayasmita Malik Policy Number 12-8435-0000107784-00

Scan QR to view your policy details

Health Card Number: 31-8435-0017804065-0001
Customer ID: PI32691240
Policy No: 12-8435-0000107784-00
First Policy Inception
Date: 08/01/2025
Valid Up to: 07/01/2026
Member Name: Jayasmita Malik
Age: 32

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 - 411 006. 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 www.bit.do/bjazgi

[email protected] Demystify Insurance http://support.bajajallianz.com

 Certificate for the purpose of deduction under Section 80-D of Income Tax
Amendment Act, 1986

This is to certify that Jayasmita Malik has paid Rs. 6036 towards Health Insurance premium for HEALTH ENSURE -
INDIVIDUAL for the period from 08/01/2025 to midnight of 07/01/2026 under Policy no 12-8435-0000107784-00

FINANCIAL YEAR AMOUNT

2024-2025 6036.00

Issue Date: 09/01/2025

Place: BALASORE-2nd Flr, Mittal Tower,O.T Road,Iti Chawk,

For & on the behalf of

Bajaj Allianz General Insurance Company Ltd.
Signature Not Verified
Digitally signed by DS BAJAJ
ALLIANZ GENERAL INSURANCE
COMPANY LIMITED
Date: 2025.01.09 18:09:48
18:09:38 IST
Authorized Signatory
This certificate must be surrendered to the company for issuance of fresh certificate in case of cancellation of the Policy or any alteration
in the insurance affecting premium.

Notes:
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.

“The amounts present in the document are calculated with INR currency if not mentioned otherwise.”

Policy Verification
Claim Registration

Bajaj Allianz General Insurance Co. Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. 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 www.bit.do/bjazgi

[email protected] Demystify Insurance http://support.bajajallianz.com

 TAX INVOICE
(Customer Copy)

Invoice Number 212501I000030283 Customer ID PI32691240

Invoice Date 09/01/2025 Policy No. 12-8435-0000107784-00

Recipient/ Details of Insured Supplier/ Details of Insurer

GSTIN Unregistered GSTIN 21AABCB5730G1Z9

PAN NA PAN AABCB5730G

Name (Proposer) Jayasmita Malik Name Bajaj Allianz General Insurance Company Ltd.

Address-1 Nilgiri Address-1 2nd Flr, Mittal Tower

Address-2 NA Address-2 O.T Road

Address-3 Baleswar Address-3 Iti Chawk

Pin Code 756040 Pin Code 756001

City BALESWAR City BALASORE

State ODISHA State ODISHA

Client Category NON HNI Place of Supply 21 - ODISHA

Premium Details
Description Amount Description Amount

Net Premium 5116 State GST(9%) 460

Receipt Number: SYS-24-000011555857 Date: 09/01/2025
Central GST(9%) 460
Premium Payer ID: PI32691240 Float: NA; ** If Premium paid
through Cheque, the Policy is void ab-initio in case of dishonour 0
IGST(18%)
of Cheque
UTGST(9%) 0

CESS 0

Gross Premium 6036

Total Invoice Value (In Words) : Six Thousand Thirty-Six 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.

Signature Not Verified

Digitally signed by DS BAJAJ
ALLIANZ GENERAL INSURANCE
COMPANY LIMITED
Date: 2025.01.09 18:09:48
18:09:35 IST
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.”

This is a digitally signed document and hence no physical signature is required

Bajaj Allianz General Insurance Co. Ltd. Bajaj Allianz House,Airport Road,Yerwada,Pune - 411 006. 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 www.bit.do/bjazgi

[email protected] Demystify Insurance http://support.bajajallianz.com