Bajaj Allianz General Insurance Company Ltd.

Regd.Office - GE Plaza, Airport Road, Yerwada, Pune - 411006 (India)

GENERIC CONTINGENCY POLICY SCHEDULE

Policy No : OG-11-2001-6401-00044336 Policy issued on : 05-AUG-2010

Policy Commencement date : 05-AUG-2010 19:11 Policy Expiry Date : 04-AUG-2011
Insurance Plan Chosen : Accident and Home Cover Imdcode : 10029213
Date Of Birth: Sub Imdcode :
Proposer Name : RELIANCE LOYALTY AND ANALYTICS LIMITED Partner Id: 21412732
Address : RelianceCorporate Park, Ghansoli, ,-, Thane
Pincode : 400701
Application No Scrutiny No
Master Policy No : OG-09-9999-9960-00000004

Cover Details :
Section Cover Description Cover Parameters Premium
Generic Death and Disability SUM_INSURED:150000 136
AGE:45
Generic Acc_Hospitalisation SUM_INSURED:25000 136
AGE:45
Discount ( if Any ) : 0 Net Premium : 272
Service Tax :27 Edu Cess : 1 Gross Premium : 300
Other Details :
Membership No. : 2266111324853332
Membership Name. : MEIKANDAN.S
Date of Birth : 31-OCT-1964
Contact No. : 9843092127
Death :
Death/Disability : 1.Pays 100% of SI for Death & 125% of SI for PTD.2.Does not cover suicide; aviation; terrorism; criminal act;
motor racing; military operations etc;3.Disability is loss of sight; physical separation or loss of ability to use
hands or feet.
AccidentalHospitalization : 1. Covers medical expenses incurred due to accidental hospitalisation for a minimum period of 24 hrs. Also cov-
ers for fracture;2. Does not cover in case of attempt to suicide; aviation; terrorism; criminal act; motor racing;
military operations etc.
Fire :
Disclaimer : The above information is only indicative in nature. For details of the coverage and exclusions please contact our
nearest office.
Type of Member : New
Ril Ref No :

In case of any claim, please contact our 24 Hour Call centre at 1800-22-5858, 1800-102-5858 (Toll Free) / 91-020-30305858
(chargeable, add area code before this number in case of mobile call) or email us at 'info@bajajallianz.co.in'.
Policy Servicing Office : Bajaj Allianz General Insurance Company Ltd, Vardhaman, 4th Floor, 7 Loves Chowk, Shankar Sheth Road,
,, Pune-411042 Phone No :66240100

ReceiptNo / Collection No / Amt(INR) := 1101-00462749 / 1/300 (INR) (If Premium is paid through cheque the policy is void ab-initio in case of dis-
honor of chq.)
Service Tax Reg.No.AABCB5730G-ST-001

For & On Behalf of Bajaj Allianz General Insurance Company Ltd.

Stamp
Duty
Rs. 0.5

Authorized Signatory
Consolidated stamp Duty paid vide Receipt No:
.9793 dated 10-JUN-10
Regd Office : GE Plaza,Airport Road, Yerwada Pune-411006 (India)
 Invoice
(Issued in terms of Rule 4A of Service Tax Rules, 1994)

Invoice No. : GCP/10-11/102337879

Invoice Date : 05-AUG-2010

Name of client / customer

Name of customer : MEIKANDAN.S
Membership Number : 2266111324853332
Tel. : 9843092127

Master Policy Number : OG-09-9999-9960-00000004

Policy Schedule Number : OG-11-2001-6401-00044336

Description of Service: Service Charges

PARTICULARS No. of Covers RATE AMOUNT

Service Charge 2 44.43 88.85
Subtotal 88.85
Add: Service Tax @ 10% 8.89
Add: Education Cess @ 2% 0.18
Add: SHE Cess @ 1% 0.08
TOTAL AMOUNT 98.00

Amount in words : Rupees Ninety Eight Only

Central Service Tax Registration : AADCR8059CST001

Category of Service : Club and Membership Service

Reliance Loyalty and Analytics Ltd.

Authorised Signatory

Registered Office : Reliance Corporate Park, Building No. 4,Ground Floor,'C' Wing,Thane Belapur Road,Ghansoli,Navi Mumbai-400 701