*142505648*

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)

GROUP PERSONAL ACCIDENT POLICY SCHEDULE UIN : IRDA/NL-HLT/BAGI/P-H/V.I/151/13-14

Policy issuing office and Correspondence address for communication by policyholder for Bajaj Finserv Building,1st Floor,Behind Weikfield IT-Park,Pune-411014,Phone No :1800-
claim, service request, notice, summons, etc. : 209-0144
Insured Name SCHNSESHU KUMAR THOTA Child Certificate Number OG-20-9906-6401-00054118

INSURED DETAILS POLICY DETAILS

Policy Issued on 08-JAN-2020
SECOND LEFT,
WEST GODAVARI, ANDHRA PRADESH,INDIA, From: 08-JAN-2020 00:00
Insured Address Period of Insurance
WEST GODAVARI - 534101, To : 07-JAN-2021 Midnight
ANDHRA PRADESH
Endorsement NA
Customer ID 173321314 Previous Policy Number NA
GSTIN / UIN NA
Policy Status ISSUED STATE CODE / NAME 37 - Andhra Pradesh
Company GST No : 27AABCB5730G1ZX
Invoice No : 139570547/0 Company PAN : AABCB5730G
Master Policy Number OG-20-9999-9960-00000042 Plan Chosen Group Personal Accident Policy for BFSD App users
Cover Details
PLAN RISK COVERED RATES/SUM INSURED
Group Personal Accident Permanent Partial Disability SUM_INSURED:-Rs.1,00,000
Group Personal Accident Permanent Total Disability SUM_INSURED:-Rs.1,00,000
Premium Details
Discounts ( if Any ) Rs.0
Net Premium. Rs.35
Final Premium Rupees Fourty One only.
Integrated GST (18%) Rs.6
Gross Premium. Rs.41

Other Details
Scope of coverage 1 PERMANENT PARTIAL DISABILITY - SUM INSURED INR 100,000
Scope of coverage 2 PERMANENT TOTAL DISABILITY- SUM INSURED INR 100,000
Scope of coverage 3 ROAD AMBULANCE COVERED UP TO INR 25,000
Scope of coverage 4 AIR AMBULANCE COVERED UP TO INR 500,000
Scope of coverage 5 ALL OTHER TERMS AND CONDITIONS AS PER STANDARD GROUP PERSONAL ACCIDENT POLICY
Nominee Name KANAKAMAHALAKSHMI THOTA
Nominee Relationship SPOUSE
Any existing NO
disability/infirmity
Special Terms and conditions NA
Bank Reference No. 2
BAGIC. RM. Code 0
BAGIC RM Name PINAKI
IMD RM. Code
IMD RM Name
Customer Consent YES
Electronic Insurance Account
Number (EIA No)
Remarks
S P Code

Receipt Number:9906-03397636 | Date:08-JAN-20 | Premium Payer ID:59888002 | Float: AF

Premium Details ** If Premium paid through Cheque, the Policy is void ab-initio in case of dishonour of Cheque.
Financial Institution Ref. No. 26124488

Agency Code 59888002,BAJAJ FINSERV Contact No. 02071877060,0207187706

& Name DIRECT LIMITED 0
E-Mail ID. insuranceconnect@bajajf
inservmarkets.in
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: Bagichelp@bajajallianz.co.in , 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

 *142505648*

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)

GROUP PERSONAL ACCIDENT POLICY SCHEDULE UIN : IRDA/NL-HLT/BAGI/P-H/V.I/151/13-14

Policy issuing office and Correspondence address for communication by policyholder for Bajaj Finserv Building,1st Floor,Behind Weikfield IT-Park,Pune-411014,Phone No :1800-
claim, service request, notice, summons, etc. : 209-0144
Insured Name SCHNSESHU KUMAR THOTA Child Certificate Number OG-20-9906-6401-00054118
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. MH008583958201920M Defaced No. 0004665448201920 ORDER NO.CSD/240/2019/5894/19
ORDER DATED 07.12.2019DEFACED DATE dated 07-DEC-19 timing 16:28:29 of General Stamp Office,Mumbai,India.
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.
Schedule (1) | Printed on : 08-Jan-2020 06:02:53 pm |Silent Print|WEB|NA

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: Bagichelp@bajajallianz.co.in , 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

 *142505648*

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)

GROUP PERSONAL ACCIDENT POLICY SCHEDULE UIN : IRDA/NL-HLT/BAGI/P-H/V.I/151/13-14

Policy issuing office and Correspondence address for communication by policyholder for Bajaj Finserv Building,1st Floor,Behind Weikfield IT-Park,Pune-411014,Phone No :1800-
claim, service request, notice, summons, etc. : 209-0144
Insured Name SCHNSESHU KUMAR THOTA Child Certificate Number OG-20-9906-6401-00054118

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:173321314 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 Bagichelp@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329

Policy No : OG-20-9906-6401-00054118
ID Card No : 21-139570547
Valid Upto : 07-Jan-2021
SCHNSESHU KUMAR THOTA (34 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: Bagichelp@bajajallianz.co.in , 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