6/24/2022

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BAJAJ FINANCE LIMITED

DEALER CODE- 688158 - SHREE DURLAVA#TIHIDI#BPES RCD#39626

TIHIRI

Date- 24/06/2022

Time- 05:32:28 PM

CHARGE SLIP

By clicking on the “I Agree” button and/or by entering the one-time password (OTP), sent by BFL and/or by providing
physical signature on this Charge-slip, I accept the loan facility from BFL. I hereby confirm that I (i) am at least 18 years o
age, (ii) can understand, read and access the world wide web / internet in English language, (iii) have read, understood and
agree to be bound by Charge Slip, Fee and charges, the Loan Terms and Conditions, Value Added/Cross-sell product Ter
and Conditions.

Further, I agree that my action of (i) submission of the OTP sent by BFL or (ii) providing physical signature on this Charge
slip, constitutes a valid acceptance of the terms and conditions and same shall have binding upon effect on me.

Personal Details

Customer Name

: BIBHUTI ROUT BHUSAN T

Customer Address

: S/O-RABINDRA ROUT BODAK null

: ORALI BHADRAK

Customer Mobile Number

: 9439647598

Customer Email ID

I. Charge-Slip and Fee for 32HS301C - LLOYD - LED Rs20000 (Product 1)

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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Customer ID

: 554353859

Transaction Details

: CS217567546404

RRN

: CS217567546404

Opportunity ID

: BR64641794

Auth Code

: dfe005bdb3010551bb75

EMI Network Card Number (if already availed)

: 2030402093954293

Purpose of Loan

: Purchase of Consumer Durable Product

Product(s)/Services(s) availed on loan from BFL (Product)

: RCD

Product Price

: 20000

Loan Amount for availing Product

: 20000

Annualized Rate of Interest for Loan:% (pa)

: Customer will be charged upfront interest (as applicable). As a part of our tie-up, the manufacturer/Dealer/
shall pay us the interest subsidy directly. Our effective Internal Rate of Return (IRR) shall range from 23-27
% on an annualized basis.

Product Loan Tenure (Months)

:8

EMI Details

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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EMI Amount for Product Loan

: 2500

EMI for CLC Loan

: 124.88

EMI for Loan

:0

EMI for Loan

:0

Total EMI Amount

: 2624.88

Indicative EMI Start Date

: 2022-08-02
This EMI Date may vary and actual date will be communicated through SMS and welcome letter, once
the loan is booked

Fees and charges to be collected along with 1st EMI

Convenience Fee(Inclusive of applicable taxes)

: Rs. 117/- (Inclusive of applicable taxes) will be collected along with 01st instalment.

CIBIL TransUnion Report Fee(Inclusive of applicable taxes)

Loan Enhancement Fee(inclusive of applicable taxes)

:0

Down Payment To be Made

Processing Fee(Inclusive of applicable taxes)

:0

EMI Network Card Fees(Inclusive of applicable taxes)

:0

Mandate Registration Fee(Inclusive of applicable taxes)

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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Health EMI Network Card Fees(Inclusive of applicable taxes)

:0

Add on EMI Network card fee(Inclusive of applicable taxes)

:0

Cash Repayment Charges (Inclusive of applicable taxes)

:0

Total

:0

Details of Down Payment Made

Amount paid through Dealer Reward Points Redemption(P)

Amount paid through BFL Reward Points Redemption(Q)

Amount paid through RBL Bank Points Reward Redemption(R)

:0

Amount paid through any other mode(S)

Total (P+Q+R+S)

:0

Bank Details

NACH Mandate (ECS)

: Existing ECS

Account Number

: 34730466263

Bank Name

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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: STATE BANK OF INDIA

MICR Code

: 756002100

IFSC Code

: SBIN0000036

II. Fee and Charges applicable for the present loan(s) or future loan(s) availed using Bajaj Finserv EMI
Network Card and Health EMI Network Card

Bounce Charges

: Rs. 450/- (inclusive of applicable taxes) levies in case of default due to the repayment instrument(s) being
dishonoured

Mandate Registration Charges

: Rs. 118/-(inclusive of applicable taxes)if applicable (Click on https://www.bajajfinserv.in/all-fees-and-

charges)

Mandate Rejection Charges

: Rs. 450/- (inclusive of applicable taxes) per month from the first instalment due date for mandates rejected by
customers bank until the new mandate is registered.

Cash Repayment Charges

: Cash Repayment Charges of Rs. 499/- (Inclusive of applicable taxes) are applicable for repayment of EMI
dues in Cash at BFL Branches

Penal interest

: Any delay in payment of Monthly Instalment shall attract penal interest at the rate of 4% per month
on the instalment outstanding, from the respective due date until the date of receipt.

Full Pre-payment(Foreclosure)Charges

: Nil, Any time post disbursement of loan.

Part Pre-payment Charges

: Nil, Any time post disbursement of loan.

III. Most Important Terms and conditions of Loan (MITC)

I hereby agree, acknowledge and agree as under:

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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1) The Loan is granted for buying products/value added services/extended warranty/insurance or any other general purpose
except for any speculative activities (Product(s)). The amount will be disbursed to company/entity who is providing the
products/services for which the loan is being availed to buy such products/services.

2) BFL may at its sole and absolute discretion, without assigning any reasons, accept or reject the Loan request.

3) The loan availed shall be governed by Master Terms and Conditions, prescribed by Bajaj Finance Limited (BFL) and avail
on website: https://www.bajajfinserv.in/master-terms-and-conditions.pdf (Master Terms)

4) I authorize BFL to procure my CIBIL report, share it with me and recover from me Rs. 36 (including applicable taxes) for

5) All the particulars, information and details provided by me for availing the loan is be true, correct and up to date in all resp
and I shall keep the BFL immediately updated of any change in the information provided. BFL is entitled to verify this dire
or through any third-party agent.

6) I authorizes BFL to use my existing KYC details and I acknowledge that in case of any changes in registered KYC, same
needs to be updated to BFL.

7) You shall repay the loan repaid in Equated Monthly Installments (EMI) on or before due date till discharge of the entire loa
amount with interest & charges as specified herein by BFL with respect to Loan and as more specifically detailed above wh
are also available on https://www.bajajfinserv.in/all-fees-and-charges. The fee and/or charges and Terms and Conditions ar
subject to changes at sole discretion of BFL, however such changes shall be made applicable prospectively..

8) If the EMI due date in respect of any amounts payable in respect of the loan falls on a day which is not a Business Day, the
immediately preceding Business Day shall be the EMI due date for such payment.

9) The company will earn interest/commission from manufacture/dealer/third party service provider, on the Product(s) availed
the customer which enables the company to offer interest free loan to such customer for purchase/payment of Product(s). T
upfront interest/additional upfront interest paid by the manufacturer/dealer/third party service provider, is not refundable. I
case the tenor of said loan is extended for whatever reasons including due to my request for resolution plan, I shall pay the
interest at the rate of 24% per annum on the revised equated monthly instalments due and payable by me, as may be
communicated by BFL.

10) In case of cancelation and surrender of insurance policy/value added services/extended warranty and/or on death of the
customer, BFL shall have the right to appropriate insurance claim paid thereunder or pursuant to cancellation or the surrend
value of the insurance policy/value added services/extended warranty towards the Outstanding Dues of any loan(s) availed
from BFL. If there is any surplus leftover, it shall be paid to the Customer. If there is any deficit, then the Customer shall b
liable to pay entire deficit forthwith.

11) The NACH mandate given by Customer in favour of BFL can be used to recover all Outstanding Amount including fees,
penalties, cost and other applicable charges in connection with any Loan availed by the Customer from BFL. Customer sha
forthwith issue fresh Cheque or NACH or Electronic Payment Instructions to BFL, if there is any revision in the repaymen
schedule/ EMI by BFL.

12) This single Charge Slip would apply for different Product(s)/services availed by Customer on a single day by making a cle
mention about the varying details of loan vis--vis each Product(s)/services availed by Customer. Since the loan amount,

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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interest rate and other charges/expenses could vary for each product/service availed by Customer, as also, it would be
convenient for the Customer to easily identify the applicable EMI for each product/service availed by him/her, separate loa
account numbers and separate Statement of Account for each Product(s)/services will be issued for administrative
convenience, and the same are convenient accessible by the Customer on the dedicated experia portal and/or through the
Application of Bajaj Finance Limited.

13) In the event of default on any one of the loan(s) detailed in this Charge Slip, BFL reserves the right to recall the other loan(

14) The EMI of the loan availed can be clubbed with EMI of other loan availed by customer from BFL or the same can be deb
from customers account separately.

15) That in case of occurrence of default by reason of dishonor of Cheque or NACH or Electronic Payment Instructions provid
Customer shall be liable to pay to BFL the bounce charges ("Bounce Charges") as mentioned above, for each dishonour e
occurrence.

16) In the event of any default in repayment of the Outstanding Amount, Customer shall be liable to pay penal interest ("Penal
Interest") at the rate/or amount as stated above, from the date of default till the date of realization by BFL without prejudic
any other rights of BFL under these terms and condition.

17) BFL shall be authorized (a) to disclose, exchange, share or part with all information from time to time relating to loan to cr
bureaus/credit reference agencies, its group companies, financial institutions, Credit Information Companies (CIC), Centra
KYC Registry (CERSAI) or any authorized third-party agency as BFL may deem necessary or appropriate for use or
processing of the said information and shall not hold BFL or any of its group companies or its/ their agents/representatives
liable for use/sharing of the information as stated above, (b)to seek/obtain any other information, relating to customer, from
any third party, (c)To procure/avail CIBIL report and provide it to customer by deducting applicable charges for the same a
(d) share the all information to any Regulator, Court, Law enforcement agency, Quasi-Judicial authority etc. on a need to n
basis.

18) BFL and its group companies, affiliates and/or business associates and their respective representatives are authorized to sen
communications regarding loans, insurance and third-party products and services, availed by customer, through telephone
calls/SMSs/emails/post/WhatsApp etc. including but not limited to promotional communications.

19) BFL is not an issuer/provider of the Product(s) purchased/services availed by the Customer on the loan availed from BFL.
Accordingly, BFL shall not be responsible for the quality or any assurances and/or representations made in relation to such
products/services provided by third parties. BFL shall not be liable for any delay in delivery or no-delivery of product and/
with respect to the quantity, quality, conditions, fitness, suitability or otherwise whatsoever of the product.

20) I understand and acknowledge that, upon availing moratorium from BFL, the benefits of third party products namely Digit
Fone Safe (DFS)/ScreenProtect/Mobile Protect, whichever product availed by me, shall cease to be of effect, until the loan
dues pertaining to the moratorium period are paid by me to BFL.

21) Customer hereby expressly consent for taking my photo/video evidencing the conduct of loan transaction by me and that su
photo/video is unconditionally agreed to be stored and preserved for a period of at least five (5) years or otherwise from the
date of closure of the loan and/or as the law/regulations may so mandate, whichever is higher.

22) Customer agrees to have read and understood the BFL-WhastsApp Terms and Conditions available at
(https://bfin.in/RJX23SRWCy) and hereby expressly consent to receive BFL loan related important updates on WhatsApp.

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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IV. EMI Network Card/Health EMI Network Card

Name to be Displayed

Email ID

Mobile Number

Date of Birth

Add on EMI Network Card 1

Name

Email ID

Mobile Number

Date of Birth

Relationship

Add on EMI Network Card 2

Name

Email ID

Mobile Number

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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Date of Birth

Relationship

Fees and Charges

EMI Network Card Fees (Inclusive of applicable taxes)

:0

Health EMI Network Card Fees(Inclusive of applicable taxes)

:0

EMI Network Card/Health EMI network Card Annual Fee

: Rs. 117 (inclusive of applicable taxes) Annual fee will only be charged to the EMI Network card/Health EMI
Network Card holders who have not availed any loan using the EMI Network card/Health EMI Network Card
in the preceding year. The duration of the preceding year is calculated 12 months from last year’s validity
month, which is printed on the face of your EMI Network card/Health EMI Network Card. For example, If the
EMI Network card/Health EMI Network Card is issued in the month of February 2019 (referred to as ‘Member
Since’, on the EMI Network card/Health EMI Network Card) the date for payment of the annual fee will be
March, 2020.

Loan Enhancement Fee

: Rs. 117/- (Inclusive of applicable taxes) for temporary increase in EMI card limit for the loan transaction.
Same will be charged only for increase in limit in excess of Rs. 999/- to be collected along with 01st
instalment.

EMI NETWORK CARD & HEALTH EMI NETWORK CARD: TERMS AND CONDITIONS

(All terms used but not defined herein shall have the meaning ascribed to them in the Master Terms)

A.CUSTOMERS REPRESENTATIONS

1) I have applied for EMI Network Card and/or Health EMI Network Card as specified in this Application Form, from Bajaj
Finance Limited (BFL).

2) I hereby unconditionally acknowledge and accept that:

i. The EMI Network Card and/or Health EMI Network Card may be issued by BFL either in Electronic or Physical form.

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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ii. All particulars, information and details provided by me in relation to my application are true, correct and up to date and
I have not withheld any material information and I am obligated to keep BFL immediately updated of any change in the
information provided by me in this Application Form.

iii. I shall submit all documents/KYC in such form and manner as may be required by BFL in relation to my application.

iv. I have read and understood the Master Terms and Conditions applicable to Loans for Consumer Durable, Digital, Life s
products & EMI Cards (Master Terms) prescribed by BFL and available on website: https://www.bajajfinserv.in/master-
terms-and-conditions.pdf and understand the applicability of the same for issuance and usage of EMI Network Card and/or
Health EMI Network Card and hereby agree to be bound by the same at all times including any additions/amendments ther
from time to time.

v. I shall make payment of applicable fee and/or charges as specified by BFL with respect to EMI Network Card and/or He
EMI Network Card, details whereof are provided on BFL Website https://www.bajajfinserv.in/all-fees-and-charges

vi. I understand that the aforesaid fees and/or charges are subject to changes and are non-refundable and non-transferable.

vii. BFL has sole and absolute discretion, without assigning any reasons to accept or reject my application.

viii. I shall keep myself updated of any revisions in the Master Terms as may be communicated by BFL through any
acceptable means of communications (as defined in the Master Terms).

ix. The loan limit shall be assigned to me as per BFLs sole discretion and internal policies and the same is subject to furthe
revision at BFLs sole discretion. BFL shall not be liable in any manner whatsoever for such revision or cancellation of limi

x. The NACH mandate given in favour of BFL shall be used to recover all outstanding amount including fees, penalties, co
and other applicable charges in connection with the loan availed by me.

xi. That no insolvency proceeding or suit for recovery of outstanding dues or monies and or any criminal proceedings, has
been initiated and/or are pending against me and that I have never been adjudicated insolvent by court or any other authorit
have not taken any action and no other steps have been taken or legal proceeding started by or against me in any court of la
and/or in any other authority for appointment of a receiver, administrator, administrative receiver, Insolvency professional,
similar officer with respect to any of my assets.

xii. I will keep my credentials including the login id and password/PIN issued by BFL and/or reset by me (Credential) as
confidential and not to share the same with any person/third party. Any use or misuse of the credentials including the
transactions carried out using the credentials shall be my sole responsibility and BFL shall not be held responsible for any
loss/damage incurred on account of such use or misuse.

xiii. That the EMI Network Card and/or Health EMI Network Card is/are NOT assignable to any person. I hold myself
responsible for any use/misuse of the EMI Network Card/Health EMI Network Card.

3) I authorize BFL

B. COMMON TERMS FOR EMI NETWORK CARD AND/OR HEALTH EMI NETWORK CARD

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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a) To exchange, share or part with all information relating to this application to credit bureaus/credit reference agencies, its
group companies, financial institutions, Credit Information Companies (CIC), Central KYC Registry (CERSAI) or any
authorized third- party agency as BFL may deem necessary or appropriate for use or processing of the said information and
shall not hold BFL or any of its group companies or its/ their agents/representatives liable for the use/sharing of the
information as stated above.

b) To seek/obtain any other information, relating to me, from any third party.

c) To procure/avail my CIBIL report and provide it to me by deducting applicable charges for the same;

d) To share certain information related to EMI Network Card and/or Health EMI Network Card which may include my KY
and transaction details with its business associates subject to confidentiality restrictions) for integrating the EMI Network C
and/or Health EMI Network Card usage on such business associates website/ wallet etc. as may be required for facilitating
use of EMI Network Card/Health EMI Network Card.

4) I authorize BFL to share certain information related to EMI Network Card and/or Health EMI Network Card, which may
include my KYC and transaction details with its Selected Business Associates, Sourcing Partners, and/or Technology Partn
(subject to confidentiality restrictions) for integrating the EMI Network Card and/or Health EMI Network Card usage on su
business associates website/ wallet etc. as may be required for facilitating my use of EMI Network Card/Health EMI Netw
Card.

5) That this Application Form, together with all its contents may be submitted to:

a) The subsidiaries and affiliates of BFL, any service provider/third party with reference to rendering services in connectio
with the product(s) availed by me.

b) To any Regulator, Court, Law enforcement agency, Quasi-Judicial authority etc. on a need to need basis.

6) I hereby authorize group companies, affiliates and/or business associates of BFL and their respective representatives to sen
me communications regarding loans, insurance and their respective products and/or services (Collectively Other Products)
through telephone calls/SMSs/emails/post/WhatsApp/bot/bitly, etc. including but not limited to promotional communicatio
agree and understand that such Other Products if availed, are governed by their own set of terms and conditions, which sha
in addition to and not in derogation to the terms and conditions prescribed by BFL herein. I understand that I can at any tim
opt to withdraw my consent to receive any telecommunication.

1) The EMI Network Card and/or Health EMI Network Card is/are an Existing Membership Identification number(s) used for
authentication and is/are neither credit card(s) nor stored value card(s).

2) For each valid transaction initiated and approved by the BFL on the EMI Network Card and /or Health EMI Network Card
new Loan account will be created by BFL, provided that BFL may at its sole discretion reject such transaction initiated
through the EMI Network Card and/or Health EMI Network Card. Further BFL may require additional documentations fro
the Customer for approving the said loan transaction(s).

3) BFL may, at any time, in its sole and absolute discretion and without assigning any reason, decide to withdraw the EMI
Network Card and/or Health EMI Network Card, service and/ or terminate any specific EMI Network Card and/or Health E

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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Network Card. Further BFL will have no liability to the EMI Network Cardholder and/or Health EMI Network Cardholder
any other person, in this regard in any manner whatsoever.

4) BFL is not the issuer/provider of the products purchased/services availed by the Customer through the EMI Network Card
and/or Health EMI Network Card. Accordingly, BFL shall not be responsible for the quality or any assurances and/or
representations made in relation to such products/services/offers provided by any third party. BFL shall not be liable for an
delay in delivery or no-delivery of product and services and/or with respect to the quantity, quality, conditions, fitness,
suitability or otherwise whatsoever of the product/services.

5) In the event of an unauthorized access to or use of EMI Network Card and /or Health EMI Network Card, the cardholder sh
immediately inform BFL and call or write to BFLs Customer and request for blocking the respective EMI Network Card
and/or Health EMI Network Card.

6) The usage of the EMI Network Card and/or Health EMI Network Card would be construed as the deemed acceptance of th
Master Terms governing the usage of such EMI Network Card and/or Health EMI Network Card.

7) EMI Network Card and/or Health EMI Network Card shall not be used for any unlawful / unauthorized purpose.

8) BFL would charge convenience/processing fees at its sole discretion on the Loan availed by customer using EMI Network
Card and/or Health EMI Network Card, same would be communicated to the Customer through the Transaction SMS.

9) BFL Customer Care Contact details:

For any grievances/queries, Customers can write to BFL at wecare@bajajfinserv.in

EMI Network Card and/or Health EMI Network Card may also call BFL Customer Care for any grievances/queries related
the respective EMI Network Card and/or Health EMI Network Card at 8698010101. This is not a toll-free number and norm
call charges will be applicable

C. SPECIFIC TERMS AND CONDITIONS FOR EMI NETWORK CARD

1) By using the EMI Network Card, the customer may engage in the following transactions

i. Purchase a Consumer Durable (CD) (LED, refrigerator, AC, smartphones, laptops etc.), Lifestyle (LSF) (furniture, life ca
elective procedures etc.) or Retail (apparel, footwear, small appliances, travel, coaching classes, hotels, eyewear, accessorie
etc.) product, from outlets /stores owned and operated by Dealers & POS Online & Offline, on equated monthly instalment
from BFL where EMI Card Network is available & authorized;

ii. Enquire about the available loan amount for CD, LSF or Retail purchase; and/or enquire about personal loan eligibility
and/or apply for the same at BFLs call center, branch or online customer portal and

iii. Use it for his/her identification/authentication in BFL network/system.

2) By providing/entering the EMI Network Card number or providing the registered mobile number of the cardholder (as per
BFLs records), at Merchant Counter or BFLs branches or online platform, the issuance date and the name of the EMI Netw

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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Card-holder, where the Customer is required to show one photo identification card or enter his/her PIN or Transaction Cod
One Time Password (OTP) received on the registered mobile number and/ or the registered email id of the customer. Once
Customer identity is authenticated, the EMI Network Cardholder will receive an SMS providing Commercial Terms of the
proposed Loan being offered (Transaction SMS) and containing a specific numeric code (the Transaction Code).

3) As a token of acceptance to the terms and conditions provided in the Transaction SMS, the customer shall convey his/her
acceptance by entering the PIN or Transaction Code or OTP at the counter or BFL branch or OTP at the online/digital
platform, as the case may be.

4) All EMI Network Cardholders, who have not availed loan using the EMI Network Card in the preceding year, will be char
an Annual Fee, as detailed in https://www.bajajfinserv.in/all-fees-and-charges. Preceding year will be calculated starting th
issuance month mentioned on the EMI Card. In case the Customer uses the EMI Card for availing the Loan within the
stipulated time period as prescribed by BFL, then the Annual Fee levied shall be refunded. For example: If the EMI Card i
issued in the month of February 2019 (referred to as Member Since, on the EMI Card) the date for payment of the annual f
will be March 2020.

5) Notwithstanding anything contained in these terms and this application payment of Instant Activation Fee by the Customer
EMI Network Card cannot be used for purchase on eCommerce platforms and of retail (apparel, footwear, small appliance
travel, coaching classes, hotels, eyewear, accessories etc.) products, until successful registration of the ECS/NACH mandat
for the loan availed by the Customer as per this Application Form and until 90 (ninety) days from issuance of the EMI
Network Card.

6) Loan Enhancement Fee will be applicable, in case where BFL allows to approve the Loan transaction amount over and abo
EMI Network Card loan limit, as per its internal risk/credit policies and at its sole and absolute discretion. It is hereby clari
that payment of such fee would not enhance overall EMI Network Card loan limit. Further, payment of such fee would be
added to the first EMI/monthly instalment of such Loan transaction.

D. SPECIFIC TERMS AND CONDITIONS FOR HEALTH EMI NETWORK CARD

1) The Health EMI Network Card can be used only at limited Life Care Counters (LCF) including Multi Specialty Hospitals
(MSH), Non-MSH and diagnostic centres and such other counters as may be decided by BFL at its sole discretion (Selecte
Business Associates). Updated list of Selected Business Associates can be accessed through https://www.bajajfinserv.in/em
network-multispeciality. This Health EMI Network Card cannot be used for purchase on e-Commerce platforms and of ret
(apparel, footwear, small appliances, travel, coaching classes, hotels, eyewear, accessories etc.), consumer durables, digital
lifestyle products, etc.

2) Details of the treatments eligible for loan and benefits under the Health EMI Network Card are listed on BFL Website-
https://www.bajajfinserv.in/emi-network-multispeciality

3) The Personal Guard Individual Accident Policy upto an amount of Rs.1,00,000 will be issued by M/s. Bajaj Allianz Genera
Insurance Company (BAGIC) which will be valid for a period of one year from the date of issuance of the Health EMI
Network Card. The Terms and Condition as may be prescribed by BAGIC shall be applicable to the said Personal Acciden
Insurance Policy. Such Terms and Conditions as listed on BAGIC website: https://www.bajajallianz.com/Corp/health-
insurance/personal-accident-insurance-ppg.jsp shall be in addition and not in derogation of the Terms and Conditions of th
Application Form. Any claims pertaining to the said Personal Guard Individual Accident Policy issued by BAGIC shall be
directly taken up with BAGIC.

4) In the event of termination of Health EMI Network Card withdrawal of Health EMI Network Card services, the Personal
Guard Individual Accident Policy or any other facility provided with Health EMI Network Card services shall be immedia

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

13 of 22
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terminated.

5) The Selected Business Associates may run different offers for Health EMI Network Card Customers. Such offers shall be
subject to specific terms and conditions of such offers, which shall be in addition to the terms and conditions mentioned in
Application Form.

6) By using the Health EMI Network Card, the customer may engage in the following transactions:

i) to avail loan to pay their medical expenses on easy EMIs.

ii) enquire about the loan limit for availing loan for the eligible treatments at the Selected Business Associates as aforesaid

iii) Use it for his/her identification/authentication in BFL network/system.

7) To avail loan for the treatment at Selected Business Associates, Health EMI Network Card holder will need to follow the
below mentioned procedure:

i) share Health EMI Network Card number or registered mobile number, card validity date, name on the Health EMI Netw
Card and/or one photo identification at Merchant Counter or BFLs branches or online platform.

ii) enter his/her Transaction Code or One Time Password (OTP) received on the registered mobile number and/or the
registered email id of the customer.

iii) Once the Customer identity is authenticated, the Health EMI Network Card holder will receive a SMS providing the
Commercial Terms of the proposed loan being offered (Transaction SMS) and containing a specific numeric code (the
Transaction Code).

CPP Livcare Lite

Sum Assured

: 50000

Premium Amount

: 999

Nominee Name

: KUNTALA ROUT

Nominee Relation

: Mother

Nominee DOB

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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: 1960-01-01

Date

: 24/06/2022

Place

: TIHIRI

Signature

Declaration:I hereby agree to buy CPP LivCare Lite at the price mentioned above. I understand that CPP LivCare Lite is a
product provided by CPP Assistance Services Pvt.Ltd.(CPP) and the services provided to me will be subject to the terms an
conditions of CPP LivCare Lite. I hereby give my consent to CPP to contact me through phone, post or email for the purpo
of activation and provision of services of CPP LivCare Lite.
Further, I agree and hereby inform CPP that in the event I purchase a CPP LivCare Lite on finance from Bajaj Finance Ltd
(BFL) then I agree that the tenure of CPP LiveCare Lite will be subject to the tenure of the loan availed by me from BFL. I
hereby confirm, agree and undertake to fulfill all my obligations towards BFL including payment of all applicaple charges
BFL, which BFL may incur in relation to my purchase of CPP LivCare Lite on finance.I hereby authorize CPP to cancel m
CPP LivCare Lite membership,upon instruction received by CPP from BFL,in the event I default on the repayment of the
finance facility availed by me from BFL for the CPP LivCare Lite and/or the loan as mentioned above and pay the cancella
refunfd if any to BFL.
*Further, I hereby give my consent to CPP to enroll me into the Group Term Life Insurance Policy taken by CPP for its
customers from Indian Life Insurance Company for the complimentary term life insurance cover as per the terms and
conditions of the Group Insurance Policy issued by the Insurer.
Declaration of Good Health
I have never had/ currently have any disorder of heart/ circulatory system/ blood pressure/ stroke/ asthma/ lung/
cancer/tumour/ HIV positive/ brain/ nervous system/ diabetes/ hepatitis/ liver/ digestive tract/urinary/ kidney/depression
/mental/psychiatric /epilepsy /blood / musculoskeletal/any disability. I have never had symptoms persisting more than 7day
nor been absent from work for any illness/ injury/ disabilities for more than 10days in last 3years.
This is health Declaration shall form the basis of your enrolment. Any known misstatement, misrepresentation and /or
omission of material importance may void the coverage under this policy.
I authorise an Indian Life Insurance Company to send certificate of insurance through SMS -Bitly Link instead of a hard co
The same would be sent to my mobile phone number and/or email mentioned in the application form.
I have agreed and understood the product benefits and exclusions and voluntarily applied for CPP LivCare Lite

DISCLAIMER, AUTHORIZATION AND DECLARATION FOR INSURANCE PRODUCT

#Conditions apply. These products are offered under the Group Insurance scheme wherein Bajaj Finance Limited is the Ma
policyholder. The above-mentioned benefits and premium amount are subject to various factors such as applied loan disbur
age of insured, lifestyle habits, health, etc.

Caution
You are obliged to make a full and frank disclosure of all material facts. If there is any change in the information given by
over the call or new information comes to light which affects your insurability, then you must inform us of the same in writ
without any delay.

Authorization
I do hereby authorize and instruct the insurer# to refund, the premium (in full or prorated as the case may be) in terms of th
master policyholder, in event of cancellation/withdrawal of the insurance cover to me/us under the group policy to the mas

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

15 of 22
6/24/2022

policy holder. In event the insurer refunds the premium amount as per instructions above, it shall be considered full and
complete discharge of any liability by the insurer towards me and I shall not have any objection for such refund subsequen
payment as per above instructions.

Statutory Warning (Prohibition of Rebates)Section 41 of Insurance Act 1938:

(i) No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew
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
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 maybe allowed in accordance with the published prospectus or
tables of the insurer.
(ii) Any person making default in complying with the provisions of this section shall be punishable with fine which may
extend to Ten Lakh Rupees
• Fraud, Misrepresentation and forfeiture: Fraud, Misrepresentation and forfeiture would be dealt with in accordance with
provisions of Sec 45 of the Insurance Act 1938 as amended from time to time

Cancellation/ Termination
• Once the Insured ceases to be a member or the policy is cancelled by the Master policyholder or the insurer for any reaso
whatsoever, the cover will automatically stand cancelled. However, the Insured under this policy can port to a similar appro
retail health policy available with the company as per 'Portability Guidelines', subject to the Company's medical underwriti
criteria.

Disclaimer *Conditions apply. This product is offered under the Group Insurance scheme wherein Bajaj Finance Limited i
the Master policyholder. The insurance coverage is provided by our partner Insurance Company. Bajaj Finance Limited do
not underwrite the risk. IRDAI Corporate Agency Registration Number CA0101. BFL does NOT hold any responsibility f
the issuance, quality, serviceability, maintenance and any claims post sale. This product provides insurance coverage for th
product. Please refer insurer's website for Policy Wordings. Purchase of this product is purely voluntary in nature. BFL doe
not compel any of its customers to mandatorily purchase any third party products. Tax laws are subject to change. BFL doe
NOT provide Tax/Investment advisory services. Please consult your advisors before proceeding to purchase an insurance
product.

Income-tax Rules, 1962

FORM NO. 60

[See second proviso to rule114B]

Form for declaration to be filed by an individual or a person (not being a company or firm) who does not have
a permanent account number and who enters into any transaction specified in rule 114B

First Name

: BIBHUTI ROUT

Middle Name

: BHUSAN

Surname

:T

Date of Birth/ Incorporation of declarant

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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: 1995-02-12

Father's Name (in case of individual)

First Name

: MR RABINDRA ROUT

Middle Name

Surname

:T

Flat/ Room No.

: S/O-RABINDRA ROUT BODAK

Floor No.

: null

Name of premises

: ORALI

Block Name/No.

Road/ Street/ Lane

Area/ Locality

: S/O-RABINDRA ROUT

Town/ City

: BHADRAK

District

State

: ORISSA

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

17 of 22
6/24/2022

Pin code

: 756163

Telephone Number (with STD code)

Mobile Number

: 9439647598

Amount of transaction (Rs.)

: 21490

Date of Transaction

: 2022-06-24T11:41:11Z

In case of transaction in joint names, number of persons involved in the transaction

Mode of transaction

Cash
Cheque
Card
Draft/Bank Cheque
Online transfer
Other

Aadhaar Number issued by UIDAI (if available)

If applied for PAN and it is not yet generated enter date of application and acknowledgementnumber

If PAN not applied, fill estimated total income (including income of spouse, minor child etc. as per
section 64 of Income-tax Act, 1961) for the financial year in which the above transaction is held

a. Agricultural income (Rs.)

b. Other than agricultural income (Rs.)

: <Rs 15000

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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6/24/2022

Details of document being produced in support of identify in Column 1 (Refer Instruction overleaf)

Document code

Document identification number

Name and address of the authority issuing the document

Details of document being produced in support of address in Columns 4 to 13 (Refer Instruction

overleaf)

Document code

Document identification number

Name and address of the authority issuing the document

The yellow Highlighted rows are mandatory to be filled by customers.

Verification
I, BIBHUTI ROUT BHUSAN T do hereby declare that what is stated above is true to the best of my
knowledge and belief. I further declare that I do not have a Permanent Account Number and my/ our
estimated total income (including income of spouse, minor child etc. as per section 64 of Income-tax Act,
1961) computed in accordance with the provisions of Income-tax Act, 1961 for the financial year in which
the above transaction is held will be less than maximum amount not chargeable to tax. Verified today -
24/06/2022

Place: BHADRAK

Note: (Signature of declarant)

1) Before signing the declaration, the declarant should satisfy himself that the information furnished in this form is true, cor
and complete in all respects. Any person making a false statement in the declaration shall be liable to prosecution under
section 277 of the Income-tax Act, 1961 and on conviction bepunishable,

(i) in a case where tax sought to be evaded exceeds twenty-five lakh rupees, with rigorous imprisonment which shall not be
than six months but which may extend to seven years and withfine;

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

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6/24/2022

(ii) in any other case, with rigorous imprisonment which shall not be less than three months but which may extend to two yea
and withfine.

2) The person accepting the declaration shall not accept the declaration where the amount of income of the nature referred t
item 22b exceeds the maximum amount which is not chargeable to tax, unless PAN is applied for and column 21 is
dulyfilled.

Preferred Language : English

Vernacular Declaration Form

The content of this Application/Agreement/Letter/Terms and Conditions has been read out,
English explained and interpreted to the applicant(s)/Borrower and to the Co-Borrower(s) in English and
understood by the applicant(s)/Borrower and Co-Borrower(s).

इस आवेदन / करार / प / िनयम एवं शत के त आवेदक (को) / ऋणी और सह-ऋणी (ऋिणयों) को

Hindi िहं दी म पढ़ कर सुनाए गए, िव ार से बताए गए और समझा िदए गए ह और आवेदक (को) / ऋणी और
सह-ऋणी (ऋिणयों) इस त को समझ गए ह।

এই আেবদনপ /চ প /িচ ঠ/িনয়ম ও শতািদর িবষয়ব আেবদনকারী(গণ)/ ণ হীতা ও সহ-

ঋণ হীতা (গণ) ক পেড় নােনা হেয়েছ, িবস্তৃতভােব ব াখ া করা হেয়েছ এবং বাংলা অনুবাদ
Bengali
কের বু ঝেয় দওয়া হেয়েছ এবং আেবদনকারী(গণ) / হীতা ও সহ ঋণ হীতাগণ) িবষয় ট বুঝেত
পেরেছন।

અર /કરારનામુ/પ /શરતોનો મજકૂ ર અરજદાર(રો)/કરજ લેનાર અને કરજ લેનાર (રાઓ) વાચીને
Gujrati
સંભળવવામાં, સમ વવામાં અને તેનો અથ પ કરવામાં આ યો છે અને અરજદાર(રો)/કરજ લેનાર

ಈಆ /ಒಪ ಂದ ಪತ ಧ ಗ ಮ ಷರ ಗಳ ಅಂಶಗಳ ಅ ರ( )
Kannada ಲ ರಮ ( ) ಯ ಳ , ವ ಸ ಮ ಅ ರ ( )/
ಲ ರ

Malayalam അേപ യുെട കാറിന്െറ വ വ കളുെടയും ഉപാധികളുെടയും

ഉ ട ം. അേപ കർ ് വാ െയടു യാളിനും വാ ാർ ും
മലയാളം ഭാഷയിൽ വായി ുേകൾ ി ുകയും വിശദീകരി ു
വ ാഖ ാനി ു തരികയും അേപ കർ ും)നും വാ െയടു യാളിനും
വാ ാർ ും

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

20 of 22
6/24/2022

या करार / प अटी आिण शत मधील मजकूर, अजदाराला (रां ना) कजदाराला सह-कजदाराला (रोना)
Marathi
वाचून दाखवली आहे आिण ाचा अथ सां ग ात आला आहे आिण कजदाराला समजली आहे .

ଆେବଦକ/ ଣକ ା ଏବଂ ସହ-ରଣଜ(ମାନ) ୁ ଏହି ଆେବଦନପ / ଚୁ ି ପ / ଚିଠ/ି ସ ାବଳିର ବିଷୟବ ୁ କୁ

Oriya ଓଡ଼ିଆ ପଡ଼ିକରି ଶୁଣାଇ ଦିଆଯାଇଛି, ବୁ ଝାଇ ଦିଆଯାଇଛି ଏବଂ ଅଥ ବଢାଇଦିଆଯାଇଛି ଏବଂ ଏହାକୁ ଆେବଦକ(
ମାେନ) / ଣକ ା ଏବଂ ସହ - ରଣକ( ମାେନ) ବୁ ଝଛ ି ି।

ਇਸ ਐਪਿਲਕਸ਼ਨ/ਸਮਝੌਤੇ ਪੁੱਤਰ ਿਨਯਮ ਅਤੇ ਸ਼ਰਤਾਂ ਦੀ ਸਮੱਗਰੀ ਨੂੰ ਪੰਜਾਬੀ ਿਵੱਚ ਿਬਨੈਕਾਰਾਂ/ ਉਧਾਰਕਰਤਾ ਅਤੇ
Punjabi ਸਿਹ-ਉਧਾਰਕਰਤਾਵਾਂ ਨੂੰ ਪੜ ਿਦਤਾ, ਇਸ ਦੀ ਿਵਆਿਖਆ ਕੀਤੀ ਅਤੇ ਅਨੁ ਵਾਦ ਕਰ ਿਦੱਤਾ ਿਗਆ ਹੈ ਅਤੇ ਇਸ ਨੂੰ
ਿਬਨੇਕਾਰ ਰਾ) ਉਧਾਰਕਰਤਾ ਅਤੇ ਸਿਹ-ਉਧਾਰਕਰਤਾ ਵਾਂ) ਦੁਆਰਾ ਸਮਝ ਿਲਤਾ ਿਗਆ ਹੈ।

இந்த ண்ணப் பம் / ஒப் பந்தம் / க தத் ள் ள வரங் கள் /

நிபந்தைனகள் மற் ம் ஷரத் கள் , ண்ணப் பதாரர் / கடன் யாங் பவர்
மற் ம் அவ டன் ேசர்ந் கடன் வாங் பவர் த ழ் ெமா ல் ப த் க்
Tamil
காட்டப் பட் வரிக்கப் பட் ெமா யாக்கம் ெசய் யப் பட்டன ேம ம்
அவற் ைற ண்ணப் பதாரர் (கள் )'/ கடன் வாங் பவர் மற் ம் அவ டன்
ேசர்ந் கடன் வாங் பவர்கள் ) ரிந் ெகாண்டனர்

ఈ దర /ఒప ందం/ ఖ/ యమ బంధనల ష దర ( )/

ణగ తమ సహ- ణ గ త (ల ) చదవబ . వ ంచబ
Telugu
మ ంచబ మ దర ( ) ణగ తమ సహ-
ణగ త ( ) అరం ..

‫ ﻗﺮﺿﺪار‬/(‫ ﺗﻔﺼﯿﻞ ﺳﮯ ﮔﺌﮯ اور ﺳﻤﺠﮭﺎ دﯾﮯ ﮔﺌﮯ ﮨﯿﮟ درﺧﻮاﺳﺖ ﮔﺰار)ﮔﺰاروں‬،‫ﮔﺰار)ﮔﺰاروں( اور ﻣﯿﮟ ﭘﮍھ ﺳﻨﺎﺋﮯ ﮔﺌﮯ‬
Urdu
‫اور )ﻓﺮﺿﺪاروں( ﻧﮯ ان ﻣﺸﻤﻮﻻت ﮐﻮ ﺳﻤﺠﮭ ﻟﯿﺎ ﮨﮯ۔‬

By clicking on "I Agree" below,

a) I hereby confirm that I have read & understood the entire text, features, disclosures, exclusions, etc. and voluntarily
applying for Product 1.

b) I hereby confirm that I have read & understood the entire text, features, disclosures, exclusions, etc. and voluntarily
applying for CLC.

c) I hereby confirm that I have read & understood the entire text, features, disclosures, exclusions, etc. and voluntarily
applying for .

I agrees to have read and understood the BFL-WhastsApp Terms and Conditions available at
(https://bfin.in/RJX23SRWCy) and hereby expressly consent to receive BFL loan related important updates on

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

21 of 22
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d) I hereby confirm that I have read & understood the entire text, features, disclosures, exclusions, etc. and voluntarily
applying for .

WhatsApp.

BFL/B2B/Dig/AppF/Appl/Eng/March22/V.7

Consent Details : Accepted

IP Address : 2401:4900:313e:5078:0:56:287c:f801

Application Number : BR64641794

Date & Time: 2022-06-24 17:36:49

Mobile Number: 9439647598

Email ID: null

22 of 22