Bajaj Allianz General Insurance Company Ltd

[Corporate Identity Number (CIN) : U66010PN2000PLC015329]

Unique Identification Number (UIN) : BAJHLGP22165V012122
Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune
Transcript of Proposal for Flexi Health Protect Plan (Group) Policy Schedule
Dear MR PRASHANT DATTATRY MADKAR,
We, Bajaj Allianz General Insurance Company Limited [âCompanyâ] wish to inform you that the your contract will based on the information and declaration given by you through
telephonic conversation / email / web-inputs / TAB 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 back within a period of 15 days from the date of your receipt of this document [but in case of short term policies, your revert shall reach us before the activities/risks
covered by policies are started]. 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, 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. Kindly note that as the information/contents and declarations/confirmations provided by you as
contained in this transcript is the basis on which we 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.

Personal Information of Insured

First Name PRASHANT
Middle Name DATTATRY Last Name MADKAR
Email Address SPRASHANTMADKAR@GMAIL.COM Mobile Number 9673730734
Date of Birth 25-MAY-96 Nationality INDIAN
Unique Identity (Aadhaar
Pan No No.)
Salary Occupation NA
Marital Status NA Family Monthly Income
Permanent Address Mailing Address
House No/ Building No/ VASANT PARK SOCIETY PUNE-411060 PLOT NO. 43 House No/ Building No/ VASANT PARK SOCIETY PUNE-411060 PLOT NO. 43
Flat No Flat No
Street/ Locality/ Street/ Locality/
. .
Landmark Landmark
State MAHARASHTRA State MAHARASHTRA
City PUNE City PUNE
Area MOHAMMADWADI Area MOHAMMADWADI
Pincode 411060 Pincode 411060

Q1. Do you or any of the family members to be covered have/had any health complaints/disability/met with any accident in the past and/or have been taking treatment/
hospitalization? Please provide the details & duration of illness along with treatment taken in below table. NO
Sum Add On Total
Insured/Beneficiar Relation with Nominee Relation Pre Existing
Gender Date of Birth insured(Individual Nominee Name Cover Monthly
y Name Insured with Beneficiary Diseases
Basis) Details INcome
prashant dattatry 25-MAY-1996 RENUKA PRASHANT
Self Male 500000 SPOUSE N
madkar MADKAR

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.
A. Coverage Details :
FHPP(Individual)Medical Insurance + Hospital Cash + Health Services For Customers of
1. Plan Name : Bandhan Bank
2. Period of Insurance : 04-MAR-23 to 03-MAR-24
3. Previous Insurance Provider : NA
4. Previous Policy number : NA
5. Previous Policy expiry Date : NA

To Support Go Green initiative, send policy copy link on registered mobile number / email id : null
B. 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
C. 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.

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

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D. 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 prospectus 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.
Toll free Number: 1800-103-2529, 1800-102-5858 and 1800-209-5858
Email address: Bagichelp@bajajallianz.co.in
Website: www.bajajallianz.com
Contact our Policy servicing branch at: 1st Floor, Tower 1,Commer Zone,Samrat Ashok Path,Jail Road, Yerwada,Pune-411006,Phone No :66240100
** This is print of electronic records maintained by us in accordance with law and hence does not require signature.
Scrutiny No: 355599653

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

 *355599653*

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 â 411006 (India)

FLEXI HEALTH PROTECT PLAN (GROUP) POLICY SCHEDULE UIN : BAJHLGP22165V012122

Policy issuing office and Correspondence address for communication by policyholder for 1st Floor, Tower 1,Commer Zone,Samrat Ashok Path,Jail Road, Yerwada,Pune-
claim, service request, notice, summons, etc. : 411006,Phone No :66240100
Insured Name MR PRASHANT DATTATRY MADKAR Child Certificate Number OG-24-2001-6052-00019980

INSURED DETAILS POLICY DETAILS

Policy Issued on 12-JUL-2023
VASANT PARK SOCIETY HOUSE NO 43,
.,DPS,MOHAMMADWADI, From: 04-MAR-2023 00:00
Insured Address Period of Insurance
PUNE - 411060, To : 03-MAR-2024 Midnight
MAHARASHTRA
Endorsement NA
Customer ID 396682465 Previous Policy Number NA
GSTIN / UIN NA
Policy Status ISSUED STATE CODE / NAME 27 - Maharashtra
Company GST No : 27AABCB5730G1ZX
Invoice No : 385929536/0 Company PAN : AABCB5730G
Master Policy Number OG-23-9999-9960-00000013 Plan Chosen FHPP(Individual)Medical Insurance + Hospital Cash + Health
Services For Customers of Bandhan Bank
Cover Details
PLAN RISK COVERED RATES/SUM INSURED
NO OF PERSONS :- Self
Self Medical Insurance Expenses + Health Services SUM_INSURED:-Rs.5,00,000
AGE :- 25
Premium Details
Discounts ( if Any ) Rs.0
Net Premium. Rs.5,543
Final Premium Rupees Six Thousand Five Hundred and Fourty One only. State GST (9%) Rs.499
Central GST (9%) Rs.499
Gross Premium. Rs.6,541

Family Member Details

Insured Name
prashant dattatry
madkar
Other Details
Scope of Coverage 1
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Scope of Coverage 5
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Scope of Coverage 9
Scope of Coverage 10
Scope of Coverage 11
Scope of Coverage 12
Scope of Coverage 13
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Scope of Coverage 15
Scope of Coverage 16
Scope of Coverage 17
Scope of Coverage 18
Scope of Coverage 19
Scope of Coverage 20
Scope of Coverage 21
Self Height(Cm)
Self Weight(Kg)
Spouse Height(Cm)
Spouse Weight(Kg)
Pre-Existing Disease
Bank Reference No. 2
Relation Gender DOB Rate(%) Nominee Name Nominee Relation Pre Existing Diseases
25-MAY-1996 RENUKA PRASHANT
Self Male SPOUSE N
MADKAR
IN-PATIENT HOSPITALIZATION TREATMENT-ROOM RENT AND ICU CHARGES-AS PER ACTUAL
PRE-HOSPITALIZATION- 90 DAYS
POST HOSPITALIZATION- 180 DAYS
DAY CARE TREATMENT COVERED
ORGAN DONOR EXPENSES UP TO SUM INSURED
DOMICILIARY HOSPITALIZATION COVERED UP TO IN-PATIENT SUM INSURED
ROAD AMBULANCE- 2000 PER HOSPITALIZATION
AYUSH TREATMENT COVERED UP TO IN-PATIENT SUM INSURED
MATERNITY EXPENSES COVERED UP TO INR 25000 PER DELILVERY FOR MAXIMUM 2 DELIVERIES/TERMINATION AFTER 36 MONTHS WAITING PERIOD
CATARACT SUB-LIMIT WILL BE RESTRICTED TO 20% OF THE SUM INSURED FOR EACH EYE SUBJECT TO MAXIMUM OF RS 100000/- FOR EACH OF YOU,
AFTER THE EXPIRY OF THE 24 MONTHS PERIOD
HOSPITAL DAILY ALLOWANCE OF INR 1000/DAY FOR MAX 15 DAYS IN A POLICY YEAR (OVER AND ABOVE THE BASE SUM INSURED)
CUMULATIVE BONUS -10% OF BASE SUM INSURED IF NO CLAIM IN PRECEDING YEAR MAX UP TO 100%
CRITICAL ILLNESS MULTIPLIER FOR CIS LISTED IN PLAN A OF POLICY WORDINGS-2 TIMES OF THE IN-PATIENT HOSPITALIZATION SUM INSURED.
SUM INSURED REINSTATEMENT BENEFIT OF 100% BASE SUM INSURED TWICE A YEAR
E-SECOND OPINION:IF THE INSURED BENEFICIARY IS SUFFERING FROM ANY CRITICAL ILLNESS OR MEDICAL CONDITION OCCURRING DURING THE
COVER PERIOD HE/SHE CAN OPT FOR E-SECOND OPINION FROM MEDICAL PRACTITIONER/PHYSICIAN/DOCTOR LISTED ON THE DIGITAL PLATFORM
OF CONCERNED SERVICE PROVIDERS APPLICATION VIA VIDEO AUDIO OR CHAT CHANNEL AS SPECIFIED IN POLICY SCHEDULE OR CERTIFICATE OF
INSURANCE.
INITIAL WAITING PERIOD -30 DAYS (EXCEPT FOR ACCIDENTAL CASES)
PRE-EXISTING DISEASE WAITING PERIOD-36 MONTHS
WAITING PERIOD FOR NAMED AILMENTS (LIST AS MENTIONED IN POLICY WORDING) -24 MONTHS
IF BASE SUM INSURED OPTED IS 2 LAC OR 3 LAC HEALTH SERVICES INCLUDE TELE CONSULTATION COVER = UNLIMITED (ALL SPECIALTIES) +
INVESTIGATIONS COVER (PATHOLOGY AND RADIOLOGY EXPENSES) = 1500 + ANNUAL PREVENTIVE HEALTH CHECK -UP COVER = 1 VOUCHER
IF BASE SUM INSURED OPTED IS 4 LAC AND ABOVE HEALTH SERVICES INCLUDE TELE CONSULTATION COVER = UNLIMITED (ALL SPECIALTIES) +
INVESTIGATIONS COVER (PATHOLOGY AND RADIOLOGY EXPENSES) = 5000 + DOCTOR CONSULTATION COVER = 2000 + ANNUAL PREVENTIVE HEALTH
CHECK -UP COVER = 1 VOUCHER
ALL OTHER TERMS CONDITIONS AND EXCLUSIONS AS PER FLEXI HEALTH PROTECT PLAN (GROUP)
175
61
N
BANKREF02

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