12-9910-0000830549-00

Bajaj Allianz General Insurance Company Limited

Welcome to Bajaj Allianz Family

Dossani Waheeda Mohammed Anwar

null Qaswa Heights, Flat No 502, Plot 100, Sector 50e,,
Seawoods, Navi Mumbai, -, Thane,Thane,400706
Maharashtra
Mobile No.: 7021548052
e-mail : [email protected]
Customer ID : PI20833916

Dear Customer,

Thank you for choosing Bajaj Allianz General Insurer as your preferred insurer. Bajaj Allianz General
Insurance Company Limited, a consistently profitable insurer enjoys a reputation of expertise,
stability and strength. We are a customer focused market leader present in over 200 locations
across India. As an organization we strive to understand the risk management needs of our
consumers and translate it into affordable products and services of global quality that deliver value
for money. Bajaj Allianz has an ISO Certified claims process and has received iAAA rating for the last
three consecutive years from ICRA Limited, an associate of Moody's Investors Service, for claims
paying ability. The rating indicates highest claims paying ability and a fundamentally strong position
in the industry.

We request you to kindly go through the contents of the policy schedule and the terms and
conditions. In case of any clarification or disagreement, please write to us at
[email protected] within fifteen days of receipt of this policy.

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 01
Date: 2022.02.04 17:17:03 IST

Authorized Signatory
Policy issuing office & correspondence address for communication by holder of Certificate of Insurance for claim, service request, notice, summons, etc: WEB SALES-Bajaj Finserv
Building,1st Floor,Behind Weikfield It-Park,Viman Nagar,Pune,Maharashtra,INDIA,411014
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada, Pune – 411006 (India).
Email: [email protected] , Website www.bajajallianz.com

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Bajaj Allianz General Insurance Company Limited

Bajaj Allianz General Insurance Company Ltd

[Corporate Identity Number (CIN): U66010PN2000PLC015329]

[Unique Identification Number (UIN):BAJTIOP22124V022122]

Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune

Transcript of Proposal for INDIVIDUAL TRAVEL

Dear Dossani Waheeda Mohammed Anwar, null

Policy No. 12-9910-0000830549-00

We 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 immediately and before start of your journey. 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, immediately before start of your travel, 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.

Personal Information of Proposer

First Name Dossani

Middle Name Waheeda Last Name Anwar

Mohammed
Email Address arbaazdossani@gm Mobile Number 7021548052
ail.com
Date of Birth 18/10/1967 Nationality India

Pan No Not Available Unique Identity (Aadhaar No.) Not Available

Passport No. T7645493

Permanent Address Mailing Address

House No/ Building No/ Flat No Qaswa Heights, House No/ Building No/ Flat No Qaswa Heights, Flat No 502,
Flat No 502, Plot Plot 100, Sector 50e,
100, Sector 50e,
Street/ Locality/ Landmark Seawoods, Navi Street/ Locality/ Landmark Seawoods, Navi Mumbai, -
Mumbai, -
State Maharashtra State Maharashtra

City Thane City Thane

Area Thane Area Thane

Pincode 400706 Pincode 400706

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Bajaj Allianz General Insurance Company Limited

Insured / Beneficiary Details

Serial No. Insured/ Beneficiary Name Date of Birth Gender Passport No. Nominee
1 Dossani Anwar 18/10/1967 Female T7645493 Arfan Anwar Dossani

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:

1. Plan Name : Travel Elite Silver

2. Geographical Coverage : Worldwide Excluding USA and Canada

3. Departure Date : 29-MAR-22

4. Return Date : 24-JUN-22

5. No of Journey Days : 88 Days

6. Rider Details:

Rider Name Rider Sum Insured

7. Medical Declaration
Is the proposed insured’s ever been diagnosed with or advised to seek treatment for any illness/ disease / ailment up to the date
of making this proposal or suffer from physical defect or deformity?.

YES NO

If Yes Please provide the details in the below table

(*) Applicable in case of family plan.

B. EXCLUSIONS AND TERMS AND CONDITIONS:

The detailed list of exclusions, standard terms and conditions, including the exclusion of pre-existing
ailments/diseases, as mentioned in this transcript 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.

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Bajaj Allianz General Insurance Company Limited
C. The contents of the proposal [transcript of proposal of you is this document] and connected documents have been
fully explained to you and you have fully understood the significance of the proposed contract basis which you
have confirmed for policy issuance.

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 immediately and before start of your journey.

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 as in this transcript 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, as in this transcript, 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 and
realisation of the premium chargeable.

3. I further declare that I will notify in writing any change occurring in general health of me and other persons to be
insured/proposer after the proposal has been submitted [as in this transcript] 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 [as in this transcript] 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.

NOTE: 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.

WhatsApp Number: +91 7507245858

Email address: [email protected]
Website: www.bajajallianz.com

Contact our Policy servicing branch at:BAJAJ ALLIANZ GENERAL INSURANCE CO. LTD.BAJAJ ALLIANZ
HOUSE,AIRPORT ROAD, YERAWADA,PUNE - 411006
For Bajaj Allianz General Insurance Company Ltd,

** This is print of electronic records maintained by us in accordance with law and hence does not require signature.
Scrutiny No:

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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)

Endorsement Schedule INDIVIDUAL TRAVEL UIN. BAJTIOP22124V022122

PROPOSER DETAILS ENDORSEMENT DETAILS
Customer ID : PI20833916 Policy No. 12-9910-0000830549-00
Insured Name: Dossani Waheeda Mohammed Anwar Issued on 08/01/2022 | Policy Status: ACTIVE POLICY
Corresp. Address: Qaswa Heights, Flat No 502, Plot 100, Sector 50e, Seawoods, Navi Period of From: 29/03/2022 00:00 Hrs.
Mumbai, -, Thane,Thane, Maharashtra PIN-400706 Insurance To : 24/06/2022 Midnight
Mobile No. : 7021548052 Endorsement 13-9910-0000830549-00-01
e-mail id : [email protected] End Dt. 04/02/2022 Wef. 25/03/2022

Endorsement Details:
Endorsement Type Endorsement Title Endorsement Wordings
Financial Change of Travel Dates

Premium:
Particulars Premium on Policy Endorsement Premium Total Premium after Endorsement
Net Premium 2391 0 2391
SGST @9% 215
CGST @9% 215 0 215
IGST @ % 0 0 0
CESS @ % 0 0 0
Gross premium 2606 0 2821
Gross premium in word Rupees TWO THOUSAND EIGHT HUNDRED TWENTY-ONE ONLY.
Premium Details: Receipt No: Date: Instrument No: PB44847974_152408583 Bank & Branch name receipt Amount Rs 0 | Premium Payer ID: PI20833916 | Float: Online Payment | If
Premium paid through Cheque, the Policy is void ab-initio in case of dishonour of Cheque.
Proposer GSTIN/UIN: |Place of Supply: 27 - MAHARASHTRA |Supply to SEZ unit or SEZ developer for authorised operations under bond or letter of undertaking without payment of
integrated tax. | Company GST.No.: 27AABCB5730G1ZX |Invoice Number: |Company PAN: AABCB5730G
Previous Policy No: Expiry Dt.
Code: 10043080| Name: POLICYBAZAAR INSURANCE BROKERS PRIVATE LIMTED|Contact No.:9999999999, E-Mail : [email protected]
Financial Institution Ref. No.: null | SP Code:
For & on the behalf Stamp Duty Consolidated Stamp Duty of Rs. 0/- paid towards paid towards Insurance
Bajaj Allianz General Insurance Company Ltd. 0 Premium Stamps Vide Challan No. MH001915407201819M defaced number
0001369763201819/order no.CSD/45/2018/2156/18 dated 08-JUN-18 timing
17:49:13 of General Stamp of India.

This document is system generated, hence counter signature / stamp is not required.
Corporate Identification Number: U66010PN2000PLC015329 | Service Tax Regd. Number AABCB5730G-ST-001

Policy issuing office & correspondence address for communication by holder of Certificate of Insurance for claim, service request, notice, summons, etc: WEB SALES-Bajaj Finserv
Building,1st Floor,Behind Weikfield It-Park,Viman Nagar,Pune,Maharashtra,INDIA,411014
Principal Location: 1000 |Service Accounting Code: 997134 .No reverse charge is payable on these services.
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada, Pune – 411006 (India).
Email: [email protected] , Website www.bajajallianz.com
Demystify Insurance http://support.bajajallianz.com https://www.facebook.com/BajajAllianz; https://twitter.com/BajajAllianz; http://bit.do/bjazgi

Signature Not Verified

Digitally signed by DS BAJAJ ALLIANZ
GENERAL INSURANCE COMPANY LIMITED 01
Date: 2022.02.04 17:17:03 IST

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Bajaj Allianz General Insurance Company Limited

RECEIPT

Receipt Number :
Receipt Date :
Business Channel : Websales
Received with thanks from Dossani Waheeda Mohammed Anwar
(Customer ID: PI20833916) a total sum of Rupees ZERO ONLY
Instrument Type Inst./Ref. No. Instrument Date Bank Name Branch Name Amount (Rs.)
NA NA NA NA NA NA
Total Amount 0

Issuance of this receipt does not amount to 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.
On specific request and subject to terms and conditions, record of information exchange will be made available.
For & on behalf of
Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory
Policy issuing office & correspondence address for communication by holder of Certificate of Insurance for claim, service request, notice, summons, etc: WEB SALES-Bajaj Finserv Building,1st
Floor,Behind Weikfield It-Park,Viman Nagar,Pune,Maharashtra,INDIA,411014
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada, Pune – 411006 (India).
Email: [email protected] , Website www.bajajallianz.com

Signature Not Verified

Digitally signed by DS BAJAJ ALLIANZ
GENERAL INSURANCE COMPANY LIMITED 01
Date: 2022.02.04 17:17:03 IST

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