Bajaj Allianz Life Insurance Company

Certificate for Premium Paid

Master Policy Holder CITI BANK N.A.

Master Policy Number 0177206484

Policy No 0229327901
Member Name MR KRISHNANANDA PAI B
Application No 5600021867

Product SVS
Premium Type Monthly
Sum assured 720000
Period 01-APR-19 to 31-MAR-20

This is to certify that with reference to the above details, premium amount received by Bajaj Allianz Life Insurance
Company Limited during the Financial year 2019 - 2020 from the member MR KRISHNANANDA PAI B towards to
policy number 0229327901, as follows:

Receipt No Receipt Date Premium Received

(in )
0754735438 11-APR-19 1500
0760541485 21-MAY-19 1500
0763405337 10-JUN-19 1500
0770666154 23-JUL-19 1500
0773158067 08-AUG-19 1500
0777042133 05-SEP-19 1500
0781965210 03-OCT-19 1500
0787969064 06-NOV-19 1500
0793617550 04-DEC-19 1500

Total Premium 13500

 Bajaj Allianz Life Insurance Company

Certificate for Premium Paid

Authorised Signatory

For Bajaj Allianz Life Insurance Company Limited.

Disclaimer:In compliance of the provisions relating to deduction of tax at source under section 194
DA of Income Tax Act,1961 as introduced by Finance Act,2014,any payment(except payment
exempted u/s 194DA) made by Bajaj Allianz Life Insurance Co Ltd shall be subject to deduction of
applicable TDS.In absence of PAN details,TDS would be deducted @20% instead of 1%(w.e.f 01-
June-2016)in case where PAN is provided.TDS once deducted shall not be refunded.**GST is
applicable w.e.f 01-July-2017
Please update your PAN immediately. Kindly ignore if PAN details already provided. For further det
Note:
This certificate is issued for the purpose of claiming deductions, rebates as per the provisions of Income Tax Act,
1961.

* Receipts issued subject to realization of cheques.

* Life Insurance Premium is eligible for tax rebate/deduction under Section 80C.
* HCB/CI/Post Hospitalization/Surgical Benefit Rider Premium is eligible for tax rebate/deduction under Section 80D..
* Partial Withdrawals, surrender Values, Death Benefit and Maturity Benefit are eligible for Tax Benefit as per Sec 10
(10D) of Income Tax Act.
* Policies where the premium exceeds 20% of sum assured with date of commencement prior to 1st April 2012 and
the policies where the premium exceeds 10% of sum assured with date of commencement from 01st April 2012, will
not be eligible for tax benefits u/s 10(10D) and u/s 80C.
* For your actual eligibility please refer to provisions of IT Act 1961 as modified and consult your tax consultant.
*Service Tax Registration Number :AADCA1701EST001
Service Category :Life Insurance Service.

Regd. & Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune 411006. Tel (+91 20) 66026777. Fax (+91 20)
66026789 Customer Helpline: 020-30587888 Toll Free No: 1800 233 7272