Declaration

Prohibition of Rebate

I hereby declare and warrant that the above statements are true and complete in all respects and that there is no other information, which is relevant to my application of insurance that has not been disclosed to you. I agree that this proposal and the declarations shall be the basis of the contract between me and Bajaj Allianz General Insurance and I agree to accept a policy subject to the conditions prescribed by Bajaj Allianz General Insurance and to pay premium on the amount estimated above at the end of each policy period. I undertake to exercise all ordinary and reasonable precaution for safety of the property as if it were uninsured.

Place: Signature of Proposer

Date:

Section 41 of the 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 port the commission payable or any rebate of the premium shown on the policy except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer. Any person making default in Company with the provisions of the section shall be punishable with fine which may extend to five hundred rupees.

Has any General Insurance Company, in respect of the risk to which this proposal relates, ever :

a) Declined a proposal, refused renewal or terminated insurance Yes No

b) Required an increased premium or imposed special conditions Yes No

If 'Yes" in either case, please give details :

Mode of payment

a) By Cheque : Cheque No.______________________ Bank _________________________________ Branch ___________________

b) By Cash

Period of Insurance: From To

Previous Insurance Details :

Is your previous insurance policy with Bajaj Allianz General Insurance Yes No

If Yes, kindly provide the previous Policy No. _______________________________________ Policy Expiry Date ________________________

If No, kindly provide name of the previous Insurer (if any) _____________________________ Previous Policy No. ________________________

Policy Expiry Date _________________________

Please provide the claims history for past 3 yrs No. of Claims made Total Claimed amount

Bajaj Allianz General Insurance Company Limited

**Extra details (if any):

3 Convenient Plans | Affordable Premium | Hassle Free Documentation | Waiver of Underinsurance*

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Easy Householders Package PolicyA simplified householders policy designed for your convenience.

Contact DetailsBajaj Allianz General Insurance Company Limited, G.E. Plaza, Airport Road, Yerawada, Pune - 411 006.Tel: (020) 6602 6666. Fax: (020) 6602 6667.www.bajajallianz.com email: info@bajajallianz.co.in

For any queries please contact :

BSNL/MTNL(Tollfree)

Any Mobile & Landline(Tollfree)

Other(Chargeble)

1800 22 5858 <Prefix City Code> 3030 58581800 209 5858

*Conditions Apply

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Your dream home can now be protected with Bajaj Allianz Easy Householders Package Policy. This comprehensive package policy is designed to cover various risks and contingencies faced by householders. It provides protection for your household contents, domestic appliances, electronic equipments and domestic travel baggage.

Bajaj Allianz Easy Householders Package Policy

Section 1 - Fire and Allied Perils:This section covers loss or damage to the premises (if specifically declared and insured) and contents whilst contained in the premises due to the following perils:1. Fire 2. Lightning 3. Explosion/ Implosion 4. Aircraft Damage 5. Riots, Strike and Malicious Damage 6. Storm, Cyclone, Typhoon, Tempest, Hurricane, Tornado, Flood and

Inundation 7. Impact Damage 8. Subsidence and Landslide including Rockslide 9. Bursting and/ or overflowing of Water Tanks, Apparatus and Pipes10. Missile Testing Operations11. Leakage from Automatic Sprinkler Installations 12. Bush Fire 13. Earthquake (Fire and Shock)Optional Coverage: Building can be covered under this section by payment of additional premium @ Rs. 45 (Service Tax Extra) per Rs. 100000 of Sum Insured

Coverage

Section 2 - Burglary and Theft:This section pays for the loss or damage to the Insured's premises and contents whilst contained in the premises caused by actual or attempted burglary and/ or theft

S e c t i o n 3 - B r e a k d o w n o f Domestic Appliances:This section is meant to cover the repair or replacement costs arising from the unexpected mechanical o r e l e c t r i c a l b r e a k d o w n o f domestic appliances (excluding A.C.) whilst contained in or fixed at the Insured's premises. Deductibles: The Insured shall bear 1% of the Sum Insured set against this section or Rs. 500/-, whichever is higher, in respect of each and every claim.Optional Coverage: Air Conditioners can be covered under this section by payment of additional premium @ Rs. 10 (Service Tax Extra) per Rs. 1000 of Sum Insured

Section 4 - Electronic Equipments:This section is meant to cover the repair or replacement costs in respect of electronic equipments caused by any unforeseen and sudden physical loss (except a cause specifically excluded) whilst contained in or fixed at the Insured's premises.Deductibles: The Insured shall bear the first 10% or Rs. 2500/- (whichever is higher) of any claim concerning computers, and the first 10% or Rs. 500/- (whichever is higher) of any claim concerning any other item of electronic equipment.

Section 5 - Baggage:This sect ion wi l l cover the accidental loss or damage caused t o p e r s o n a l b a g g a g e accompanying the Insured or Insured's family while traveling anywhere in India.

No indemnity would be available under the policy for the following cases:1) Consequential loss of any kind or description2) Loss or damage caused by depreciation or wear and tear 3) Damage to contents of a consumable nature 4) Loss or damage to mobile phones or similar communication devices 5) Loss of or damage to valuables, jewellery or precious items6) Other exclusions as listed in the policy wordings

Major Exclusions

! Call Toll Free No. given below! Submit completely filled Claim Form at the nearest Bajaj Allianz

General Insurance Office

Claims Process

Bajaj Allianz General Insurance Company LimitedBajaj Allianz General Insurance Company Limited

3 convenient plans to choose fromPlan I Plan II

Sum Insured (Rs.)

Plan III

1 Fire and Allied Perils: Contents 1,00,000 2,00,000 4,00,0001,00,000 2,00,000 4,00,0002 Burglary and Theft

3 Breakdown of Domestic Appliances (excluding A.C.)

25,000 30,000 50,000

4 Electronic Equipments 25,000 30,000 50,0005 Baggage 2,500 5,000 7,500

Coverage*Sum Insured (Rs.) Sum Insured (Rs.)

Total Premium** 589 934 1732* Waiver of Underinsurance applicable only for Coverage 1 to 5 under Plans I, II and III **Service tax extra

a) Premium for the Plan selected (Plan I : Rs. 589, Plan II : Rs. 934, Plan III : Rs. 1732) : Rs. ______________________b) Additional premium for covering Building under 6 (a) above @ Rs. 45/- per Rs. 1,00,000 of Sum Insured : Rs. ______________________c) Additional premium for covering A.C. under 6 (b) above, @ Rs. 10 per Rs. 1,000 of Sum Insured: Rs. ______________________d) Service Tax : Rs. ______________________Total Premium Payable (a+b+c+d) Rs. ______________________

Disclaimer: The above mentioned information is only indicative in nature. For details of the coverage and exclusions, please refer to the policy wordings.

Regd. Office & Head Office : GE Plaza, Airport Road, Yerwada, Pune - 411 006

IMD Code :

IMD Name :

Sub IMD Code :

Mobile No. :

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EASY HOUSEHOLDERS PACKAGE POLICY - PROPOSAL FORM1) Please answer all questions in BLOCK letters.2) The Liability of the Company does not commence until this Proposal has been accepted by the Company and premium has been paid.3) This Proposal will be the basis of any subsequent policy that We issue to You. It is therefore essential that You provide all the information in this Proposal FULLY AND ACCURATELY and that You provide Us with any and all additional information relevant to the risk to be insured or our decision as to acceptance of the risk or the terms upon which it should be accepted.

Proposer Name

(Title) (First name) (Middle name) (Last name)

Address Line 1

Address Line 2

Landmark

City State

Pin Code Mobile No.

Telephone No. (Landline) #1 Telephone No.

E-mail ID

Customer ID (in case you are already holding a policy with us)

Please select your choice of insurance coverage under this policy:

Plan I Plan II Plan III

(Landline) #2

**Please fill extra details (if any) in the space provided overleaf.

Plan II Plan IIISum Insured (Rs.) Sum Insured (Rs.)

2,00,000 4,00,000

4,00,0002,00,000

50,00030,000

50,00030,000

5,000 7,500

Coverage*

1 Fire and Allied Perils: Contents2 Burglary and Theft

3 Breakdown of Domestic Appliances (excluding A.C.)

**Item Description

Item 1

Item 2

4 Electronic Equipments

**Item Description

Item 1

Item 25 Baggage

6 Additional Coverage (on payment of additional premium)

a) Fire and Allied Perils : Building

b) Breakdown of Domestic Appliances : A.C.

Plan ISum Insured (Rs.)

1,00,000

1,00,000

25,000

25,000

Make & Model

2,500

**Item Description

Item 1

Item 2

Make & Model Make & Model

Make & Model Make & Model Make & Model

Make & Model Make & Model Make & Model

Contact DetailsBajaj Allianz General Insurance Company Limited, G.E. Plaza, Airport Road, Yerawada, Pune - 411 006.Tel: (020) 6602 6666. Fax: (020) 6602 6667.www.bajajallianz.com email: info@bajajallianz.co.in

For any queries please contact :

BSNL/MTNL(Tollfree)

Any Mobile & Landline(Tollfree)

Other(Chargeble)

1800 22 5858 <Prefix City Code> 3030 58581800 209 5858

* Waiver of Underinsurance applicable only for Coverage 1 to 5 under Plans I, II and III

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