Bajaj Allianz General Insurance Company Limited

Mode of payment a) b) By Cheque : Cheque No.______________________ Bank _________________________________ Branch ___________________ By Cash From To

Period of Insurance:

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

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 b) Required an increased premium or imposed special conditions If 'Yes" in either case, please give details : Yes Yes No No

**Extra details (if any):

Declaration 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.
BJAZ-B-0036/29-Sep-10

Easy Householders Package Policy

A simplified householders policy designed for your convenience.

Place: Date:

Signature of Proposer

Contact Details Bajaj 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

For any queries please contact :

BSNL/MTNL
(Tollfree)

Any Mobile & Landline

(Tollfree)

Other
(Chargeble)

Insurance is the subject matter of solicitation

Prohibition of Rebate 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.

1800 22 5858

1800 209 5858

<Prefix City Code> 3030 5858

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

*Conditions Apply

email: info@bajajallianz.co.in

Bajaj Allianz General Insurance Company Limited

Bajaj Allianz General Insurance Company Limited

Bajaj Allianz Easy Householders Package Policy

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.

Coverage
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 Pipes 10. Missile Testing Operations 11. 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 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

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.

IMD Code : IMD Name : Sub IMD Code : Mobile No. :

EASY HOUSEHOLDERS PACKAGE POLICY - PROPOSAL FORM

1) 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)

Section 5 - Baggage: This section will cover the accidental loss or damage caused to personal baggage accompanying the Insured or Insured's family while traveling anywhere in India.

Address Line 1 Address Line 2 Landmark City Pin Code Telephone No. (Landline) #1 E-mail ID Customer ID
(in case you are already holding a policy with us)

State Mobile No. Telephone No. (Landline) #2

Major Exclusions
No indemnity would be available under the policy for the following cases: 1) Consequential loss of any kind or description 2) 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 items 6) Other exclusions as listed in the policy wordings

Please select your choice of insurance coverage under this policy: Plan I Plan II Plan III

Coverage* 1 Fire and Allied Perils: Contents 2 Burglary and Theft

Plan I Sum Insured (Rs.) 1,00,000 1,00,000 25,000 Make & Model

Plan II Sum Insured (Rs.) 2,00,000 2,00,000 30,000 Make & Model

Plan III Sum Insured (Rs.) 4,00,000 4,00,000 50,000 Make & Model

3 convenient plans to choose from

Coverage* 1 Fire and Allied Perils: Contents 2 Burglary and Theft 3 Breakdown of Domestic Appliances (excluding A.C.) Plan I 1,00,000 1,00,000 25,000 25,000 2,500 589 Plan II 2,00,000 2,00,000 30,000 30,000 5,000 934 Plan III 4,00,000 4,00,000 50,000 50,000 7,500 1732
Sum Insured (Rs.) Sum Insured (Rs.) Sum Insured (Rs.)

3 Breakdown of Domestic Appliances (excluding A.C.) **Item Description Item 1 Item 2 4 Electronic Equipments **Item Description Item 1
BJAZ-B-0036/29-Sep-10

Insurance is the subject matter of solicitation

Section 3 - Breakdown of Domestic Appliances: This section is meant to cover the repair or replacement costs arising from the unexpected mechanical or electrical breakdown of 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

4 Electronic Equipments 5 Baggage Total Premium**

25,000 Make & Model

30,000 Make & Model

50,000 Make & Model

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

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

Item 2 5 Baggage 6 Additional Coverage (on payment of additional premium) a) Fire and Allied Perils : Building b) Breakdown of Domestic Appliances : A.C. **Item Description Item 1 Item 2
* Waiver of Underinsurance applicable only for Coverage 1 to 5 under Plans I, II and III

2,500

5,000

7,500

General Insurance Office

Make & Model

Make & Model

Make & Model

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

Contact Details Bajaj 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

For any queries please contact :

BSNL/MTNL
(Tollfree)

**Please fill extra details (if any) in the space provided overleaf. a) Premium for the Plan selected (Plan I : Rs. 589, Plan II : Rs. 934, Plan III : Rs. 1732) : b) Additional premium for covering Building under 6 (a) above @ Rs. 45/- per Rs. 1,00,000 of Sum Insured : c) Additional premium for covering A.C. under 6 (b) above, @ Rs. 10 per Rs. 1,000 of Sum Insured: d) Service Tax : Total Premium Payable (a+b+c+d) Rs. ______________________ Rs. ______________________ Rs. ______________________ Rs. ______________________ Rs. ______________________

Any Mobile & Landline

(Tollfree)

Other
(Chargeble)

1800 22 5858

1800 209 5858

<Prefix City Code> 3030 5858

email: info@bajajallianz.co.in

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