Affix Passport Size Recent
Photograph
Self Declaration of KYC Document Submission
And
For Institute/Company Partner Sign Across
--------------------------
To, Company / Firms
Representative
Bajaj Allianz General Insurance Co. Ltd
G.E. Plaza, Airport Road,
Yerawada, Pune - 411006
Company Representative / Officer Name ……………………………………………………………………………………………………
Designation ……………………………………………………………………………………………………
Name of Payment Receiver Company / Firms ……………………………………………………………………………………………………..
Address………………………………………………………………………………………………………………………………………………………………..
City…………………………………………State………………………………………………………… Pin Code…………………………………………
Telephone No……………………………………………………………… Mobile No……………………………………………………………………
(Please tick the relevant document in the list below)
Proof of Identity (any one) Proof of Residential Address (any one)
Memorandum & Articles of Association Land Line Telephone Bill
Resolution of the Board for Accounts Co / Firms Electricity Bill
Power of Attorney / Letter to Transact business Co / Firms Registration Certificate
Copy of PAN Card , allotment letter
Co / firms Registration Certificate
Partnership Deed
Memorandum & Articles of Association
The documents provided as proof of identity and proofs of address have been self-attested. I have also attached my
recent photograph above.
Date…………………………………Place……………………………………… …………….…………………………………........................
Signature of the Representative / Officer
Bajaj Allianz General Insurance Company Ltd. GE Plaza, Airport Road, Yerawada, Pune 411 006 Tel- (+91 020) 66026777 Fax- (+91 020) 66026791
