Bajaj General Insurance Limited

(Formerly known as Bajaj Allianz General Insurance Company Ltd.)

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POLICY NUMBER	PARTNER ID	CREATED DATE	KYC STATUS

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I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the herein statements, answers and/or particulars given by me 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.

Bajaj General Insurance Limited

(Formerly known as Bajaj Allianz General Insurance Company Ltd.)

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