IN THIS POLICY, THE INVESTMENT RISK IN INVESTMENT PORTFOLIO IS BORNE BY THE POLICYHOLDER.

Bajaj Allianz Life Goal Assure II 35 se pehle apna start-up?

A Unit-linked Non-Participating Individual Life
Savings Insurance Plan
SAMJHO HO GAYA.

Key Features of the plan

Bajaj Allianz Life Goal Assure II is a unit- linked non- participating individual life savings insurance plan that offers you the opportunity to plan for
your goals with Zero worries. It comes with Loyalty Additions1 payable from the 6th Year and Fund Boosters payable at maturity. It also returns the
Aim of the mortality charges on policy maturity thereby assuring you maximized returns on your investment while also offering protection from Day 1
policy Disclaimer1: Loyalty additions are payable only for premium of INR 5 lacs & above and wherein the policy term is 10 years & above

Maturity Benefit
You will receive the Regular Premium Fund Value plus Top-up Premium Fund Value as on the maturity date, provided the policy is in-force.

Death Benefit
If all due premiums are paid, then, in case of unfortunate death of the life assured during the policy term, the death benefit payable will be:
a. Higher of, prevailing Regular Premium Sum Assured or Regular Premium Fund Value plus
b. Higher of, Top-up Sum Assured or Top-up Premium Fund Value
The death benefit is subject to the Guaranteed Death Benefit of 105% of the total premiums* paid, till the date of death.
* Total premiums paid shall be sum of all regular/limited and top-up premiums paid till date
All the above is paid as on date of receipt of intimation of death at the Company’s office.
Note- Please refer Sales Literature for more details.

Benefits Return of Mortality Charge (ROMC)

under At the end of the policy term, on the maturity date, the total amount of mortality charges deducted in respect of life cover provided throughout the
the policy policy term, will be added back as ROMC, to the Regular Premium Fund Value and Top-up Premium Fund Value, as applicable. ROMC is not
applicable in case of a Surrendered, Discontinued or Paid-up policy and will be payable provided all due Regular Premiums under the policy have
been paid up to date.

Loyalty Additions
The Company shall allocate Loyalty Additions to the Regular Premium Fund Value as percentage of one Annualized Premium from
the 6th year onwards, provided all due Regular Premiums have been paid up to date. The Loyalty Additions are below:

Policy Term Loyalty Additions (% of one Annualized Premium)

5 years Not Applicable
10 years 0.50%
15 years 1%
20 years 1.5%

Bajaj Allianz Life Insurance Co. Ltd.,

Bajaj Allianz House, Airport Road, Yerawada, Pune - 411006. Reg No.: 116. Ver 1 : English_Web
 Fund Booster
On the maturity date, Fund Booster will be added to the Regular Premium Fund Value, provided all due Regular Premiums have been paid up to the
date. The Fund Booster are as below -

Policy Term Fund Booster (% of one Annualized Premium)

5 years Not Applicable
10 years 20%
15 years 40%
20 years 60%

Loyalty Addition & Fund Booster are based on Prevailing Annualized Premium
There will not be any Loyalty Addition & Fund Booster for Top-up Premium paid. Also, Loyalty Addition & Fund Booster will not be paid for
surrendered, discontinued or policy converted to paid-up policy. Loyalty Addition will be available only for annualized premium of 5 lacs & above.

Bonus No bonus is payable in this policy.

Premium Premiums are payable as per the option chosen as indicated in the Benefit Illustration.
payment
You have an option to enhance your protection by opting for rider available in the product.
Riders
• Bajaj Allianz Life Linked Accident Protection Rider UIN: 116A055V01

If you do not pay regular premiums during the first five policy Year, If you do not pay regular premium after the first five policy years,
then at the end of grace period the policy will be converted to then, your policy will be converted to a paid-up policy immediately
discontinued policy. with reduced paid-up benefits. You will have to choose the following
 You can revive your policy by paying all due regular premiums two options on receiving the notice from us to intimate you about
within a period of three(3) years. If we do not receive any your policy status -
intimation from you about the policy revival, or we receive an Option A - Pay all due regular premiums or communicate agreeing
Non-payment intimation, but the policy is not revived, then, we will be to pay all due regular premiums, within a period of three (3) years
of premium constrained to take discontinuance action. Or
 Alternatively, you can choose to surrender the Policy without any Option B - Surrender the Policy
risk cover and in that case your life cover shall cease immediately.
The Surrender Value of your policy will be available after the end of If you do not pay all due regular premiums or we do not receive any
first 5 years or at end of surrender, whichever is later. intimation from you then, policy will continue as paid-up till the
You will not be able to revive your policy once surrendered. expiry of the revival period, at the end of which, the surrender
benefit will be paid.

Although it is not advisable to surrender your policy unless there is an extreme urgency, you will have the option to surrender your policy anytime
• On surrender during the lock-in period of first five years, the regular premium fund value, less the discontinuance/surrender charge plus the
top up premium fund value, if any, as on the date of surrender, will be transferred to the discontinued life policy fund (maintained by the
company), and risk cover shall cease immediately. The discontinuance value as at the end of the lock-in period will be available to you as
Surrender surrender benefit.
Benefit • On surrender during the lock-in period, the option to revive the policy will not be available to such a surrendered policy. The discontinuance
value as at the end of the lock-in period will be available as surrender benefit.
• On surrender after the lock-in period of first five years, the surrender benefit available will be regular premium fund value plus top up
premium fund value, if any, as on the date of surrender.
The policy shall thereafter terminate upon payment of the full surrender/ discontinuance value by the company.

Charges Details
Premium Nil
Allocation Charge
Policy Administration `400per annum inflating at 5% per annum, subject to a maximum of ` 500 per month. The charge will be
Charge (PAC) deducted at each monthly anniversary by cancellation of units at prevailing Unit Price.
Fund Fund Management Charge per annum
Equity Growth Fund II 1.35%
Accelerator Mid Cap Fund II 1.35%
Pure Stock Fund 1.35%
Pure Stock Fund II 1.30%
Charges Fund Management Asset Allocation Fund II 1.25%
Charge (FMC) Bluechip Equity Fund 1.25%
Flexi Cap Fund 1.35%
Sustainable Equity Fund 1.35%
Liquid Fund 0.95%
Bond Fund 0.95%
Discontinued Life Policy Fund 0.50%
Small Cap Fund 1.35%
Dynamic Asset Allocation Fund 1.35%
Individual Short Term Debt Fund 0.95%
Debt Plus Fund 0.70%
Midcap Index Fund 1.35%
This charge would be adjusted in the Unit Price

Bajaj Allianz Life Insurance Co. Ltd.,

Bajaj Allianz House, Airport Road, Yerawada, Pune - 411006. Reg No.: 116. Ver 1 : English_Web
 Miscellaneous A miscellaneous charge of `100/- per transaction in respect of alteration of premium mode, alteration of
premium apportionment, change in portfolio strategy, change in premium paying term or decrease in sum
Charge assured shall be charged.

Charges Details

Where the policy is Discontinuance charge for the Discontinuance charge for the
discontinued policies having annualized policies having Annualized
during the policy year premium up to ` 50000/- Premium above `50,000/-
Lower of 20% * (AP or FV) Lower of 6% * (AP or FV)
1
subject to maximum of ` 3,000 subject to maximum of ` 6,000
Discontinuance/ Lower of 15% * (AP or FV) Lower of 4% * (AP or FV)
2 subject to maximum of ` 2,000
Surrender Charge subject to maximum of ` 5,000
Lower of 10% * (AP or FV) Lower of 3% * (AP or FV)
3 subject to maximum of ` 1,500 subject to maximum of ` 4,000
Lower of 5% * (AP or FV) Lower of 2% * (AP or FV)
4 subject to maximum of ` 1,000 subject to maximum of ` 2,000
5 & above Nil Nil
AP - Annualized Premium & FV - Regular Premium Fund Value. Discontinuance Charge for Top-ups is Nil.
Mortality Charge will be deducted at each monthly anniversary by cancellation of units at the prevailing unit
price from the Regular Premium Fund Value.
Mortality Charge Premium for female life assured will be based on 3 years younger male.
For sub-standard lives, extra mortality charge will be applicable which will be deducted as charges by
cancellation of units.

Goods & Service

Tax/any other
applicable tax As applicable on all Charges mentioned above.
levied, subject to
changes in tax laws

You may revive your lapsed policy during the revival period of three (3) years from the due date of first unpaid premium, subject to the revival
Revival conditions under the policy.

a) All risk cover under the Policy will terminate immediately, and the Policy will terminate on payment of the last instalment.
• If you have opted for the Settlement Option.
b) This Policy shall automatically and immediately terminate on the earlier occurrence of any of the following events:
• On foreclosure of the policy
Termination • On the date of receipt of intimation of death of the Life Assured (unless the Policyholder has opted for the Settlement Option)
• On payment of Discontinuance Value or Surrender Benefit.
• The Maturity Date, unless the Policyholder has opted for the Settlement Option.
• The expiry of the Settlement period, if opted.
• Opting of Free Look Cancellation

You will have the option to review the terms and conditions of the policy and if you disagree to any of the terms & conditions, you will have an option
Free Look to return the policy within 15 days and thirty (30) days in case of electronic Policy or Policy obtained through Distance Mode, stating the reasons for
Cancellation your objections.

Regd. Office Address: Bajaj Allianz House, Airport Road, Yerawada, Pune - 411006., IRDAI Reg No.: 116, Visit us: www.bajajallianzlife.com, CIN :
Contact us U66010PN2001PLC015959, Mail us : customercare@bajajallianz.co.in, Call on : Toll free no. 1800 209 7272.

Do’s
• Do fill the proposal form very carefully and personally in CAPITAL letters in blue ink only
• Do provide true and complete information
• Do provide correct contact number, address and email ID, and update in case of any change, so that you can receive necessary
communication
• Do sign on all the documents provided by you (Self Attestation)
• Do provide your recent passport photograph
• Do draw cheque/ DD, in favour of “Bajaj Allianz Life Insurance Co. Ltd.”
• Do read the policy bond carefully upon receipt of the same.
Do’s & Don’ts • Do contact us if you do not receive the policy bond or any other communication from the Company within 30 days.
• Do read the enclosed Benefit Illustration carefully before signing
• Do register for Auto Debit Instructions/ ECS to ensure timely payments of your premium on due dates.
Don’ts
• Do not sign any blank proposal form
• Do not leave any column blank in the proposal form
• Do not conceal any facts as this could lead to dispute at the time of a claim
• Do not miss or delay your premium payment
• Do not rely on any commitments of any additional benefits made by anyone apart from what has been highlighted herein above.

Disclaimer: This document contains the highlights of the product Bajaj Allianz Life Goal Assure II UIN: 116L180V02 and is subject to the terms and conditions as contained in the policy document. The
terms and conditions as contained in the policy document shall govern the contractual relationship and shall be binding. For details on any of the matters highlighted herein above, please refer to policy
document upon receipt of the same by you. The standard terms and conditions of the product is also available on the Company website (at www.bajajallianz.com)

Bajaj Allianz Life Insurance Co. Ltd.,

Bajaj Allianz House, Airport Road, Yerawada, Pune - 411006. Reg No.: 116. Ver 1 : English_Web
Quotation No : 50040055501

Bajaj Allianz Life Goal Assure II

A Unit-linked Non-Participating Individual Life Savings Insurance Plan

Name of the Prospect/ MANJUNATH HA Name of the Product: Bajaj Allianz Life Goal Assure II
Policyholder: A Unit-linked Non-Participating Individual
Tag Line:
Age (Years): 34 Life Savings Insurance Plan
Gender Male Unique Identification Number: 116L180V02
Name of the Life Insured: MANJUNATH HA GST Rate: 18.00%
Age (Years): 34 Investment Strategy Opted for: Wheel of Life Portfolio Strategy
Gender Male
Sum Assured (Rs.): 5,40,000
Policy Term (Years): 20
Premium Payment Term (Years): 20
Amount of Instalment Premium 3,000
(Rs.):
Mode of payment of Premium: Monthly

Product / RIders Details

Base Plan Name of Product / Sum Policy Premium Premium Instalment Instalment
/ Rider Rider Option Chosen UIN Assured Term Payment Payment Premium GST Rate Premium with
(Years) Term (Years) Mode Without GST GST
Base Plan Bajaj Allianz Life Goal Not Applicable 116L180V02 5,40,000 20 20 Monthly 3,000 18% on 3,000
Assure II Charges
Total 3,000 3,000

Some benefits are guaranteed and some benefits are variable with returns based on the future performance of your insurer carrying on life insurance
business. If your policy offers guaranteed benefits then these will be clearly marked 'guaranteed' in the illustration table on this page.If your policy
offers variable benefits then the illustrations on this page will show two different rates of assumed future investment returns, of 8 % p.a.and 4 %
p.a.These assumed rates of return are not guaranteed and they are not the upper or lower limits of what you might get back, as the value of your policy
is dependent on a number of factors including future investment performance.
How to read and understand this benefit illustration?
This benefit illustration is intended to show what charges are deducted from your premiums and how the unit fund, net of charges and taxes, may grow
over the years of the policy term if the fund earns a gross returns of 8% p.a. and 4% p.a. These rates, i.e. 8% p.a. and 4% p.a. are assumed only for the
purpose of illustrating the flow of benefits if the returns are at this level. It should not be interpreted that the returns under the plan are going to be
either 8%p.a. or 4% p.a.
Net Yield mentioned corresponds to the gross investment return of 8% p.a., net of all charges but does not consider mortality, morbidity charges,
underwriting extra, if any, guarantee charges and cost of riders, if deducted by cancellation of units. It demonstrates the impact of charges exclusive of
taxes on the net yield. Please note that the mortality charges per thousand sum assured in general, increases with age.
The actual returns can vary depending on the performance of the chosen fund, charges towards mortality, morbidity, underwriting extra, cost of riders,
etc. The investment risk in this policy is borne by the policyholder, hence, for more details on terms and conditions please read sales literature carefully.
Part A of this statement presents a summary view of year-by-year charges deducted under the policy, fund value, surrender value and the death benefit,
at two assumed rates of return. Part B of this statement presents a detailed breakup of the charges, and other values.

1
Quotation No : 50040055501

Part A (Amount in Rupees)

At 4% p.a. Gross Investment Return At 8% p.a. Gross Investment Return

Policy Annualized Mortality Other Fund Value (at Surrender Value Death Mortality Other Fund Value (at Surrender Value Death
GST GST Commission
Year Premium Charge Charges # Year End) (at year end) Benefit Charge Charges # Year End) (at year end) Benefit
1 36,000 490 654 206 35,399 32,399 5,40,000 489 658 207 36,135 33,135 5,40,000 0
2 36,000 480 1,146 293 71,635 69,635 5,40,000 479 1,170 297 74,549 72,549 5,40,000 0
3 36,000 471 1,652 382 1,08,724 1,07,224 5,40,000 466 1,715 393 1,15,384 1,13,884 5,40,000 0
4 36,000 460 2,170 473 1,46,686 1,45,686 5,40,000 450 2,295 494 1,58,797 1,57,797 5,40,000 0
5 36,000 451 2,701 567 1,85,540 1,85,540 5,40,000 432 2,911 602 2,04,952 2,04,952 5,40,000 0
6 36,000 433 3,183 651 2,25,390 2,25,390 5,40,000 403 3,497 702 2,54,119 2,54,119 5,40,000 0
7 36,000 413 3,681 737 2,66,260 2,66,260 5,40,000 365 4,123 808 3,06,500 3,06,500 5,40,000 0
8 36,000 387 4,177 822 3,08,200 3,08,200 5,40,000 316 4,772 916 3,62,340 3,62,340 5,40,000 0
9 36,000 351 4,671 904 3,51,268 3,51,268 5,40,000 248 5,444 1,025 4,21,907 4,21,907 5,40,000 0
10 36,000 306 5,163 984 3,95,521 3,95,521 5,40,000 160 6,142 1,134 4,85,495 4,85,495 5,40,000 0
11 36,000 247 5,654 1,062 4,41,025 4,41,025 5,40,000 45 6,867 1,244 5,53,425 5,53,425 5,53,425 0
12 36,000 170 6,143 1,136 4,87,854 4,87,854 5,40,000 0 7,619 1,371 6,25,927 6,25,927 6,25,927 0
13 36,000 69 6,632 1,206 5,36,092 5,36,092 5,40,000 0 8,399 1,512 7,03,275 7,03,275 7,03,275 0
14 36,000 0 7,119 1,281 5,85,756 5,85,756 5,85,756 0 9,207 1,657 7,85,823 7,85,823 7,85,823 0
15 36,000 0 7,604 1,369 6,36,825 6,36,825 6,36,825 0 10,045 1,808 8,73,950 8,73,950 8,73,950 0
16 36,000 0 7,954 1,432 6,89,515 6,89,515 6,89,515 0 10,730 1,931 9,68,289 9,68,289 9,68,289 0
17 36,000 0 8,353 1,504 7,43,833 7,43,833 7,43,833 0 11,513 2,072 10,69,219 10,69,219 10,69,219 0
18 36,000 0 8,739 1,573 7,99,861 7,99,861 7,99,861 0 12,308 2,215 11,77,251 11,77,251 11,77,251 0
19 36,000 0 9,112 1,640 8,57,681 8,57,681 8,57,681 0 13,115 2,361 12,92,940 12,92,940 12,92,940 0
20 36,000 0 9,469 1,704 9,43,715 9,43,715 9,43,715 0 13,932 2,508 14,42,337 14,42,337 14,42,337 0

# includes all charges other than mortality charge, See Part B for details

IN THIS POLICY, THE INVESTMENT RISK IS BORNE BY THE POLICYHOLDER AND THE ABOVE INTEREST RATES ARE ONLY FOR ILLUSTRATIVE PURPOSE.

I, ____ _____, have explained the premiums, charges and benefits under I, ____MANJUNATH HA _____, having received the information with
the policy fully to the prospect / policyholder. respect to the above, have understood the above statement before
entering into the contract.

Place:
Date: Signature of Agent/ Intermediary / Official Date: Signature of Prospect / Policyholder

Part B

Net
Gross Yield 8% Yield 6.77 % (Amount in Rupees)

Annualised
GST Loyalty Fund Fund
Premium Premium - Policy
Other Addition + Fund Return
of Fund
Policy Annualised Allocation Premium Mortality (Excl Administration Guarantee Mortality Before Management Value Surrender Death
Value (at Benefit
Year Premium Charge on Charge Charges Family Booster Charge Incl (at Year Year
Charge Allocation Charge Charge FMC End)
FMC) Benefit GST End)
Charge
1 36,000 0 36,000 489 160 400 0 0 0 0 0 36,440 304 36,135 33,135 5,40,000
2 36,000 0 36,000 479 162 420 0 0 0 0 0 75,434 885 74,549 72,549 5,40,000
3 36,000 0 36,000 466 163 441 0 0 0 0 0 1,16,888 1,504 1,15,384 1,13,884 5,40,000
4 36,000 0 36,000 450 164 463 0 0 0 0 0 1,60,959 2,162 1,58,797 1,57,797 5,40,000
5 36,000 0 36,000 432 165 486 0 0 0 0 0 2,07,813 2,861 2,04,952 2,04,952 5,40,000
6 36,000 0 36,000 403 164 511 0 0 0 0 0 2,57,643 3,524 2,54,119 2,54,119 5,40,000
7 36,000 0 36,000 365 162 536 0 0 0 0 0 3,10,733 4,232 3,06,500 3,06,500 5,40,000
8 36,000 0 36,000 316 158 563 0 0 0 0 0 3,67,306 4,966 3,62,340 3,62,340 5,40,000
9 36,000 0 36,000 248 151 591 0 0 0 0 0 4,27,634 5,727 4,21,907 4,21,907 5,40,000
10 36,000 0 36,000 160 140 621 0 0 0 0 0 4,92,011 6,515 4,85,495 4,85,495 5,40,000
11 36,000 0 36,000 45 125 652 0 0 0 0 0 5,60,759 7,334 5,53,425 5,53,425 5,53,425
12 36,000 0 36,000 0 123 684 0 0 0 0 0 6,34,110 8,183 6,25,927 6,25,927 6,25,927
13 36,000 0 36,000 0 129 718 0 0 0 0 0 7,12,338 9,063 7,03,275 7,03,275 7,03,275
14 36,000 0 36,000 0 136 754 0 0 0 0 0 7,95,797 9,974 7,85,823 7,85,823 7,85,823
15 36,000 0 36,000 0 143 792 0 0 0 0 0 8,84,869 10,919 8,73,950 8,73,950 8,73,950
16 36,000 0 36,000 0 150 832 0 0 0 0 0 9,79,970 11,681 9,68,289 9,68,289 9,68,289
17 36,000 0 36,000 0 157 873 0 0 0 0 0 10,81,774 12,555 10,69,219 10,69,219 10,69,219
18 36,000 0 36,000 0 165 917 0 0 0 0 0 11,90,693 13,441 11,77,251 11,77,251 11,77,251
19 36,000 0 36,000 0 173 963 0 0 0 0 0 13,07,279 14,339 12,92,940 12,92,940 12,92,940
20 36,000 0 36,000 0 182 1,011 0 0 0 21,600 3,854 14,32,130 15,247 14,42,337 14,42,337 14,42,337

Gross Yield 4% (Amount in Rupees)

Annualised GST Loyalty Fund Fund

Premium Policy Return of Fund Management Value Surrender Death
Policy Annualised Allocation Premium - Mortality (Excl Guarantee Other Addition + Fund
Administration Charge Charges Family Booster Mortality Before Charge Incl (at Value (at
Year Premium Premium Charge on
Charge Charge Charge FMC Year Year End) Benefit
Allocation Charge FMC) Benefit GST
End)
1 36,000 0 36,000 490 160 400 0 0 0 0 0 35,699 300 35,399 32,399 5,40,000
2 36,000 0 36,000 480 162 420 0 0 0 0 0 72,492 857 71,635 69,635 5,40,000
3 36,000 0 36,000 471 164 441 0 0 0 0 0 1,10,152 1,429 1,08,724 1,07,224 5,40,000
4 36,000 0 36,000 460 166 463 0 0 0 0 0 1,48,700 2,014 1,46,686 1,45,686 5,40,000

2
Quotation No : 50040055501

Gross Yield 4% (Amount in Rupees)

Fund
Annualised GST Loyalty Fund
Premium Policy Return of Fund Value Surrender
Policy Annualised Premium - Mortality (Excl Guarantee Other Addition + Fund Management Death
Allocation Administration Mortality Before (at Value (at
Year Premium Premium Charge on Charge Charges Family Booster Charge Incl Benefit
Charge Charge Charge FMC Year Year End)
Allocation Charge FMC) Benefit GST End)
5 36,000 0 36,000 451 169 486 0 0 0 0 0 1,88,153 2,613 1,85,540 1,85,540 5,40,000
6 36,000 0 36,000 433 170 511 0 0 0 0 0 2,28,544 3,154 2,25,390 2,25,390 5,40,000
7 36,000 0 36,000 413 171 536 0 0 0 0 0 2,69,971 3,711 2,66,260 2,66,260 5,40,000
8 36,000 0 36,000 387 171 563 0 0 0 0 0 3,12,464 4,264 3,08,200 3,08,200 5,40,000
9 36,000 0 36,000 351 170 591 0 0 0 0 0 3,56,082 4,814 3,51,268 3,51,268 5,40,000
10 36,000 0 36,000 306 167 621 0 0 0 0 0 4,00,881 5,360 3,95,521 3,95,521 5,40,000
11 36,000 0 36,000 247 162 652 0 0 0 0 0 4,46,928 5,903 4,41,025 4,41,025 5,40,000
12 36,000 0 36,000 170 154 684 0 0 0 0 0 4,94,296 6,442 4,87,854 4,87,854 5,40,000
13 36,000 0 36,000 69 142 718 0 0 0 0 0 5,43,069 6,978 5,36,092 5,36,092 5,40,000
14 36,000 0 36,000 0 136 754 0 0 0 0 0 5,93,267 7,510 5,85,756 5,85,756 5,85,756
15 36,000 0 36,000 0 143 792 0 0 0 0 0 6,44,863 8,038 6,36,825 6,36,825 6,36,825
16 36,000 0 36,000 0 150 832 0 0 0 0 0 6,97,920 8,405 6,89,515 6,89,515 6,89,515
17 36,000 0 36,000 0 157 873 0 0 0 0 0 7,52,660 8,827 7,43,833 7,43,833 7,43,833
18 36,000 0 36,000 0 165 917 0 0 0 0 0 8,09,091 9,231 7,99,861 7,99,861 7,99,861
19 36,000 0 36,000 0 173 963 0 0 0 0 0 8,67,297 9,616 8,57,681 8,57,681 8,57,681
20 36,000 0 36,000 0 182 1,011 0 0 0 21,600 4,730 9,27,366 9,981 9,43,715 9,43,715 9,43,715

Notes:
1. Refer the sale literature for explanation of terms used in this illustration.
2. Fund management charge is based on the specific fund option(s) chosen.
3. In case rider charges are collected explicitly through collection of rider premium, and not by way of cancellation of units, then, such charges are not considered in this
illustration. In other cases, rider charges are included in other charges.

I, ___________________________ (name), have explained the premiums, I, ___________________________ (name), having received the information
charges and benefits under the policy fully to the prospect / policyholder. with respect to the above, have understood the above statement before entering
into the contract.

Place:
Date: Signature of Agent/ Intermediary/ Official Date: Signature of Prospect / Policyholder

Disclaimers

1. Please consult our 'Insurance Consultant' for any clarifications on this illustration.

2. Unit Linked Life insurance Products are different from the traditional insurance products and are subject to the risk factors.

3. All benefits payable under the Policy are subject to the tax laws and other financial enactments, as they exist from time to time.

4. The Regular Premium and Top Up Premium, if any, paid is subject to investment risks associated with capital markets and Unit Prices may go up and down based
on the performance of the underlying assets in the Funds and the factors influencing the Capital market and the Life Assured/ Policyholder is responsible for his/ her
decisions.

5. Bajaj Allianz Life Insurance is the name of the company & Bajaj Allianz Life Goal Assure II is only the name of the Plan and does in no way indicate the quality
of the policy, its future prospects or returns.

6. Death Benefit :
i) On death of the life assured during the policy term while the policy is not terminated, if all the premiums are paid up to date: Higher of (Sum assured or Regular
Premium Fund Value) Plus Higher of (Top up Sum Assured or Top up Premium Fund Value) as on date of intimation of death. This benefit is subject to a minimum
guaranteed benefit of 105% of total premiums paid.
ii) The policy will terminate on the date of intimation of death of the life assured.

7. Loyalty Addition: For a policy with annualized premium Rs. 5 lacs & above and with policy term 10 years or above, at the end of each policy year, starting from
the 6th policy year, if all premiums under the policy are paid up to date, Loyalty Addition will be added into the Regular Premium Fund Value. The amount of Loyalty
Addition that will be added in to the Regular Premium Fund Value will be a percentage of one Annualized Premium, as per the table given below. No Loyalty Addition
will be available on the surrendered policy, discontinued policy or a policy converted to paid-up. Loyalty Addition is not available for a policy with PT 5 years.

PT 10 Years 15 Years 20 Years

Loyalty Addition 0.50% 1.00% 1.50%

8. Fund Booster: For a policy with policy term 10 years or above, at the end of the policy term, on the date of maturity, if all premiums under the policy are paid up to
date, Fund Booster (FB) will be added into the Regular Premium Fund Value. No Fund Booster will be available on the surrendered policy, discontinued policy or a policy
converted to paid-up. The amount of FB that will be added in to the Regular Premium Fund Value will be a percentage of one Annualised Premium (AP), as per the
table given below. Fund Booster is not available for a policy with PT 5 years.

PT 10 Years 15 Years 20 Years

Fund Booster % 20% 40% 60%

9. Return Of Mortality Charge (ROMC): At the end of the policy term, on the date of maturity, if all premiums under the policy are paid up to date, the total amount
of mortality charge deducted throughout the policy term w.r.t regular premium and top-up premium will be added, respectively, into the Regular Premium Fund Value and

3
Quotation No : 50040055501

into the Top up Fund Value, as applicable. The above will exclude any extra mortality charge and/or any GST w.r.t. mortality charge deducted. The amount of ROMC
w.r.t. regular premium and top up premium (if any) will be added into each fund will be in the same proportion of the fund values as at the date of addition. Unit Price as
on the date of ROMC addition will be used for the unitisation .No ROMC will be available in a surrendered policy, discontinued policy or a policy converted to paid-up.

10. The Company declares that the mortality charges is subject to underwriting of proposal, and may change before the acceptance of risk. The company further
declares that the proposal deposit receipt given herein does not bind the company to accept the risk.

11. The mortality charges & policy administration charges, if any, are deducted through cancellation of units.
- Policy Administration Charge Rs. 400 p.a. inflating at 5% p.a., subject to maximum of Rs. 6,000 in any year. The charge is applicable during and after the premium
payment term and will be deducted at each monthly anniversary by cancellation of units at prevailing unit price.

12. Fund Management Charge will be adjusted in the unit price. Fund Management charge would be 1.35% for Equity Growth Fund II , Accelerator Mid Cap Fund II,
Pure Stock Fund , Flexi Cap Fund, Sustainable Equity Fund, Small Cap Fund ,Dynamic Asset Allocation Fund and Midcap Index Fund. 1.30% for Pure Stock Fund II.
1.25% for Asset Allocation Fund II and Bluechip Equity Fund. 0.95% for Liquid Fund, Bond Fund and Individual Short Term Debt Fund. 0.70% for Debt Plus Fund.
0.50% for Discontinuance Life Policy Fund

13. Equity Growth Fund II,Accelerator Mid Cap Fund II , Pure Stock Fund,Pure Stock Fund II, Asset Allocation Fund II,Bluechip Equity Fund , Liquid Fund , Bond
Fund , Flexi Cap Fund , Sustainable Equity Fund, Small Cap Fund, Dynamic Asset Allocation Fund , Individual Short Term Debt Fund ,Debt Plus Fund and Midcap Index
Fund are the name of the Funds being offered currently with Bajaj Allianz Life Goal Assure II and in any manner does not indicate the quality of the Fund, their future
prospects or returns.

14. Segregated Fund Identification Number (SFIN) of the funds offered with this product are given below:

Fund SFIN No
Equity Growth Fund II ULIF05106/01/10EQTYGROW02116
Accelerator Mid Cap Fund II ULIF05206/01/10ACCMIDCA02116
Pure Stock Fund ULIF02721/07/06PURESTKFUN116
Pure Stock Fund II ULIF07709/01/17PURSTKFUN2116
Asset Allocation Fund II ULIF07205/12/13ASSETALL02116
Bluechip Equity Fund ULIF06026/10/10BLUECHIPEQ116
Liquid Fund ULIF02510/07/06LIQUIDFUND116
Bond Fund ULIF02610/07/06BONDFUNDLI116
Flexi Cap Fund ULIF07917/11/21FLXCAPFUND116
Sustainable Equity Fund ULIF08017/11/21SUSEQUFUND116
Small Cap Fund ULIF08717/01/23SMALLCAPFU116
Dynamic Asset Allocation Fund ULIF08617/01/23DYNASALLOC116
Individual Short Term Debt Fund ULIF08817/01/23INDSTRMDBT116
Debt Plus Fund ULIF00923/07/04DEBTPLUSFU116
Midcap Index Fund ULIF08919/10/23MIDCPINDFD116
Discontinuance Life Policy Fund ULIF07026/03/13DISCONLIFE116

15. The past performance of any of the funds of the company is not indicative of the future performance of the fund.

16. Discontinuance/ Surrender Charge as applicable in Regular Premium Units in this policy is given below. It is applicable when regular premium under the policy is
discontinued or the policy is surrendered.

Where the policy is discontinued Discontinuance charge for the policies having Discontinuance charge for the policies having annualized
during the policy year annualized premium up to Rs. 50000/- premium above Rs. 50000/-
Lower of 20% * (AP or FV) subject to maximum of Rs.
1 Lower of 6% * (AP or FV) subject to maximum of Rs. 6,000
3,000
Lower of 15% * (AP or FV) subject to maximum of Rs.
2 Lower of 4% * (AP or FV) subject to maximum of Rs. 5,000
2,000
Lower of 10% * (AP or FV) subject to maximum of Rs.
3 Lower of 3% * (AP or FV) subject to maximum of Rs. 4,000
1,500
Lower of 5% * (AP or FV) subject to maximum of Rs.
4 Lower of 2% * (AP or FV) subject to maximum of Rs. 2,000
1,000
5 & above Nil Nil
17. The policyholder may, at any time, surrender the policy. On surrender during the lock-in period, fund value, less the applicable discontinuance/surrender charge as
on the date of surrender, will be transferred to the Discontinued Life Policy Fund, and all risk cover will be terminated immediately. The option to revive the policy will
not be available to such a surrendered policy. The discontinuance value as at the end of the lock-in period will be available as surrender value. On surrender after the
lock-in period, the surrender value available will be fund value as on the date of surrender.
18. Indicated Surrender value is not Guaranteed.

19. Charges under the policy are subject to applicable Goods & Service Tax, and will be deducted by cancellation of units.

20. The rate of return illustrated for various funds are shown at 4% and 8% in confirmation with the guidelines on illustrations set by the IRDA, and should not be
construed as forecast.

Returns demonstrated are net of all charges.

Please refer to the product brochure for details about the product including the exclusions under the plan.
Please see the product brochure for details about the product.

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Quotation No : 50040055501

Insurance is the subject matter of the solicitation.

Bajaj Allianz Life Insurance Co. Ltd.,

Bajaj Allianz House, Airport Road, Yerawada, Pune - 411006. Reg No.: 116.
Tel:(020) 66026777.
Email: customercare@bajajallianz.co.in
www.bajajallianzlife.com