Bharti AXA Life Policy Number
*
:
PAN Number
*
:
Employee ID
*
:
Name
*
:
DOB
*
:
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
January
Febraury
March
April
May
June
July
August
September
October
November
December
I, an employee of Cognizant Technology Solutions India Private Limited, hold a Bharti AXA Life Insurance policy. I authorize Bharti AXA Life to share with Cognizant the premium payment made by me. I understand and hereby acknowledge that Bharti AXA Life can disclose my said premium payment to Cognizant only on basis of this authorisation provided by me and that Bharti AXA Life shall not be liable to be for any loss or damage that I may suffer/incur as a consequence of disclosure of the said data/information by Bharti AXA Life.
Bharti AXa Life Insurance Company Limited. Reg no.: 130.
Reg. Address: 6th Floor. Unit - 601 & 602, Raheja Titanium, Off
Western Express Highway, Goregaon (East), Mumbai - 400 063.