PARAMOUNT HEALTH SERVICES (TPA) PVT. LTD.

Plot No. A-442,Road No-28.M.I.D.C Industrial Area,Wagale Estate,Ram Nagar,Vitthal Rukhumani Mandir.Thane (W), Thane-400604. Tel-66620808, Fax-66444754 / 55, E-mail -accounts.dept@paramounttpa.com Date : 11/20/2013

CUMMINS INDIA LTD.

Dear Sir / Madam, Enclosed please find claim settlement report and discharge voucher. Kindly send us back the discharge voucher duly signed affixing Revenue Stamp.

Claim Payment cum Discharge Voucher

Name of Insurance Co Float Ac No Policy No Amt of Claim Lodged Amount Paid PHS Amount Paid Member Bank Name : : : : : : : United India Insurance Company UIIC-20.11.2013 500600/48/13/41/00000055 13480 0 13480 CITI BANK

Received from Paramount Health Services (TPA) Pvt. Ltd.

Rupees Thirteen Thousand Four Hundred Eighty And Zero Paise

In full and Final Settlement of My / Our Claims details as attached Over Rs 5000 /affix Re. 1 Revenue Stamp

PARAMOUNT HEALTH SERVICES (TPA) PVT. LTD.

Insurance Co : United India Insurance Company Group : CUMMINS INDIA LTD.

Claim Lod. No. Fir / Fir Ext Plan Dept Emp. No. / Sr. No. Name Employee Name

Policy No: 500600/48/13/41/00000055

Final Bill Amt Not Payable Exp Amt of Claim Lodged Cl Lod PHM Paid Cl Lod Mem Paid Cheque No. Member Paid Branch File No. Reasons

281388

2356383

RT&E -CIL

KF773

BABY OF PRAJAPATI ARTI VIJAYKUMA R

PRAJAPATI VIJAYKUMAR

13480

13480

13480

1269752

Total :

13480

13480

13480