/wEPDwULLTE4N

OWY4NmQwODE4

National Insurance Company Limited

Divisional Office III, Shri Lakshmi Complex,
St. Marks Road, Bangalore 560001.
Tel: 080-2558 7443; 2558 6433. Fax: 080-2558 6336..

Tailormade Hospitalisation Benefit Policy for the Dependents of Infosys Employees

Certificate No. ITL-157602
Policy
Period

From

Attached to and forming part of Policy No. 602200/46/15/8500000163

01 Aug 2015

Name of the Proposer :

Address:

To

31 Jul 2016

Infosys Employee ID 157602

Location
CHENNAI

Rajagobalan Sankaranarayanan
Flat No G1, Plot No 5A Bharathi Cross Street New Perungalathur
CHENNAI
TAMIL NADU
India
*All amount in INR

Name

Gender Relation Date Of Birth Age Plan type Sum Insured Premium

Sankaranarayanan Narayanan

Father

04 Jul 1930

85

Krishnammal Sankaranarayanan F

Mother

12 Dec 1950

65

Proposal & Declaration Date:

30 Jul 2015

Name of the TPA:

Medi Assist India Pvt Ltd
Sri Krishna Arcade
47/1, 9th Cross, 1st Main Road,

Floater

Total Premium :
Loyalty Discount:
No-Claim Discount:
Group Discount:
Total Discount:
Net Premium Payable:

For and on behalf of

National Insurance Co Ltd.

2,00,000

22,300

22,300
2,230
0
0
2,230
20,070

Sarakki Industrial Layout, 3rd Phase, J.P.Nagar,

Bangalore 560078
Toll Free: 1-800-425-9596.
Toll Free Fax: 1-800-425-9559/1-800-102-5254.
Email: mediassist@infosys.com

Sd/Authorised Signatory

Note:
1.

This is an electronically generated document and does not require any signature.

2.

Premium paid for natural parents only is eligible for deduction u/s 80D of Income Tax Act.

3.

*All amount are in INR

4.

Actual coverage starts from the date of Nomination or 1st August 2015 whichever is later