C E R T I F I C AT E O F I N S U R A N C E - G R O U P A S S U R A N C E H E A LT H P L A N

To,
Issuing Office : Bangalore Branch Office
Mr Chandrasekhara Keshavamurthy Sastry GSTIN : 29AAGCA1654H1ZO
101 Sri Guru Amrutham Apartment Group Policy Holder Name :Canara Bank
L G Enclave Lakshamma Layout Nanjappa Circle GSTIN/UIN (if any) of Policy Holder :
Vidyaranyapura Your Policy Number :120100/12586/2018/A016898/031
Bangalore- 560097 Date when you were first coverd by us :15-May-17
Karnataka Policy Issuance Date : 15-May-19
Contact No : 9449616720 You are covered from 00.00 hrs on 15-May-19 to 24.00 hrs on 14-May-20
Your Policy Type : Individual
Your Plan Name : Group Assurance Health Plan
Application No :CB00042898
Description/ Harmonized System of : Accident and Health insurance Services/9971
Policy Holder's State/UT Name & Code: Karnataka (29) Nomenclature Code
Place of Supply : Karnataka

Intermediary Name Intermediary Code Intermediary Contact No.

MS CANARA BANK 80155926 1800 3000 1301
The particulars of your "Group Assurance Health Plan Insurance" Policy with Apollo Munich Health Insurance Co. Limited are as given below:

INSURED PERSON'S DETAILS

Date of Birth Sum Insured Optional Critical Illness Cumulative Bonus
Member ID Member Name Age Relation
(DD-MM-YYYY) (Rs.) Sum Insured (Rs.) Sum Insured (Rs.)
10007104150 Chandrasekhara K 67 14-04-1952 Self 500000 100000

Premium Details
Net Premium Rs. 6517.85
Taxable Premium Rs. 6517.85
CGST @ 9% Rs. 586.61
SGST/UTGST @ 9% Rs. 586.61
IGST @ 18% Rs. 0.00
Any other Cess or Taxes, if any Rs. 0.00
Gross Premium Rs. 7691.07
Gross premium (in words) Seven Thousand Six Hundred And Ninety-One Point Zero Seven Only

Original for Recipient/ Duplicate for Supplier

Whether tax is payable on reverse charge basis : NO

Please Note: Waiting periods as specified in terms & conditions will be reduced by the number of continuous preceding years of coverage of the Insured Person under
this Group Assurance Health Plan Insurance policy.

The Certificate of Insurance has been issued basis Your confirmation of Good Health provided by You under the “Health Details” section in the Enrollment form at the
inception of Your coverage.

NOMINEE DETAILS
*Nominee Name Relationship to Proposer Address of Nominee
101 Sri Guru Amrutham Apartment L G Enclave Lakshamma Layout Nanjappa
Savithri Chandrasekhara Wife
Circle Vidyaranyapura Bangalore Karnataka

* The nominee must be an immediate relative of the Proposer. For all other Insured Persons, the Proposer shall be the nominee.

CONTACT DETAILS
Policy Related
Email servicecanara@apollomunichinsurance.com
Toll Free Number 1800-3000-1301
Website www.apollomunichinsurance.com
To contact your bank health@canarabank.com
Claims Related
Toll Free Number 1800-3000-1301
Updated Network Hospitals list http://www.apollomunichinsurance.com/our-hospital-network.aspx

For and on behalf of Apollo Munich Health Insurance Company Limited

Authorized Signatory Date: 30-May-19 Place: Gurgaon

 C E R T I F I C AT E O F I N S U R A N C E - G R O U P A S S U R A N C E H E A LT H P L A N

PREMIUM RECEIPT (For the purpose of deduction under sec 80D* of Income Tax Act, 1961 (As amended from time to time in respect of self/spouse/dependent
childrens/dependent parents only)

This is to certify that Mr Chandrasekhara Keshavamurthy Sastry has paid Rs. 7691.07 (Premium 6517.85 IGST/(SGST/UTGST+CGST) whichever applicable 1173.22)
(amount in words) Seven Thousand Six Hundred And Ninety-One Point Zero Seven Only towards premium for Group Assurance Health Plan Insurance Policy, Policy
Number 120100/12586/2018/A016898/031 for the period 15-May-19 to 14-May-20.

For and on behalf of Apollo Munich Health Insurance Company Limited

Authorized Signatory Date: 30-May-19 Place: Gurgaon

Please Note : This certificate must be surrendered to the company in case of cancellation of this policy. In event of incorrect representation of this declaration the
liability shall be upon the Policy holder.
To, Issuing Office : Bangalore Branch Office
Mr Chandrasekhara Keshavamurthy Sastry GSTIN : 29AAGCA1654H1ZO
101 Sri Guru Amrutham Apartment Policy Holder Name : Mr Chandrasekhara Keshavamurthy Sastry
L G Enclave Lakshamma Layout Nanjappa Circle GSTIN/UIN (if any) of Policy Holder :
Vidyaranyapura Your Policy Number : 120100/22001/2018/A016900/026
Bangalore- 560097 Date when you were covered us : 15-May-17
Karnataka Policy Issuance Date :
Contact No : 9449616720 You are covered from 00.00 hrs on 15-May-19 to 24.00 hrs on 14-May-20
Application No. :CB00042898
Description/Harmonized System of : Accident and Health insurance Services/
Nomenclature Code 9971
Policy Holder's State/UT Name & Code: Karnataka (29)| Place of Supply :Karnataka

Intermediary Name Intermediary Code Intermediary Contact No.

MS CANARA BANK 80155926 1800 3000 1301
The particulars of your "Group Personal Accident" Policy with Apollo Munich Health Insurance Co. Ltd. are as given below:

INSURED PERSON'S DETAILS

Date of Birth
Member ID Member Name Age Relationship Sum Insured(Rs.)
(DD-MM-YYYY)
10007104018 Chandrasekhara K 67 14-04-1952 Self 500000

The Certificate of Insurance has been issued basis Your confirmation of Good Health provided by You under the “Health Details” section in the Enrollment form
at the inception of Your coverage.

PREMIUM DETAILS
Net Premium Rs. 250
Taxable Premium Rs. 250
CGST @ 9% Rs. 22.50
SGST/UTGST @9% Rs. 22.50
IGST @ 18% Rs. 0.00
Any other Cess or Taxes, if any Rs. 0.00
Gross Premium Rs. 295.00
Gross Premium (in words) Two Hundred And Ninety-Five Only
Original for Recipient/ Duplicate for Supplier
Whether tax is payable on reverse charge basis : NO
NOMINEE DETAILS
*Nominee Name Relationship with Proposer
Savithri Chandrasekhara Wife

*The nominee must be an immediate relative of the Proposer. For all other Insured Persons, the Proposer shall be the nominee.

OUR CONTACT DETAILS

Email servicecanara@apollomunichinsurance.com
Toll Free number 1800-3000-1301
Website www.apollomunichinsurance.com

For and on behalf of Apollo Munich Health Insurance Co. Ltd.

Authorized Signatory Date: 30-May-19 Place: Gurgaon

 Chandrasekhara K
DOB:14-04-1952 - Male
ID :10007104150 Policy :120100/12586/2018/A016898
Validity Period :15-May-19 - 14-May-20