HDFC ERGO General Insurance Company Limited

2866100498386100000
MR PRAMOD KUMAR
AT JAGAMARA P.O KHANDAGIRI BHUBANESWAR
BHUBANESHWAR, 751030
ORISSA
Contact No : 9699518500
Date : 11/09/2019

We welcome you to be a part of our family!

Your Health insurance policy reference no 2866100498386100000 is confirmed on the basis of the information and declaration given by you.The details of
coverage are mentioned in the enclosed policy schedule of insurance.
As a measure of our customer convenience we have implemented a Lifetime Validity Health Card. For you, this simply means that your Health Card is
valid for all subsequent renewals and as long as your policy is active with us. Hence, need not to replace your health card every year.
We value your relationship with us and assure you our best services at all times and we look forward to serve you.
For HDFC ERGO General Insurance Company Limited

Ankur Bahorey
Head - Retail Business Group

HDFC ERGO General Insurance Company Limited

Dear Pramod Kumar,

Subject : Certificate for the purpose of deduction under section 80 D of Income Tax (Amendment) Act, 1986
This is to certify that we have received an amount of `2596.00(RUPEES TWO THOUSAND FIVE HUNDRED NINETY SIX AND ZERO PAISE)towards
premium for my: health Medisure Super Top Up Insurance, Policy No.2866100498386100000 issued to PRAMOD KUMAR for the period
11/09/2019 to 10/09/2020

Note:

1. This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended from time to time.
2. 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.
For HDFC ERGO General Insurance Company Limited
Date : 11/09/2019
Policy Issuing Office: Mumbai

Duly Constituted Attorney

2004/4125/CR 690/M-1

HDFC ERGO General Insurance Company Limited UIN : HDE-MO-P14-40-V02-14-15 | IRDAI Reg No.146 | CIN : U66030MH2007PLC177117
Registered & Corporate Office: 1st Floor, HDFC House, 165/166 Backbay Reclamation, Customer Service Address: D 301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg,
H.T.Parekh Marg, Mumbai - 400 020 Bhandup (West), Mumbai - 400 078
HDFC ERGO General Insurance Company Limited 2866100498386100000

my: health Medisure Super Top Up Insurance

Policy Details
Policy No. 2866 1004 9838 6100 000 Premium Frequency Yearly
Period of From 11 Sep, 2019 18:00 hrs hrs Policy Type Family Floater
Insurance To 10 Sep, 2020 Midnight PAN
2866100498386100000 Issuance Date 11/09/2019 GST No.
MR PRAMOD KUMAR
AT JAGAMARA P.O KHANDAGIRI BHUBANESWAR Proposer Name MR PRAMOD KUMAR
BHUBANESHWAR
ORISSA, 751030
Contact No : 9699518500
Email ID : KUMAR.PKRIO@GMAIL.COM 0

Insured Person’s Details & Sum Insured

Insured's Name Relation with Gender Date of Nominee Name Nominee 1st Policy Sum Insured Deductible Pre Existing
policy holder Birth Relationship Inception (`) (`) Disease
Pramod Kumar
Self Male 20/07/1980 Nira Prabha Sethi Spouse 11/09/2019 No

Nira Prava Sethi

Wife Female 03/05/1983 Nira Prabha Sethi Spouse 11/09/2019 600000 400000 No

Ritik Kumar
Dependent Son Male 28/07/2009 Nira Prabha Sethi Spouse 11/09/2019 No

Premium Details (`)

Basic Premium 2200.00
Total Premium excluding Taxes 2200.00
Additional Loading 0.00
Integrated Tax 18% 396.00
Total Premium 2596.00

Payment Details
Cheque No./DD/Fund Transfer Date Bank Name
LH1909002897 11/09/2019 BizDirect

Special Conditions
Age proof/identity proof will be collected in event of claim under the policy.

Invoice No. 100498386100000 HSN Code 9971

For Claim Services Phone 022 - 6234 6234 / 0120 - 6234 Fax no. 1860 2000 600 E-mail healthclaims@hdfcergo.com
Processing Centre HDFC ERGO General Insurance Company Ltd. 5th floor, Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
For any other query call toll-free 022 - 6234 6234 / 0120 - 6234 6234 or email us at care@hdfcergo.com or log on to www.hdfcergo.com

If the premium is not realised the policy shall be void from inception.
Consolidated stamp duty for this Insurance Policy i s paid b y Demand Draft, vide Receipt/Challan no. CSD/36/2019/2289/19 dated 27-05-2019 a s prescribed in Government Notification Revenue and Forest
Department No. Mudrank 2004/4125/CR690/M-1, dated 31/12/2004.. Goods and Service Tax Registration No: 27AABCL5045N1Z8. Goods and Service Tax for this invoice is not payable under reverse charge
basis.
Branch :LEELA BUSINESS PARK, 6TH FLR, ANDHERI - KURLA RD, MUMBAI, 400059. Phone No. :+91-22-66383600
For HDFC ERGO General Insurance Company Limited

Duly Constituted Attorney

*$*PARTHANIL_GHOSH#$#

HDFC ERGO General Insurance Company Limited UIN : HDE-MO-P14-40-V02-14-15 | IRDAI Reg No.146 | CIN : U66030MH2007PLC177117
Registered & Corporate Office: 1st Floor, HDFC House, 165/166 Backbay Reclamation, Customer Service Address: D 301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg,
H.T.Parekh Marg, Mumbai - 400 020 Bhandup (West), Mumbai - 400 078
HDFC ERGO General Insurance Company Limited
2866100498386100000
Health Insurance - Proposal Form For Health Medisure
SuperTop Up Insurance

Proposal No. 2866 1004 9838 6100 000

Proposer Name MR. PRAMOD KUMAR Premium Frequency Yearly
Correspondence AT JAGAMARA P.O KHANDAGIRI BHUBANESWAR Permanent AT JAGAMARA P.O KHANDAGIRI BHUBANESWAR
Address BHUBANESHWAR,ORISSA,751030 Address BHUBANESHWAR,ORISSA,751030
Mobile 9699518500 Phone - E Mail KUMAR.PKRIO@GMAIL.COM Policy Type Family Floater

Period of Insurance From Date & Time 11/09/2019 18:00 hrs To Date & Time 10/09/2020 Midnight
0

Insured Person’s Details & Sum Insured

Insured's Name Relation with Gender Date of Nominee Name Nominee Height Weight Sum Insured Deductible Pre Existing
policy holder Birth Relationship (`) (`) Disease
Pramod Kumar Self Male 20/07/1980 Nira Prabha Sethi Spouse 600000 400000 No

Nira Prava Sethi Wife Female 03/05/1983 Nira Prabha Sethi Spouse No

Ritik Kumar Dependent Son Male 28/07/2009 Nira Prabha Sethi Spouse No

Premium Details (`)

Basic Premium 2200.00
Total Premium excluding Taxes 2200.00
Additional Loading 0.00
Integrated Tax 18% 396.00
Total Premium 2596.00

Payment Details
Cheque No./DD/Fund Transfer Date Bank Name
LH1909002897 11/09/2019 BizDirect
Policy Issuing Office: Mumbai

Proposer declaration

“I/We hereby declare, on m y behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are true and complete in all
respects to the best of my knowledge and that I/We am/are authorized to propose on behalf of these other persons.

understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurance company and that the
policy will come into force only after full receipt of the premium chargeable.

I/We further declare that I/we will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been submitted but
before communication of the risk acceptance by the company.

I/We declare and consent to the company seeking medical information from any doctor or from a hospital who at anytime has attended on the life to be insured/proposer or from any
past or present employer concerning anything which affects the physical or mental health of the life to be assured/proposer and seeking information from any insurance company to
which an application for insurance on the life to be assured/proposer has been made for the purpose of underwriting the proposal and/or claim settlement.

I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or claims settlement and
with any Governmental and/or Regulatory authority.”

For Claim Services Phone 022 - 6234 6234 / 0120 - 6234 Fax no. 1860 2000 600 E-mail healthclaims@hdfcergo.com
Processing centre HDFC ERGO General Insurance Company Ltd. 5th floor, Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
For any other query call toll-free 022 - 6234 6234 / 0120 - 6234 6234 or email us at care@hdfcergo.com or log on to www.hdfcergo.com

HDFC ERGO General Insurance Company Limited UIN : HDE-MO-P14-40-V02-14-15 | IRDAI Reg No.146 | CIN : U66030MH2007PLC177117
Registered & Corporate Office: 1st Floor, HDFC House, 165/166 Backbay Reclamation, Customer Service Address: D 301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg,
H.T.Parekh Marg, Mumbai - 400 020 Bhandup (West), Mumbai - 400 078
 HDFC ERGO General Insurance Company Limited 3
Policy No.:2866100498386100000 This card is for identification purpose only.
Valid From: 11/09/2019 Renewal Date: 10 September
Card has to be presented to the Network Service Provider at the time of admission/ availing
Insured Name Date Of Birth Gender cashless hospitalization o r any other services. Insurance claim will be processed in accordance with
Pramod Kumar 20/07/1980 Male the policy term & conditions. Card does not guarantee cashless hospitalization or any other service.
Nira Prava Sethi 03/05/1983 Female For more details and updated list of Network Service Provider please refer our website or call our call
Ritik Kumar 28/07/2009 Male centre. This card is valid till the time policy is active.

Customer Service No : 022 - 6234 6234 / 0120 - 6234 6234

Fax Number : 1860 2000 600
Email : healthclaims@hdfcergo.com
Processing Centre : HDFC ERGO General Insurance Company Ltd. 5th floor,
Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
Website : www.hdfcergo.com

HDFC ERGO General Insurance Company Limited UIN : HDE-MO-P14-40-V02-14-15 | IRDAI Reg No.146 | CIN : U66030MH2007PLC177117
Registered & Corporate Office: 1st Floor, HDFC House, 165/166 Backbay Reclamation, Customer Service Address: D 301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg,
H.T.Parekh Marg, Mumbai - 400 020 Bhandup (West), Mumbai - 400 078