Ref No.: GEN/WEL/SG/0008.

3/1099239600

Date: 27/09/2019

To,
Mr. Kuldeep Baijnath Mishra
FNMB 181 11,BHARAT NAGAR,PLO
T NO.10,SEWRI CROSS ROAD,NEAR

Mumbai - 400031
District: MUMBAI
MAHARASHTRA, India
Contact Details 8879032864

Policy number: KGAP-M006

Subject: Risk assumption for Kotak Group Accident Protect

Dear Mr. Kuldeep Baijnath Mishra,

We welcome you to Kotak Mahindra General Insurance Company Limited and thank you for choosing us as your preferred service
provider.

This is with reference to your above mentioned Policy issued under Kotak Group Accident Protect .

Kotak Group Accident Protect UIN: IRDAI/HLT/KMGI/P-H(G)/V.I/61/2016-17; Certificate of Insurance

Enclosed please find the Policy Schedule outlining the details of your policy. Kindly note that the proposal is underwritten and policy is
issued based on the information submitted to us by you, as well as acceptance of the terms and conditions. Policy schedule must be read
in conjunction with the product brochure and policy wordings. The policy wordings detailing the terms and conditions has been sent to your
registered email id and is also available on our website www.kotakgeneralinsurance.com under the downloads section.

We request you to carefully go through the same once again and in case of any disagreement, discrepancy or clarifications, please call us
on our toll free number 1800 266 4545 or write to us at care@kotak.com within 15 days from the date of this letter. Alternatively, you can
also write to us at 8th Floor, Kotak Infinity, Building No. 21 Infinity Park, Off Western Express Highway General AK Vaidya Marg, Malad
(E) Mumbai - 400 097, India.

Please note that the information provided by you will be verified at the time of claim and the captioned Policy shall be treated as void in
case of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure in any form whatsoever made by you or by
your agent, on your behalf, at any stage.

As a valued customer, we would like to provide regular updates on your policy through email and SMS. We therefore request you to keep
us updated of any change in your contact details.

Assuring you of our best services at all times.

Thanking you,

Yours sincerely,

For Kotak Mahindra General Insurance Company Limited

Authorised Signatory

Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneralinsurance.com IRDAI Reg. No. 152
 Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneralinsurance.com IRDAI Reg. No. 152
 Kotak Group Accident Protect
For any assistance please call 1800 266 4545, please save the number for your reference
FOR RENEWALS: Visit www.kotakgeneralinsurance.com Call 1800 266 4545

CERTIFICATE OF INSURANCE
Kotak Group Accident Protect Policy No.KGAP-M006 dated 15/08/2018 has been issued at Mumbai by Kotak Mahindra General Insurance Company Limited to the
Policyholder, Kotak Mahindra Bank Ltd , as specified in the Policy Schedule and is governed by, and subject to the terms, conditions and exclusions therein contained or
otherwise expressed in the said Policy, but not exceeding the Sum Insured as specified in the Policy Schedule to the said policy.

This certificate issued under the signature of the authorised signatory of the Company represents the availability of benefits to the Insured person/ persons named below,
Customers of Kotak Mahindra Bank Ltd , subject to the terms, conditions and exclusions contained or otherwise expressed in the said Policy, but not exceeding the Sum
Insured as specified below.

For the purpose of this document, we consider Kotak Mahindra Bank Ltd as the policyholder and its Customers as the Insured.

DETAILS OF THE INSURED PERSON(S) UNDER THE POLICY

Certificate No. 1099239600 Policy Type New Previous Policy No NA Issue Date 27/09/2019

Issued at Ground Floor, Unit No. D2,Model Industrial ColonyOpp Aarey RoadMumbai Maharashtra 400063.

Name of the Insured Mr. Kuldeep Baijnath Mishra GSTIN

FNMB 181 11,BHARAT NAGAR,PLO T NO.10,SEWRI CROSS ROAD,NEAR Mumbai - 400031 District: MUMBAI
Mailing address of the Insured
MAHARASHTRA(27), India

Place of Supply: MAHARASHTRA Supply State Code: 27

Contact Details of the

Kotak Group Accident Protect UIN: IRDAI/HLT/KMGI/P-H(G)/V.I/61/2016-17; Certificate of Insurance

Mobile No. 8879032864 Email ID CHANDRAMANI0780@GMAIL.COM Instalment Option No
Insured

Period Period From : Time: 12:00 AM Date: 05/09/2019 To: Midnight of 04/09/2020 Instalment Frequency

INSURED PERSON INFORMATION

Membership ID/Employee Number/Account

5713412775
Number pertaining to Credit (#)
Name of the Financier (#) NA
Credit Tenure (#) NA
Name of the Insured Person KULDEEP BAIJNATH MISHRA
Applicant/ Co-applicant
Occupation (Salaried/ Self-employed)(#) Non-Salaried
Relationship with the Insured Person Self
Date of Birth DD/MM/YYYY 27/02/1985
Age 34
Gender M
Category
Sum Insured
Description/Remarks
Nominee Details
Name Pooja Mishra
Relationship with the Insured Person Wife
Appointee Details in case Nominee is a Minor

INTERMEDIARY DETAILS

Intermediary Code Intermediary Name Intermediary's Landline No. Intermediary's Mobile No.
DIRECT DIRECT BUSINESS 1800 266 4545
PREMIUM DETAILS (IN ₹)

Taxable value of Services (₹) CGST @ 9% (₹) SGST @ 9% (₹) Total Premium (₹)

2,033.71 183.03 183.03 2,400.00
Page 1

Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneralinsurance.com IRDAI Reg. No. 152
IN THE EVENT OF CLAIM

Contact Us at:
Toll Free number: 1800 266 4545 (8 AM to 8 PM) or may write an e- mail at care@kotak.com

Please send the relevant documents to:

Kotak Mahindra General Insurance Company Limited
8th Floor, Kotak Infinity, Building No. 21
Infinity Park, Off Western Express HighwayGeneral AK Vaidya Marg, Malad (E)
Mumbai - 400 097, India.

COVERAGE DETAILS
Coverage Opted Sum Insured Limits/ Description
Section A - Benefits
1 Accidental Death (Ad) 1500000/ INR 1500000
2 Permanent Partial Disablement (Ppd) 1500000/ INR 1500000
3 Permanent Total Disablement (Ptd) 3000000/ INR 3000000
Section B - Optional Covers to Section A
1 Modification Of Residence Vehicle 100000 / INR 100000
2 Childrens Education Grant 100000 / INR 100000
Section C – Benefits
1 Accidental Hospitilization Inpatient 15000 / INR 15000

Important Condition
Sr. No Clause Description

Kotak Group Accident Protect UIN: IRDAI/HLT/KMGI/P-H(G)/V.I/61/2016-17; Certificate of Insurance

Page 2

Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneralinsurance.com IRDAI Reg. No. 152
 PERMANENT EXCLUSION

1. Arising or resulting from the Insured Person committing any breach of the law with criminal intent.
2. Any Injury or Illness directly or indirectly caused by or arising from or attributable to war or war like perils.
3. Any Illness or Injury directly or indirectly caused by or contributed to by nuclear weapons/material usage, consumption or abuse of substances intoxicants,
hallucinogens, alcohol and/or drugs. Self-destruction or self inflicted injury, attempted suicide or suicide.
4. Any consequential or indirect loss or expenses arising out of or related to any event giving rise to a Claim under the Policy.
For complete details please refer to the Policy wordings available with the Group Master Policyholder. Alternatively, the same can be downloaded from
our website www.kotakgeneralinsurance.com

DISCLAIMER

This Policy Schedule shall be read together with the Policy Wordings (which are also available on the Company website i.e. www.kotakgeneralinsurance.com). Any word
or expression to which a specific meaning has been assigned in any part of the policy or this schedule shall bear the same meaning wherever it may appear.
TAX DETAILS

GST Registration No. 2 7 A A F C K 7 0 1 6 C 1 Z T Category : General Insurance Services

SAC Code 997133 Description Accident and health insurance services

Invoice Number 1099239600

GRIEVANCE REDRESSAL DETAILS

For resolution of any query or grievance, insured may contact the respective branch office of the Company or may call at 18002664545 or may write an e- mail at
care@kotak.com
For senior citizens, please contact the respective branch office of the Company or call at 18002664545 or may write an e- mail at seniorcitizen@kotak.com
In case the insured is not satisfied with the response of the office, insured may contact the Grievance Officer of the Company at grievanceofficer@kotak.com. In the event
of unsatisfactory response from the Grievance Officer, he/she may, subject to vested jurisdiction, approach the Insurance Ombudsman for the redressal of grievance. The
details of the Insurance Ombudsman is available at website: www.kotakgeneralinsurance.com
The updated details of Insurance Ombudsman offices are also available on the website of executive council of insurers: www.gbic.co.in/ombudsman.html

Kotak Group Accident Protect UIN: IRDAI/HLT/KMGI/P-H(G)/V.I/61/2016-17; Certificate of Insurance

STAMP DUTY

The stamp duty of ₹160.75 paid in cash or by demand draft or by pay order, Vide Receipt / Challan No./
CSD1492019452819 Dated 1 3 0 9 2 0 1 9
Deface No

In Witness whereof this Policy has been signed for and behalf of Ground Floor, Unit No. D2,Model Industrial ColonyOpp Aarey RoadMumbai Maharashtra 400063.
at Mumbai this 27 day of September of 2019

For Kotak Mahindra General Insurance Company Limited

Authorised Signatory
This document is digitally signed, hence counter signature / stamp is not required.

Page 3

Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneralinsurance.com IRDAI Reg. No. 152