Insurance Certificate

Branch Office: Delhi

Policy Number 30104130201200

Policy Holder's Name Mr. Binod Bihari Dash

Communication Address 101, Rudradarshan Apartment, Jaibhawani Road,

'·
Patole Mala,Nasik Road,

Nasik,Maharashtra-422101
Policy commencement date: From 31/07/2015 00:00 a.m.
Policy Expiry date: To 30/07/2016 23:59 p.m.
Family Floater Yes

Plan Opted for Heartbeat Silver 03 Lacs 2 Adults & 1 Child

Policy Period 1 year

Sum Insured (Rs.) 300,000

Heartbeat Individual No

Heartbeat Family Floater Yes

Heartbeat Family First No

Renewal Due date: 30/07/2016

Premium Calculation:

Original Policyholder details at the time of first risk inception,

Original Policyholder Name Binod Bihari Dash

Original Policyholder's address 101, Rudradarshan Apartment, Jaibhawani Road, Patole Mala,Nasik
Road, Nasik,Maharashtra-422101

N�t Premium (Rs.) 8,024.00

Service Tax(Rs.) 963.00
Education Cess (Rs.) 19.00
Secondary &Higher Education Cess (Rs.) 10.00
Gross Premium(Rs.) 9,016.00
Gross Premium (In words) Nine Thousand Sixteen Only

Max Bupa Health Insurance Company Limited

l
C orporate Office: D-1. 2nd Floor. Salcon Ras Vilas.
District Centre. Saket. New Delhi 11 0 017
A Max India Joint Venture Registered Office: Max House. 1 D r.Jha Marg. Okhla. New Delhi 110 020
www.maxbupa.com