Policy Issuing Office : Reliance General Insurance Co. Ltd.

, 570, Policy Servicing Branch Office : Reliance General Insurance Co. Ltd, Reliance General
Naigaum Cross Road, Next to Royal Industrial Estate, Insurance Co Ltd 202-21 2nd Floor MERCANTILE HOUSE Wadala (W), Mumbai – 400031
KASTURBA GANDHI MARG New Delhi New Delhi 110001

Reliance Individual Mediclaim Policy Schedule

Name and Address of the Proposer : Arnab Roy

Mahaveer Orchid, Flat No. 119, Block-B, Rayasandra
Bengaluru, Karnataka
560099
India
Mobile No: 9899494067
Policy Number : 1303812321000328
Plan Name : Reliance HealthGain Policy
Sum Insured : As Indicated Below
Period of Insurance : From 00:01 on 25/05/2019 to mid-night on 24/05/2020
Details of previous policy (in case of renewal)
Previous policy No. : NA
Date of expiry : NA

Name of Insured Gende Date of Relationship Occupati Pre- Sum Insured Domiciliary Amount of CB Loading Premium (Rs)
Person r Birth with the on Existing (Rs) Hospitalisation (Rs) (%)
Proposer Illness Limit (Rs)
Arnab Roy M 27-12-1982 Self Others 5,00,000.00 10,00,000.00 15,00,000.00 43,271.00
Madhusree Roy F 10-02-1987 Spouse Others
Medhansh Roy M 19-11-2019 Son Others
Dilip Kumar Roy M 14-04-1949 Father Others
Smriti Roy F 15-09-1954 Mother Others
* Where an Insured Person is added to this Policy, either by way of endorsement or at the time of renewal, the pre-existing disease clause,first year exclusion
and 30 days waiting period is applicable considering such policy period as the first policy with us.
* Policy would be considered as a fresh policy if there would be break of fifteen or more days between the prevoius policy expiry date and current policy start
date.

* Any enhanced Sum insured during subsequent policy renewals will not be available for an illness, diseases, injury already contracted under the preceding
policy periods.All Waiting periods as defined in the policy shall apply for this enhanced limit from the effective date of enhancement of such Sum Insured.
* This Insurance is subject to the terms and conditions of policy attached .The policy wordings with detailed terms , conditions and exclusions is available on
our website www.reliancegeneral.co.in

Special Conditions, if any :

Premium Details Amount (Rs.)

Gross Premium 43,271.00
CGST @9% 3,894.00
SGST @9% 3,894.00
Total Premium 51,059.00
(GST No: 24AABCR6747B1ZM)
Note: In the event of dishonor of cheque, this policy document automatically stands cancelled from inception, irrespective of whether a separate
communication is sent or not.
In witness whereof this policy has been signed at Mumbai on 25/05/2019
For any assistance with claims, please contact us on 1 800 3002 8282 (toll free) and 3989 8282 (local charges apply) or email us at
services.rgicl@relianceada.com

TPA/Service Provider Details

TPA/Service Provider Name : Paramount Health Services Pvt. Ltd.
Address Please Log on to www.paramounttpa.com for locating the nearest office for submission of claim documents
24X7 Customer Helpline Number 022-66620880/ (022) 6662 0880(TollFree)
Fax Number (022) 2825 9543 /9743
Email id contact.phs@paramounttpa.com ( For Insured Grievances & for any other queries)

Premium Certificate
Premium Certificate for the purpose of deduction under Section 80-(D) of Income Tax (Amendment) Act 1986.
This is to certify that ARNAB ROY has paid Rs .51,059.00 (FIFTY ONE THOUSAND AND FIFTY NINE) towards premium for Health Insurance for the Period From
00:01 on 25/05/2019 to Midnight of 24/05/2020 on May 25 2019
Policy Number : 1303812321000328
Date : 25/05/2019
Note: This certificate must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation of policy or any alteration in the
insurance

Registered Office: Reliance Centre, 19, Walchand Hirachand Marg,Ballard Estate ,Mumbai - 400 001