HDFC ERGO General Insurance Company Limited

436531526480584009

Date: 11/08/2019
Dear Mr. Mohammed Shanawaz
P-NO-1, Lakshmi Narayana Homes
Mayuri Nagar, Miyapur.
Hyderabad, Pin Code: 500049.

We thank you for trusting HDFC ERGO General Insurance. Enclosed herewith is your insurance policy which has been confirmed on the basis of
the information and declaration given by you.

Product Name Policy No. Sum Insured (₹) Premium (₹)

(Inclusive of ST @15%)
Health Suraksha Policy 436531526480584009/1 4 00,000.00 24,100.00

The insurance policy enclosed herewith represents a written agreement confirming the terms of the cover agreed as per our telephonic
Conversation with you.

To ensure seamless & hassle – free services, we request you to kindly check your contact and other details on your policy schedule on the
Basis of which the insurance is issued. In case of any discrepancy please call our toll free 1800 2 700 700.

For any further assistance on your policy or to know more about other products, please free to contact us. We once again thank you for
Choosing HDFC ERGO and heartily welcome you to our growing family.

For HDFC ERGO General Insurance Company Ltd.

Karan Chopra
Head – Retail Business Group

--------------------------------------------------------------------------------------------------------------------------

HDFC ERGO General Insurance Company Limited

Dear Mr. Mohammed Shanawaz

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 ₹ 24,100 (RUPEES TWENTY-FOUR THOUSAND ONE HUNDRED RUPEES AND
ZERO PAISE Only) towards the premium for Health Suraksha Policy, Policy No 436531526480584009/1 issued to
MOHAMMED SHANAWAZ for the period 11/06/2019 to 10/06/2020.

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.

Date: 11/06/2019 For HDFC ERGO General Insurance Company Ltd.

Policy Issuing Office: Mumbai

Duly Constituted Attorney

Registered & Corporate Office: 1 st Floor, 165 -166 Backbay Reclamation, H. T. Parekh Marg, Church gate, Mumbai- 400 020.
Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri(E), Mumbai - 400 059.
Tel: +91 22 6638 3600 | Fax: 91 22 6638 3699 | Care@hdfcergo.com |www.hdfcergo.com. IRDA Reg. No. 125. CIN: U66010MH2002PLC134869
HDFC ERGO General Insurance Company Limited

POLICY SCHEDULE
Policy No. 436531526480584009

Health Suraksha Policy

SILVER PLAN

Proposer Name MR MOHAMMED SHANAWAZ Premium Frequency Family

Correspondence P-NO-1, LAKSHMI NARAYANA HOMES, MAYURI Permanent P-NO-1, LAKSHMI NARAYANA HOMES,
Address NAGAR, MIYAPUR, HYDERABAD -500049. Address MAYURI NAGAR, MIYAPUR, HYDERABAD -
500049.
Mobile Phone E Mail Policy Type Family Floater

Period of Insurance From Date & Time 11/06/2019 00:00 hrs. To Date & Time 10/06/2020 Midnight

Insured Person’s Details & Sum Insured

Insured Name Relationship Date of Birth Member ID 1st Policy Portability
Inception Sum Insured (₹) Pre-Existing
Disease

MOHAMMED SHANAWAZ Self 25/05/1985 10/06/2019

MOHAMMED RIMA Spouse 21/05/1987 10/06/2019

Sum Insured (₹) 400,000.00 CB Amount (₹) 0.00

In case of increase in the Sum insured at renewal, waiting period will apply afresh in relation to the amount by which the Sum Insured has been enhanced.

Coverage Details
Coverage Details Coverage Details

In-Patient Treatment Covered Pre-hospitalization(days) 60

Post-hospitalization (days) 90 Day Care Procedure Covered

Domiciliary Treatment Covered Organ Donor Expenses Covered

Emergency Ambulance Charges (Limit per hospitalization) Upto Rs 2000 Ayurvedic/Unani/Siddha/Homeopathic Covered

Health Checkup per family (Post 4 claims free years) Upto 1% Sum Enhanced Cumulative Bonus 10 % of Sum
Insure; Maximum Insured; Maximum
Upto Rs 5000 100%

Regain Benefit 100 % of basic

Sum Insured

The policy Wording attached herewith includes all the standard coverages offered by the Company to its Customers. Your entitlement for coverage/benefits shall be
Restricted to the coverages benefits as mentioned in this policy Schedule issued to you. Please read the policy Wording in conjunction with the Policy Schedule. For Any
Clarification, please call out toll free number.

Premium Details (₹)

Basic Premium 21,800
Loadings 0.00
GST (Including Education Cess & Higher Education Cess, whenever applicable) 2,300.00
Total Premium 24,100.00

Payment Details
Cheque No./DD/Fund Transfer Date Bank Name
ERGO_CC_11062019-10265660000146-SECURE PLUS 11/06/2019 HDFC Bank Ltd

Special Conditions

Exclusions

Registered & Corporate Office: 1 st Floor, 165 -166 Backbay Reclamation, H. T. Parekh Marg, Church gate, Mumbai- 400 020.
Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri(E), Mumbai - 400 059.
Tel: +91 22 6638 3600 | Fax: 91 22 6638 3699 | Care@hdfcergo.com |www.hdfcergo.com. IRDA Reg. No. 125. CIN: U66010MH2002PLC134869
HDFC ERGO General Insurance Company Limited

POLICY SCHEDULE
Policy No. 4965 3152 6480 5824 009

Health Suraksha Policy

SILVER PLAN

List of Endorsements
End No Description Effective Date

For Claim Services Phone 1800 2000 700 / 1800 2001 999 Fax no. 1800 2000 600 Email healthclaims@hdfcergo.com
Address HDFC ERGO General Insurance Company Ltd. 5th floor, Tower 1, Stellar IT Park. C-25, Sector -62, Noida - 201301

If the premium is not realized the policy shall be valid from inception.
Consolidated stamp duty for this insurance Policy is paid by Demand Draft, vide Receipt/Challan no 2837052201415 dated 20/12/2014 as prescribed in
Government Notification Revenue and Forest Department No. Mudarank 2004/4125/CR 690/M-1, dated 31/12/2004.
Policy Issuing Office: Mumbai

Agent Name: HDFC BANK LTD HDFC ERGO General Insurance Company Ltd.

Agent Code: 201587086428 Tel No. 91-22-28561818

Duly Constituted Attorney

Registered & Corporate Office: 1 st Floor, 165 -166 Backbay Reclamation, H. T. Parekh Marg, Church gate, Mumbai- 400 020.
Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road, Andheri(E), Mumbai - 400 059.
Tel: +91 22 6638 3600 | Fax: 91 22 6638 3699 | Care@hdfcergo.com |www.hdfcergo.com. IRDA Reg. No. 125. CIN: U66010MH2002PLC134869