HDFC ERGO General Insurance Company Limited

2952200784772102000
Date : 25/07/2016
Dear MR T GOPALA REDDY
HNO 3-5-2 FLT NO15
RAMAKRISHNA STRT VIVEKANANDA N
NGR KUKATPALLY .
HYDERABAD, ANDHRA PRADESH, 500072
Contact No. 9848404460
We thank you for your continued patronage with HDFC ERGO General Insurance Company Limited. Enclosed herewith is your
insurance policy which represents a written agreement confirming the terms of cover.

The policy is issued on the basis of the information and declaration given by you.

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

(Inclusive of Service Tax)
Health Suraksha Policy 2952200784772102000/1 300,000.00 4,384.00
Sarv Suraksha - Personal Accident 2952200784772102000/2 1,000,000.00 805.00
The insurance policy enclosed herewith represents a written agreement confirming the terms of the cover agreed as per the
declaration given by you. The terms and conditions of the renewed policy remain unchanged. As a part of our Go Green initiative,
we would request you to refer the policy wordings shared previously. Alternatively, you can download the Policy Wordings from
the "Downloads" section on our website www.hdfcergo.com . Health cards enclosed herewith will be valid till validity of policy and
to be preserved for life.

To ensure seamless & hassle-free services experience, we request you to carefully check your contact and other details on your
policy schedule. In case of any discrepancy please write to us on care@hdfcergo.com or call our toll free help line no. 1800 2
700 700 and our executives would be glad to assist you.

For any further assistance on your policy or to know more about our other products, please free to contact us.
For HDFC ERGO General Insurance Company Ltd.

Ankur Bahorey
Head - Retail Business Group

HDFC ERGO General Insurance Company Limited 2952200784772102000/1

Dear MR T GOPALA REDDY

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 ` 4,384.00 (RUPEES FOUR THOUSAND THREE HUNDRED
EIGHTY-FOUR AND ZERO PAISE Only) towards premium for Health Suraksha Policy, Policy No. 2952200784772102000/1
issued to T GOPALA REDDY for the period 25/07/2016 to 24/07/2017.

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 : 25/07/2016 For HDFC ERGO General Insurance Company Ltd.
Policy Issuing Office: Mumbai

Duly Constituted Attorney

Registered & Corporate Office: 1st Floor, 165-166 Backbay Reclamation, H. T . Parekh Marg, Churchgate, Mumbai - 400020. Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road,
Andheri (E), Mumbai - 400 059. Toll Free : 1800-2-700-700 (Accessible from India only) | Fax : 91 22 6638 3699 | care@hdfcergo.com | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
POLICY SCHEDULE
Policy No. 2952 2007 8477 2102 000 Health Suraksha Policy
SILVER PLAN

Customer Id:101689152131

Proposer Name MR T GOPALA REDDY Premium Frequency Yearly

Correspondence HNO 3-5-2 FLT NO15,RAMAKRISHNA STRT VIVEKANANDA Permanent HNO 3-5-2 FLT NO15,RAMAKRISHNA STRT VIVEKANANDA
Address N,NGR KUKATPALLY,., Address N,NGR KUKATPALLY,.,
0

HYDERABAD, ANDHRA PRADESH, 500072 HYDERABAD, ANDHRA PRADESH, 500072

Mobile 9848404460 Phone E Mail TGOPALAREDDY@GMAIL.COM Policy Type Individual

Period of Insurance From Date & Time 25/07/2016 21:34 hrs To Date & Time 24/07/2017 Midnight

Insured Person’s Details & Sum Insured

Insured's Name Relationship Date of Birth Member ID 1st Policy Portability Pre Existing
Inception Sum Insured (`) Disease

T GOPALA REDDY Self 21/08/1985 13/07/2012 NO

Sum Insured (`) 300,000.00 CB Amount (`) 60,000.00

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.

Nominee Name NOMINEE_NAME Relationship NOMINEE_RELATIONSHIP

The nominee must be an immediate relative of the Insured Person. For all other insured person(s), the Policyholder shall be the nominee.

Coverage Details

Coverage Details Coverage Details

In-Patient Treatment Covered Pre-hospitalization (days) 60
Post-hospitalization (days) 90 Day Care Procedures Covered
Domiciliary Treatment Covered Organ Donor Expenses Covered
Emergency Ambulance Charges (Limit per Ayurvedic /Unani/Sidha/ Homeopathic
Upto Rs. 2000 Covered
hospitalisation)
Health Check up per family (Post 4 Claims free Upto 1% Sum Insured,Maximum Upto Rs Hospital Daily Cash (only to the eldest member Rs.1000/- per day for a maximum of
years) 5000/- of the family) 30 days

The Policy Wording includes all the standard coverages offered b y the Company to its customers. Your entitlement for coverage/benefits shall be restricted to the coverage/benefits a s mentioned in this Policy
Schedule issued to you. Please read the Policy Wording in conjunction with the Policy Schedule. For any clarification, please call our toll free number.

Subject to the conditions laid down in the Policy, on completion of each four consecutive policy years with us, the eligible Insured Person(s), included in each policy year is/are entitled for a medical checkup benefit
up to an amount equals to 1% of sum insured or Rs 5000/- whichever is less.

Premium Details (`)

Basic Premium 3,812.00
Loadings 0.00
Service Tax 15% (Including Swachh Bharat Cess 0.50%, Krishi Kalyan Cess 0.50% as applicable) 572.00
Total Premium 4,384.00

Payment Details
Cheque No./DD/Fund Transfer Date Bank Name
ERGO_CC_25072016-01282990000126-SECUREPL 25/07/2016 HDFC Bank Ltd

Special Conditions

Exclusions

Registered & Corporate Office: 1st Floor, 165-166 Backbay Reclamation, H. T . Parekh Marg, Churchgate, Mumbai - 400020. Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road,
Andheri (E), Mumbai - 400 059. Toll Free : 1800-2-700-700 (Accessible from India only) | Fax : 91 22 6638 3699 | care@hdfcergo.com | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
POLICY SCHEDULE
Policy No. 2952 2007 8477 2102 000
Health Suraksha Policy
SILVER PLAN

List of Endorsements
Endt No Description Effective Date

For Claim Services Phone 1800 2700 700 Fax no. 1860 2000 600 E-mail healthclaims@hdfcergo.com
Address 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 1800 2 700 700 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 is paid by Demand Draft, vide Receipt/Challan no 4932771201516 dated 29/03/2016 as prescribed in Government Notification Revenue and Forest Department
No. Mudrank 2004/4125/CR 690/M-1, dated 31/12/2004 , Service Tax Registration No: AABCH0738EST004.

Policy Issuing Office: Mumbai For HDFC ERGO General Insurance Company Ltd.

Agent Name :HDFC BANK LTD

Agent Code :201587086428 Tel No. : 91-22-28561818 Duly Constituted Attorney

Registered & Corporate Office: 1st Floor, 165-166 Backbay Reclamation, H. T . Parekh Marg, Churchgate, Mumbai - 400020. Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road,
Andheri (E), Mumbai - 400 059. Toll Free : 1800-2-700-700 (Accessible from India only) | Fax : 91 22 6638 3699 | care@hdfcergo.com | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited

HDFC ERGO General Insurance Company Limited 1

Policy No.: 2952200784772102000 This card is for identification purpose only.

Valid From: 25/07/2016

Card has to be presented to the Network Service Provider at the time of admission/ availing
cashless hospitalization or any other services. Insurance claim will be processed in accordance
with the policy term & conditions. Card does not guarantee cashless hospitalization o r any
other service. For more details and updated list of Network Service Provider please refer our
Insured Name Date Of Birth Gender website or call our call centre. This card is valid till the time policy is active.

Phone Number : 1860 2000 700 / 1800 2001 999

T GOPALA REDDY 21/08/1985 Male
Fax Number : 1860 2000 600
Email : healthclaims@hdfcergo.com
HDFC ERGO General Insurance Company Ltd. 5th floor,
Address :
Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
Website : www.hdfcergo.com

Registered & Corporate Office: 1st Floor, 165-166 Backbay Reclamation, H. T . Parekh Marg, Churchgate, Mumbai - 400020. Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road,
Andheri (E), Mumbai - 400 059. Toll Free : 1800-2-700-700 (Accessible from India only) | Fax : 91 22 6638 3699 | care@hdfcergo.com | www.hdfcergo.com
 HDFC ERGO General Insurance Company Limited YES
POLICY SCHEDULE
Policy No. 2952 2007 8477 2102 000
Sarv Suraksha - Personal Accident
FAMILY HEALTH COVER

0
Proposer Name MR T GOPALA REDDY Premium Frequency Yearly
0
HNO 3-5-2 FLT NO15,RAMAKRISHNA STRT HNO 3-5-2 FLT NO15,RAMAKRISHNA STRT VIVEKANANDA
Correspondence Permanent
VIVEKANANDA N,NGR KUKATPALLY,., N,NGR KUKATPALLY,.,
Address Address
HYDERABAD,ANDHRA PRADESH,500072 HYDERABAD,ANDHRA PRADESH,500072
Mobile 9848404460 Phone E Mail TGOPALAREDDY@GMAIL.COM

Period of Insurance From Date & Time 25/07/2016 21:34 hrs To Date & Time 24/07/2017 Midnight Territorial Limits Worldwide

Insured Details
Insured’s Name Relationship Date of Birth Benefit
T GOPALA REDDY Self 21/08/1985 100%

Nominee Details

Insured’s Name Nominee Name Relationship Benefit

T NAGAMANI Parent
The nominee must be an immediate relative of the Insured Person. For all other insured person(s), the Policyholder shall be the nominee.

Coverage Details
Coverage* Sum Insured ( `)
1. Accidental Death
2. Permanent Total Disability 10,00,000
3. Permanent Partial Disability
The Policy Wording includes all the standard coverages offered b y the Company to its customers. Your entitlement for coverage/benefits shall be restricted to the coverage/benefits a s mentioned in this
Policy Schedule issued to you. Please read the Policy Wording in conjunction with the Policy Schedule. For any clarification, please call our toll free number.

Premium Details ( `)
Basic Premium 700
Loadings 0
Service Tax 15% (Including Swachh Bharat Cess 0.50%, Krishi Kalyan Cess 0.50% as applicable) 105
Total Premium 805
Payment Details
Cheque No./DD/Fund Transfer Date Bank Name
ERGO_CC_25072016-01282990000126-S 25/07/2016 HDFC Bank Ltd
ECUREPL
Special Conditions

List of Endorsements
Endt No Description Effective Date

For Claim Services Phone 1800 2 700 700 Fax no. 022 66383699 E-mail care@hdfcergo.com
Address 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri(E), Mumbai 400 059.
For any other query call toll-free 1800 2 700 700 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.
The stamp duty of ` 1/-paid b y Demand Draft, vide Receipt/Challan no 4932771201516 dated 29/03/2016 as prescribed in Government Notification Revenue and Forest Department No. Mudrank
2004/4125/CR 690/M-1, dated 31/12/2004.

Policy Issuing Office: Mumbai For HDFC ERGO General Insurance Company Ltd.

Agent Name :HDFC BANK LTD

Agent Code :201587086428 Tel No. : 91-22-28561818 Duly Constituted Attorney

Registered & Corporate Office: 1st Floor, 165-166 Backbay Reclamation, H. T . Parekh Marg, Churchgate, Mumbai - 400020. Customer Service Address: 6th Floor, Leela Business Park, Andheri Kurla Road,
Andheri (E), Mumbai - 400 059. Toll Free : 1800-2-700-700 (Accessible from India only) | Fax : 91 22 6638 3699 | care@hdfcergo.com | www.hdfcergo.com