Scheme member/ Annuitant's Certificate of Insurance

1. Primary Scheme Member/ Annuitant’s name: Mrs. Lata rishiraj Sharma

2. Primary Scheme Member/ Annuitant’s Address :

Ref no.: 22380364 PSCDIC3-D2C_BlueDart-366717-401720
37677594695

3. COI Number: 22380364

4. Primary Scheme Member/ Annuitant’s Code: CU470088

5. Date of Birth of the primary Scheme Member/ 9th December 1959

Annuitant:
6. Age on Commencement of Membership (In Years): 60

7. Age Admitted: 60

8. Date of Commencement of Membership: 1st March 2020

9. Purchase Price excluding applicable taxes and other 2863139.00
statutory levies:
10. Applicable taxes and other statutory levies: 51,536.00

11. Purchase Price including applicable taxes and other 2914675.00

statutory levies:
12. Mode of Premium Payment – Single

13. Gross amount of annuity payable per frequency: - 15,369.25

14. Frequency of annuity payout: Monthly

01/04/2020
15. First annuity payout :
16. Guarantee Period: 0

17. Annuity Option Chosen: Life Annuity with RoPP

18. In case of Joint Life Option:

Annuitant Information Secondary Scheme Member/ Annuitant

Name:
Gender:
Date of Birth:
Address:

19. Main Benefit: The annuity amount during the term of the membership is as specified in“Schedule of Benefits”,shown in Appendix A.

20. Benefits payable to whom: In the case of a valid claim on death or where relevant, during the term of the membership the benefit
described in the section headed "Schedule of Benefits" will then be payable. All benefits will be provided either to the Scheme
Member/ Annuitant or the Scheme Member/ Annuitant's nominee, as applicable

21. Procedure for registering the claim: The following should be undertaken to register a claim on this membership: Submit the completed
claim forms and any accompanying documentation to HDFC Life. However, for a Critical Illness claim, a claim needs to be registered
within 30 days from the detection of the illness along with the following documents a) Completed Critical Illness Claim Form, b)
Medical records for diagnosis and treatment of the illness, c) Original COI, d) Beneficiary's residence and identity proof. (2) On
payment of a claim, no further benefit will be payable, and the membership will terminate. In case of claim contact on: Telephone:
1800 227 227 / 6000 9191 / 67516666

22. Cancellation in the Free-Look Period:

In case the Scheme Member/Annuitant is not agreeable to any of the terms and conditions stated in the Master Policy/COI, the

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 Scheme Member/Annuitant has an option to return the COI to us stating the reasons thereof, within 15 days from the date of receipt
of the COI. If you have purchased your Policy through Distance Marketing mode, this period will be 30 days. However, this option will
not be available in the event of annuity purchased from the vesting proceeds of an accumulation pension product. On receipt of the
your letter along with the original COI where the reasons stated therein are found valid, we shall arrange to refund the
Premium/Purchase Price paid, subject to deduction of any statutory levies. A Policy once returned shall not be revived, reinstated or
restored at any point of time and a new proposal will have to be made for a new policy.
23. Words used but not defined herein shall have the same meaning ascribed to them in the Master Policy. In case of any discrepancy
between the Master Policy and this COI the terms and conditions of the Master Policy shall prevail

Registered office:
Lodha Excelus, 13th Floor, Apollo Mills Compound, N. M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.

Communication office:
HDFC Life Insurance Company Limited, 11th Floor Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai -
400011.

The terms and conditions as mentioned in the Master Policy between HDFC Life and the Policyholder will prevail and be binding.

Signed at Mumbai on 29th June 2020

For (HDFC Life Insurance Company Limited)

Authorised Signatory

Please note that COI is issued subject to terms and conditions of the proposal and Master Policy.

Mudrank Number: The revenue stamp duty paid by an order via Receipt number CSD/32/2018/1779-80/18 dated 1st January 2018
respectively.

Member Code: CU470088

Nomination Schedule
Share (%) Name Date of Birth Address
50 Mrs. Sweta 19th June 1996 A/601, Somdatta Tower,
Plot No. 6, Palm Beach Road
Sector 15 Sanpada
Thane
Maharastra
400705
50 Mr. Saurav 29th July 1999 A/601, Somdatta Tower,
Plot No. 6, Palm Beach Road
Sector 15 Sanpada
Thane
Maharastra
400705
Notes: This schedule replaces all previous Nomination Schedules issued prior to the effective date, noted above

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 Appendix A: Schedule of Benefits payable under “HDFC Life New Immediate Annuity Plan” Annuity Benefit:

Annuity Option Benefit

Life Annuity with RoPP INR 15,369.25

Survival Benefit:
Option Name Benefit

Life Annuity with RoPP NA

The Scheme Member/ Annuitant shall provide such proof of survival, as and when called upon to do so. The list of acceptable proofs will be

communicated from time to time. We reserve the right to suspend the Annuity payments till the proof is provided.

Death Benefit/Critical Illness Benefit*:

On death/Critical Illness* of the primary Scheme Member/ Annuitant the following benefit would be payable:

Plan Option Lump sum Benefit Annuity Amount (applicable only for Joint Life)

Life Annuity with RoPP INR 2863139.00 NA

* Critical Illness benefit shall be payable only if Life Annuity with Return of Purchase Price on diagnosis of Critical Illness option is selected.

The Critical Illnesses covered will be as specified under the Master Policy between HDFC Life and the Policyholder.

Surrender Benefit:
On surrender the following benefit would be payable:

Plan Option Guaranteed Surrender Value

Life Annuity with RoPP 10 % of INR 2863139.00

Appendix B Exclusions:

In case Life Annuity with Return of Purchase Price on diagnosis of Critical Illness option is selected then the respective exclusions as

mentioned under the Master Policy will be applicable to each of the Critical Illnesses.

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