The New India Assurance Company Ltd.

THE NEW INDIA ASSURANCE CO. LTD.

DIGITAL HUB, MUMBAI 830000,
(Govt. of India Undertaking)
41B, Maker Tower "E", Cuffe Parade, Mumbai 400 005.
CIN Number: L66000MH191900000526
Land line No.:- 022-22150330
Email ID:- nia.830000@newindia.co.in
Policy Number : 83000034201401004852 Toll Free No. :- 1800-209-1415
GSTIN : 27AAACN4165C3ZP

POLICY SCHEDULE
Family Floater Mediclaim Policy for Institute of Chartered Accountants of India

Policyholder Details Policy Details

Name CA. vijay kumar gupta Policy Number 83000034201401004852

Tax Invoice Number 8300003401004852

Customer ID PO01003553 SAC Code (Description) 997133 (General Insurance)

PAN Number AGZPG1497N Period of Insurance From : 12/07/2020 Time : 00:00:00

To : 11/07/2021
GSTIN Date of Proposal 11/07/2020

Receipt Number 8300008120XX00082021 Receipt Date : 11/07/2020

Address WZ-51, STREET NO.3, SADH NAGAR,
Zone Opted Zone 2 ( Any where in India except Mumbai and
PALAM COLONY, NEW DELHI, Palam
Greater Mumbai)
Enclave, New Delhi, Delhi, India, 110045
Floater Sum Insured(Rs) 2,000,000.00

Zone Opted for Parent/In laws Zone 2 ( Any where in India except Mumbai and
Greater Mumbai)
Floater Sum Insured for the Parent/In laws(Rs) 1,000,000.00

Total Basic Premium 50,277.00

Mobile Number +91-9871174091 SGST (@9%) 0.00

Email ID vkguptaca@gmail.com CGST (@9%) 0.00

Assignee Name CA. Tina Gupta IGST (@18%) 9,050.00

Assignee Relationship Spouse Gross Total Premium 59,327.00

Details of TPA
Name : MD India Healthcare Services Pvt. Ltd. Telephone : +91 7709189736, + 91 9168618873
Address : S.No.46/1, E-space, A-2 Building, 4th floor, Fax : 020-25300030
Pune Nagar Road, Vadgaonsheri, Pune-411014. Toll Free No : 1800-233-1166, 1800-233-4505
www.mdindiaonline.com Email ID : customercare@mdindia.com ; icai@mdindia.com

Sl. No Name of Insured Age Sex Occupation Relation Date of Issuance Details of Pre-existing Diseases
of First Policy

1 CA. vijay kumar gupta 39 Male Chartered Accountant Self 12/07/2018 None

2 Mrs. Tina Gupta 36 Female Housewife Spouse 12/07/2018 None

3 Mr. Garvit Gupta 9 Male Student Dependent Child 12/07/2018 None

4 Mr. Tanmay Gupta 7 Male Student Dependent Child 12/07/2018 None

5 Mr. Pushkar Mal Gupta 66 Male None Father 12/07/2018 None

6 Mrs. Radha Rani Gupta 59 Female None Mother 12/07/2018 None

* The Policy is subject to Family Floater Mediclaim Policy Clause as attached.

In the event of death of the insured person(s) due to an Insured peril, all benefits payable, in respect thereof under this insurance, shall become payable to the assignee declared in the proposal (incorporated herein as the schedule) and the receipt given by the said

assignee shall be construed as full and final discharge to the Company in respect of all liability under the policy.

Authorized Signatory
For & on behalf of
The New India Assurance Company Ltd
Consolidated stamp duty paid vide Mudrank-2004/4125/CR/690/M-1

(Note: This policy must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation of the policy or any alteration in the Insurance affecting the premium.)

Policy No. : 83000034201401004852 Document generated at 11/07/2020 13:19:51

Regd. & Head Office: New India Assurance Bldg., 87 M.G.Road,Fort,Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.

For Redressal of your grievance, if any, you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3.Head office. In case, you are not satisfied with our own grievance redressal