: INDORE_VIJAY NAGAR_ASSET

Agent Name CENTER

Agent code : 1481350000
Agent contact no : 1800120130130
Issuing office : Indore
Client Id :
Proposal no : 7987757745
Policy holder's Name : AKSHAY CHOUKSEY
Policy holder's address : 9/4, PARDESHIPURA NEAR RAM
MANDIR INDORE
INDORE,INDORE,MADHYA
PRADESH-452003
Place Of Supply : INDORE
Supply Code : 23
Policy Number : 0288647483
Policy name : Tata AIG MediCare
Plan type : Individual Basis
Policy period : From:27/05/2021 00:00 hrs to
Expiry Date:26/05/2022 on 11.59
PM
Business Type : New
Policy Tenure :1
Insured Persons Details:
Member Id Insured Insured Date Of Age Relationship Restore Sum Cumulative Accidental
Person's with TATA Birth to proposer Benefits % Insured Bonus(Rs.) Death
Name AIG (Rs.)
General
Insurance
Co.since
AKSHAY
798775774
CHOUKSE 27/05/2021 01/07/1992 28 Self 100 300000 0
501028
Y
* For Family Floater policy, Sum Insured and cumulative bonus floats among the insured members of the family as mentioned above.
* Sum Insured mentioned is excluding cumulative bonus. Earned cumulative bonus is separately mentioned.
Nominee Details for Proposer:
Insured Name Nominee Name Relationship to Proposer
All Insured mentioned PRAHLAD DAS CHOUKSEY Others
* The nominee must be an immediate relative of the policyholder. For all other insured persons the policyholder shall be the nominee.
Benefits Table:
cover coverage Net Premium: (Rs) 4785.0
In-Patient Treatment Upto Sum Insured Discounts: (Rs) 0.0
Pre-Hospitalization expenses Upto 60 days Loading: (Rs) 0.0
Post-Hospitalization Upto 90 days SGST(9.0%) (Rs) 431.0
expenses CGST(9.0%) (Rs) 431.0
Day Care Procedures Upto Sum Insured Duties and cess as (Rs) 0.0
Organ Donor Upto Sum Insured applicable:

Domiciliary Treatment Upto Sum Insured Gross Premium: (Rs) 5646.0

Global cover Upto Sum Insured Gross Premium amount(in words) : Rupees Five Thousand Six
Hundred Forty Six and Paise 00 Only
Bariatric Surgery Cover Upto Sum Insured
In-Patient Treatment - Dental Upto Sum Insured
• TPA Details (If any):
Restore benefit Upto Sum Insured
• Name of TPA: Tata AIG Health Claim
AYUSH Benefit Upto Sum Insured
• Website: www.tataaig.com
Ambulance Cover Upto Rs. 3000 per
Hospitalization
• Email: healthclaimsupport@tataaig.com
Health Checkup Upto 1% previous of Sum
Insured; max. Rs.10,000 • Toll Free: 18002667780
1800229966 (For Senior Citizens)
Vaccination cover Upto Rs.5000
• Fax: 022 66938170
Hearing Aid 50% of actuals; maximum
Rs.10,000 • Submit claim: TAGIC Health Claims,
TATA AIG General Insurance Company Limited
Daily Cash for choosing 0.25% of base Sum Insured; 5th and 6th Floor, Imperial Towers, H.No 7-1-6-
Shared Accommodation maximum Rs. 2000 per day 617/A,
GHMC no - 615,616, Ameerpet, Hyderabad -
Daily Cash for 0.25% of base Sum Insured; 500016,
Accompanying an Insured maximum Rs. 2000 per day Telangana,
Child
Compassionate travel Upto Rs.20,000
Consumables Benefit Upto Sum Insured Stamp Duty Registration Details
Second Opinion Covered
ConsoliatedStamp Duty has been paid to the State Exchequer

Policy Servicing Address :Central,Office no. 2-A, 2nd Floor,

TurquoisePanchawati Cross Road, C.G.Road, Ahmedabad 380006, Tel

NO:079-30000025, Fax NO:079-30072143

For Tata AIG General Insurance Co. Ltd.

Authorized Signatory
In the event of non-realization of premium, the Company shall not
be liable under the policy and the policy shall stand cancelled ab
initio (from inception).
 Proposal Form - Tata AIG MediCare

Application no.7987757745 Agent Code:1481350000

This is an application for insurance and issuance of this does not amount to acceptance of proposalby us.
Commencement of risk under this proposal is subject to acceptance of the risk by us and receipt of premium.
The information declared by you in this form is the basis for issuance of the policy. Please answer all questions
carefully. Any incomplete, incorrect or partially correct answers may lead to rejection of the proposal and also might
lead to cancelation of policy.
Please fill-up this form in CAPITAL LETTERS

1.PROPOSER'S DETAILS

AKSHAY CHOUKSEY
(Mr /Mrs /Ms /Dr):Mr
First Name Middle Name Surname

Date of
01/07/1992 Gender Male
Birth(dd/mm/yyyy)
Marital Status Single Mobile 9755615514
Occupation SERVICE Aadhaar No xxxxxxxx0063

Income Upto 3 3 to 6 6 to 10 10 to 15 15 to 20 20 to 25 Above 25

E-Mail_ID akshaychoukseyy5@yahoo.com

9/4, PARDESHIPURA NEAR RAM MANDIR INDORE

Address:

Landmark Area
City/Town INDORE Pin Code 452003
District INDORE State MADHYA PRADESH
In case Aadhaar/Voter's ID is not available: PAN Card :BBQPC8230H
(Mandatory in case of premium >Rs.1 Lac)
(In case proposer is not an individual entity then details of the entity to be filled, PAN is mandatory for such cases)

2.PLAN DETAILS

Proposed Policy Period :27/05/2021 TO 26/05/2022

Policy Tenure 1 Year 2 Year (5% premium discount) 3 Year (10% premium discount)

Sum insured type Individual Floater

Accidental Death Benefit rider* No

3.DETAILS OF THE PERSON(S) TO BE INSURED

Name of the Relationship with Sum

Sl No Gender Date of Birth Aadhaar No. Height Weight
Insured Person Proposer* Insured#
AKSHAY
1 Male Self 01/07/1992 xxxxxxxx0063 167.64 68 300000
CHOUKSEY

*Allowed relations (Spouse, children and dependent parents)

# Options available (3, 4, 5, 7.5, 10, 15, 20 Lakhs); Same Sum Insured for all members in floater option
4.NOMINEE DETAILS
In the event of the death of the Proposer any payment due under the Policy shall become payable to the nominee in accordance with the Policy
terms and conditions.
Nominee Name Date of Birth* Relationship Address of the Nominee
PRAHLAD DAS CHOUKSEY 01/01/1947 Father -
The nominee must be an immediate relative of the Proposer.

UIN No. TATHLIP21224V022021

5.EXISTING/PREVIOUS INSURER DETAILS

Is the proposer or any of the persons proposed, already Insured under a health plan with Tata AIG General Insurance Company Ltd. or any other
insurer or is a proposal pending for Policy issuance? If yes, please indicate the Policy/ Application number(s):
Since when continuously insured:

Do you want Us to consider these details for portability*? Yes No

* In case of portability, please fill up IRDAI portability form. Please note that continuity of benefits shall NOT be considered if the details are not
provided. You need to approach at least 45 days prior to your expiry date to avoid any break in coverage. Please submit all previous year
insurance policy copies.
Period of Insurance Claims lodged
Name of Sum Insured &
during the preceding
Policy No. Insured Insurer Cumulative bonus /
From To years along with the
Person (Rs)
diagnosis
NA NA NA NA NA NA NA

6.MEDICAL AND LIFESTYLE DETAILS

A. Medical History:
Please answer the below mentioned questions individually in Yes(Y)/No (N): You must answer the questions truthfully. Not doing so would lead to
termination of your policy.

Please answer each of the following questions individually for each Insured Persons
Insured Person by ticking the relevant box. 1
Have you or any of the persons proposed for insurance, ever suffered from or taken treatment, or hospitalized for or have been recommended to
take investigations / medication / surgery or undergone a surgery for the following medical conditions?

Chest Pain / Heart Disease No

Arthritis No

COPD No

Kidney Failure/Dialysis No

Liver Cirrhosis/Hepatitis B or C No

Cancer No

HIV/AIDs/STDs No

Stroke/Epilepsy/Paralysis No

Psychiatric/Mental Illness or disorder No

Ulcerative Colitis/Crohn's disease No

Auto-immune diseases No

Any other illness/disease/injury/disability in the past other than for

No
childbirth, flu or for minor injuries that have completely healed?
Are you or any persons proposed on regular medication (including any
No
Ayurvedic treatment) or awaiting any procedure/treatment?
Have you ever been diagnosed with any of these medical conditions with
or without any follow-up tests/medications? ' Elevated Blood Sugar/
No
Diabetes/ Elevated Blood Pressure/ Hypertension/High Cholesterol/
Hypothyroidism
Is any of the insured pregnant currently? If yes, please mention
expected date of delivery (EDD). Any history of pregnancy related No
complications?
Has any application for life, Health or critical illness insurance ever been
declined, postponed, loaded or been made subject to any special No
conditions by any insurance company?
Has any health or life insurance policy ever been terminated in the past? No

C. Lifestyle Information

Does any person proposed to be insured smoke or consume Gutka/Pan Masala or Alcohol? Yes No

UIN No. TATHLIP21224V022021

7.PAYMENT DETAILS
Name of the Premium Payer: (if different from proposer)
Relationship with the proposer: (if different from proposer)
Premium Amount (in Rs.) 5646.0
Instrument type:cash
Please make a Crossed Cheque/DD/Pay Order in favour of 'Tata AIG General Insurance Company Limited' only.
Sources of funds:
AML guidelines:
1. I/we hereby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been/will be paid out of proceeds
of crime related to any of the offence listed in prevention of Money Laundering Act, 2002.
2. I understand that the Company has the right to call for documents to establish sources of funds.
3. The insurance company has right to cancel the insurance contract in case I am/have been found guilty by any competent court of law under
any of the statutes, directly or indirectly governing the prevention of money laundering in India.

Nationality: India Non-Indian

Signature of Proposer & Date :AKSHAY CHOUKSEY & 27/05/2021

8.BANK DETAILS (REQUIRED FOR REFUND/CLAIMS)

As per Regulatory requirements, we can effect payment of refund / claims only through Electronic Clearing System (ECS) / National Electronics
Funds Transfer (NEFT) / Real Time Gross Settlement (RGTS) / Interbank Mobile Payment Service (IMPS)
For this purpose, please submit the following details of the proposer's bank account.
Name of the account holder AKSHAY CHOUKSEY
Name of the bank
Branch Bank
Account no.
Bank IFSC code

Account Type SB Account Current Account Others(please specify)_________________

9.DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED

I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars
given by me are true and complete in all respects to the best of my knowledge and that I am authorized to propose on behalf of these other
persons.

I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting
policy of the insurer and that the policy will come into force only after full payment of the premium chargeable.

I further declare that I will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the
proposal has been submitted but before communication of the risk acceptance by the company.

I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the
person to be insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the person
to be insured/proposer and seeking information from any insurer to whom an application for insurance on the person to be insured /proposer has
been made for the purpose of underwriting the proposal and/or claim settlement.

I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the sole
purpose of underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority.

I have understood the purpose of Aadhar authentication and hereby state that I have no objection in providing my Aadhar details.
Date:27/05/2021 Signature of the Proposer:AKSHAY CHOUKSEY

GoGreen: I would like to protect my environment and would like to help save paper by authorizing Tata AIG General Insurance Company
Limited to send all my policy and service related communication to the email id as mentioned in this application form.

10.DECLARATION/VERNACULAR DECLARATION

The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained to me. I/we have understood
these and confirm to abide by the policy terms & conditions.
Signature of the Proposer:AKSHAY CHOUKSEY
Name & Signature of agent/intermediary:

UIN No. TATHLIP21224V022021

 Vernacular Declaration (Certification in case the proposer has signed in vernacular/thumb print)
The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained by me in vernacular to the
proposer who has understood and confirmed the same.
Signature/Thumb impression of the Proposer:AKSHAY CHOUKSEY
Name & Signature of Agent/intermediary:

11.AGENT DECLARATION
I,INDORE_VIJAY NAGAR_ASSET CENTER (Full Name) in my capacity as an Insurance Advisor/ Specified Person of the Corporate
Agent/Authorized employee of the Broker/Relationship Officer, do hereby declare that I have explained all the contents of this Proposal Form,
including the nature of the questions contained in this Proposal Form to the Proposer including statement(s), information and response(s)
submitted by him/her in this Proposal Form to questions contained herein or any details sought herein will form the basis of the Contract of
Insurance between the Company and the Proposer, if this Proposal is accepted by the Company for issuance of the Policy. I have further
explained that if any untrue statement(s)/ information/response(s) is/are contained in this Proposal Form/including addendum(s), affidavits,
statements, submissions, furnished/to be furnished, the Company shall have the right to vary the benefits which may be payable and further more
if there has been a non-disclosure of any material fact, the policy issued to his/her favor pursuant to this Proposal may be treated by the Company
as null and void and all premiums paid under the Policy may be forfeited to the company.
License No.(Intermediary/Corporate Agent/Broker/Relationship Officer):
Name of the specified Person and code:INDORE_VIJAY NAGAR_ASSET CENTER
Place:INDORE_VIJAY NAGAR_ASSET
Date:27/05/2021 Signature of Agent:_____________________
CENTER

12.SECTION 41 OF INSURANCE ACT 1938 (PROHIBITION OF REBATES)

1. No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance
in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of
premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be
allowed in accordance with the published prospectus or tables of the insurer.
2. Any person making default in complying with the provisions of this section shall be liable for penalty which may extend to ten lakh rupees.
13.FOR OFFICE USE ONLY
Tata AIG Office Code : Intermediary Code and Name:1481350000
Branch Receipt Date: Channel Type:
Business Type:New Customer ID -C/NO/05/0000337676
Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully,
before concluding a sale. Tata AIG General Insurance Company Limited. Registered Office: Peninsula Business Park, Tower A, 15th Floor, G. K.
Marg, Off Senapati Bapat Road, Lower Parel, Mumbai- 400013.
24X7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) Fax: 022 6693 8170 Email:customersupport@tataaig.com Website:
www.tataaig.com.in IRDA of India Registration No: 108 CIN: U85110MH2000PLC128425

14.ACKNOWLEDGEMENT (TO BE GIVEN TO CUSTOMER)

Application Number:7987757745 Date:27/05/2021
Name of the Proposer:AKSHAY CHOUKSEY
We acknowledge with thanks the receipt of your application for Tata AIG MediCare Premier and amount by cash/cheque/Demand Draft/others
cash of amount of Rs. 5646.0. Neither the submission to us of a completed proposal for insurance nor any payment towards this application
obliges us to agree to issue a policy, which decision is and always shall be in our sole and absolute discretion. If we accept a proposal for
insurance, it shall be subject to the policy terms and conditions and we shall have no liability to make any payment if proposal is not accepted by
us or you do not accept the terms of counter offer or premium is not received by us in full and in time, or non-fulfillments of Pre-Policy Checkup
and/or additional information requested by us. We shall have no liability to make any payment under the Policy if proposal is under-process &
claim arises in the interim period before the decision on the proposal is given by us. In case of counter offer you need to revert to Us with consent
and additional premium (if any), within 15 days of the issuance of such counter offer letter. In case, You neither accept the counter offer nor revert
to Us within 15 days, we shall cancel application and refund the premium paid without interest subject to deduction of the Pre Policy Check up
charges, as applicable. If we do not accept the proposal, we will inform you and refund any payment received from you without interest within next
10 days subject to deduction of the Pre-Policy Check up charges, as applicable.

UIN No. TATHLIP21224V022021

 Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluded a sale..
Tata AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, Mumbai - 400013
IRDA Registration No. 108, CIN:U85110MH2000PLC128425, PAN L AABCT3518Q,UIN No. TATHLIP21224V022021
URN No. AH/2017-18/HL-02
Website: www.tataaig.com 24X7 Toll Free No: 1800 266 7780 Email: customersupport@tataaig.com

UIN No. TATHLIP21224V022021

 Customer information sheet

Product
Tata AIG MediCare
Name
1. In-patient Benefits - Covers hospitalization expenses for period more than 24 hrs.
2. Pre-Hospitalization - Medical Expenses incurred in 60 days before the date of admission to the hospital
3. Post-Hospitalization - Medical Expenses incurred in 90 days after the date of discharge from the hospital
4. Day-Care procedures - Medical expenses for listed Day Care Treatment due to disease/illness/Injury during
the policy period taken at a hospital or a Day Care Centre.
5. Organ Donor - Medical Expenses on harvesting the organ from the donor for organ transplantation.
6. Domiciliary Treatment - Medical Expenses incurred for availing medical treatment at home which would
otherwise have required hospitalization. We will also cover pre and post hospitalization expenses in case of
domiciliary hospitalization.
7. Global Cover - Medical Expenses of the Insured Person incurred outside India, upto the sum insured
provided that the diagnosis was made in India and the insured travels abroad for treatment.
8. Bariatric Surgery Cover - Covers reasonable and customary expenses for Bariatric surgery if the insured
fulfills:
a. Surgery to be conducted upon the advice of the Doctor
b. The member has to be 18 years of age or older and
c. BMI greater than or equal to 40 or
d. BMI greater than or equal to 35 in conjunction with any of the following severe comorbidities following
failure of less invasive methods of weight loss:
a) Obesity-related cardiomyopathy,
b) Severe sleep apnea,
c) Uncontrolled Type2 Diabetes, or
What am I
d) Coronary heart disease Section (1)
covered for:
9. In-patient Dental Treatment - Covers expenses incurred towards hospitalization for dental treatment under
anesthesia necessitated due to an accident/injury/illness.
10. Restore benefit - Automatically restore the Basic Sum Insured upon exhaustion of the Sum Insured and
accrued Cumulative Bonus, during the policy period.
11. AYUSH benefit - Medical Expenses incurred for In-patient treatment taken in AYUSH Hospital.
12. Ambulance cover - For utilizing ambulance service for transporting insured person to hospital in case of an
emergency.
13. Health Check-up - Expenses for a Preventive Health Check-up upto 1% of previous year policy sum
insured subject to a maximum of Rs. 10,000/- per policy after block of every two continuous claim free policy
years with us.
14. Second Opinion - We will provide You a second opinion from Network Provider or Medical Practitioner, if
an Insured Person is diagnosed with the mentioned Illnesses during the Policy Period.
15. Vaccination cover - We will cover for expenses related to the cost of the following vaccines:
. Without any waiting period:
a) Anti-rabies vaccine following an animal bite
b) Typhoid vaccination
. After 2 years of continuous coverage with us:
a) Human Papilloma Virus (HPV) vaccine
b) Hepatitis B Vaccine
16. Hearing Aid - We will cover reasonable charges for a hearing aid every third year. The maximum payable is
50% of actual cost or Rs. 10,000/- per policy, whichever is lower.
Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluded a sale..
Tata AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, Mumbai - 400013
IRDA Registration No. 108, CIN:U85110MH2000PLC128425, PAN L AABCT3518Q,UIN No. TATHLIP21224V022021
URN No.AH/2017-18/HL-02
Website: www.tataaig.com 24X7 Toll Free No: 1800 266 7780 Email: customersupport@tataaig.com

UIN No. TATHLIP21224V022021

 17. Daily cash for choosing shared accommodation - We will pay a fixed amount per day as mentioned in
the policy schedule if the Insured Person is Hospitalized in Shared Accommodation in a Network Hospital
for each continuous and completed period of 24 hours.
18. Daily cash for accompanying an insured child - We will pay a fixed amount per day, as mentioned in
the schedule, if the Insured Person Hospitalized is a child Aged 12 years or less, for one accompanying
adult for each complete period of 24 hours.
19. Compassionate travel - In the event the Insured Person is Hospitalized for more than Five consecutive
days in a place where no adult member of his immediate family is present, we will cover expenses related
to a round trip economy class air ticket, or first-class railway ticket, to allow the Immediate Family Member
be at his bedside for the duration of his stay in the hospital. The expenses must be incurred within India and
shall not exceed Rs. 20,000 during a policy year.
20. Consumables Benefit - We will pay for expenses incurred, for specified consumables which are listed in
'Annexure - 1 List 1 as Optional Items' 'Items for which optional cover may be offered by insurers' under
'Guidelines on Standardization in Health Insurance, 2016' and its amendments, which are consumed during
the period of hospitalization directly related to the insured's medical or surgical treatment of
illness/disease/injury. Details of Annexure I-List I-Optional items are available on our website
(www.tataaig.com)
Optional Cover
You can choose optional cover list below by paying an additional premium:
21. Accidental Death Benefit - If an Insured Person suffers an accident during the policy period and this is the
sole and direct cause of his death within 365 days from the date of accident, then we will pay a fixed
amount of 100% of the base SumInsured.

Following is a partial list of the policy exclusions. Please refer to the policy wording for the complete list of
exclusions.
We will neither be liable nor make any payment for any claim in respect of any Insured Person which is caused by,
arising from or in any way attributable to any of the following exclusions, unless expressly stated to the contrary in
this Policy.
What are the
Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof .(Code-
major
Excl12), Alcoholic pancreatitis, Congenital External Diseases, defects or anomalies, Growth hormone therapy; Section (3)
exclusions in
Sleep-apnoea, Venereal disease, sexually transmitted disease or illness; Maternity (Code - Excl 18) :Medical
the policy:
treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred
during hospitalization) except ectopic pregnancy; Expenses towards miscarriage (unless due to an accident) and
lawful medical termination of pregnancy during the policy period, Any existing disease specifically mentioned as
Permanent exclusion in the Policy Schedule , War or any act of war, nuclear, chemical and biological weapons,
ionizing radiation, Breach of law (Code - Excl10), Intentional self-injury or attempted suicide while sane or insane.
• Initial waiting period of 30 days for all illnesses (not applicable for accidents or on renewals)
Waiting • 24 months waiting period for specified diseases/ procedures Section (3)
Period
• Pre-existing disease covered after 36 months

Payment • Reimbursement of covered expenses up to specified limit.

basis • Payout of lump sum benefit amount or payment of covered expenses up to specified limit

• 10% copayment shall be applicable in case you are admitted in a hospital room where the room category
Loss Sharing opted is higher than the eligible category as specified in the policy schedule Section (4)

• The policy shall ordinarily be renewable except on grounds of fraud, misrepresentation by the insured
person.
• Request for renewal along with requisite premium shall be received by the Company before the end of the
policy period.
Renewal • Grace period of 30 days for renewing the policy is provided.
Section (4)
Conditions
• There is no maximum cover ceasing age under this Policy.
• In case of family floater option where the dependent child(ren) attains age of 26 years at the time of renewal,
proposal for a separate policy for this member needs to be submitted. Suitable credit of continuity/waiting
periods for all the previous policy years would be extended in the new policy, provided the policy has been
maintained without a break.

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluded a sale..
Tata AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, Mumbai - 400013
IRDA Registration No. 108, CIN:U85110MH2000PLC128425, PAN L AABCT3518Q,UIN No. TATHLIP21224V022021
URN No.AH/2017-18/HL-02
Website: www.tataaig.com 24X7 Toll Free No: 1800 266 7780 Email: customersupport@tataaig.com

UIN No. TATHLIP21224V022021

 • 50% increase in cumulative bonus for every claim free year
Section
• In the case a claim is made during the policy year, the cumulative bonus would reduce by 50% in the (B13) and
Renewal following year
Benefits Section
• Free health check up, upto 1% of previous sum insured (maximum upto Rs.10,000 per policy), once after (B21)
block of every two continuous claim free policy years with us.

• The Free Look Period shall be applicable on new individual health insurance policies and not on renewals or
at the time of porting/migrating the policy.
• The insured person shall be allowed free look period of fifteen days from date of receipt of the policy
document to review the terms and conditions of the policy, and to return the same if not acceptable.
• If the insured has not made any claim during the Free Look Period, the insured shall be entitled to
Free Look
Period • a refund of the premium paid less any expenses incurred by the Company on medical examination of the Section (4)
insured person and the stamp duty charges or
• where the risk has already commenced and the option of return of the policy is exercised by the insured
person, a deduction towards the proportionate risk premium for period of cover or
• Where only a part of the insurance coverage has commenced, such proportionate premium commensurate
with the insurance coverage during such period

• The Company may cancel the policy at any time on grounds of misrepresentation non-disclosure of material
facts, fraud by the insured person by giving 15 days' written notice. There would be no refund of premium on
Cancellation cancellation on grounds of misrepresentation, non-disclosure of material facts or fraud. Section (4)
• No refunds of premium shall be made in respect of Cancellation where, any claim has been admitted or has
been lodged or any benefit has been availed by the insured person under the policy

Claim procedure:
• For Cashless Service:
• Please call our designated TPA (Third Party Administrator)/Us on toll free no. 1800 266 7780 or 1800
229 966 (For Senior Citizens) in the event of hospitalization giving rise to a claim or e-mail at
healthclaimsupport@tataaig.com
• For list of network hospitals, please refer to our website www.tataaig.com
How to Claim • For Reimbursement of Claim: Section(5)
• Please intimate our TPA/Us within 7 days of completion of treatment, consultation or procedure.
• Please submit claim documents to our TPA/Us within 15 days of occurrence of incident.
• Kindly sent the claim documents to:
TAGIC Health Claims,TATA AIG General Insurance Company Limited,5th and 6th Floor,
Imperial Towers, H.No 7-1-6-617/A,GHMC No - 615,616, Ameerpet, Hyderabad - 500016,
Telangana,

• Redressal of Grievance
• In case of any grievance the insured person may contact the company through
• Website: www.tataaig.com
• Toll Free: 1800 266 7780 or 1800 22 9966 (only for Senior Citizen policyholders)
• Email: customersupport@tataaig.com
Policy/ • Fax: 022 66938170
Servicing/ Section
• Courier: Customer Support, Tata AIG General Insurance Company Limited A-501 Building No.
Grievances/ 4 IT Infinity Park, Dindoshi, Malad (E), Mumbai - 400097 (4&6)
Complaints
• Insured person may also approach the grievance cell at any of the company's branches with the
details of grievance.
• If Insured person is not satisfied with the redressal of grievance through one of the above methods,
insured person may contact the grievance officer at manager.customersupport@tataaig.com.
• For updated details of grievance officer, kindly refer the link (https://www.tataaig.com/grievance-
redressal-policy)

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluded a sale..
Tata AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, Mumbai - 400013
IRDA Registration No. 108, CIN:U85110MH2000PLC128425, PAN L AABCT3518Q,UIN No. TATHLIP21224V022021
URN No.AH/2017-18/HL-02
Website: www.tataaig.com 24X7 Toll Free No: 1800 266 7780 Email: customersupport@tataaig.com

UIN No. TATHLIP21224V022021

 • . lf Insured person is not satisfied with the redressal of grievance through above methods, the insured person
may also approach the office of Insurance Ombudsman of the respective area/region for redressal of
grievance as per Insurance Ombudsman Rules 2017. Please refer our website www.tataaig.com or for
updated list and details of Insurance Ombudsman Offices, please visit website
http://ecoi.co.in/ombudsman.html
• Grievance may also be lodged at IRDAI Integrated Grievance Management System (https://igms.irda.gov.in/)

Free-look period (as mentioned above)

Lifelong renewability (except on certain specific grounds)
Right to migrate from one product to another product of the company.Please call our 24X7 Toll free number
1800-266-7780 or 1800 22 9966 (for Senior Citizens) or you may email to the customer service desk at
customersupport@tataaig.com to get the details.
Right to port the from one company to another companyPlease call our 24X7 Toll free number 1800-266-7780
or 1800 22 9966 (for Senior Citizens) or you may email to the customer service desk at
customersupport@tataaig.com to get the details.
Change in SI during the policy term or at the time of renewalPlease call our 24X7 Toll free number 1800-266-
7780 or 1800 22 9966 (for Senior Citizens) or you may email to the customer service desk at
customersupport@tataaig.com to get the details.
• Notice with full particulars shall be sent to the Company/TPA (if applicable) as under:
i. Within 24 hours from the date of emergency hospitalization required
Insured's
ii. At least 48 hours prior to admission in Hospital in case of a planned hospitalization. Section (4)
Rights
Claim Settlement (provision for Penal Interest)
i. The Company shall settle or reject a claim, as the case may be, within 30 days from the date of receipt
of last necessary document.
ii. In the case of delay in the payment of a claim, the Company shall be liable to pay interest to the
policyholder from the date of receipt of last necessary document to the date of payment of claim at a
rate 2% above the bank rate.
iii. However, where the circumstances of a claim warrant an investigation in the opinion of the Company, it
shall initiate and complete such investigation at the earliest, in any case not later than 30 days from the
date of receipt of last necessary document. In such cases, the Company shall settle or reject the claim
within 45 days from the date of receipt of last necessary document.
iv. In case of delay beyond stipulated 45 days, the Company shall be liable to pay interest to the
policyholder at a rate 2% above the bank rate from the date of receipt of last necessary document to
the date of payment of claim.

Monthly If the insured person has opted for Payment of Premium on an installment basis i.e. Monthly, as mentioned in the Endorsement
Installment policy Schedule/Certificate of Insurance, the following Conditions shall apply (notwithstanding any terms contrary for:
Premium elsewhere in the policy) Instalment
Option I. Grace Period of _15 days would be given to pay the installment premium due for the policy. premium
II. During such grace period, coverage will not be available from the due date of installment premium till the
date of receipt of premium by Company.
III. The insured person will get the accrued continuity benefit in respect of the "Waiting Periods", "Specific
Waiting Periods" in the event of payment of premium within the stipulated grace Period.
IV. No interest will be charged lf the installment premium is not paid on due date
V. In case of installment premium due not received within the grace period, the policy will get cancelled.
VI. In the event of a claim, all subsequent premium instalments shall immediately become due and payable.
VII. The company has the right to recover and deduct all the pending installments from the claim amount due
under the policy.

Insured's • Please disclose all pre-existing disease/s or condition/s before buying a policy. Non-disclosure may result in
Obligations claim not being paid and termination of Your policy.

Legal Disclaimer Note: The information must be read in conjunction with the policy document. In case of any conflict between the CIS and the
policy document, the terms and conditions mentioned in the policy document shall prevail.

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluded a sale..
Tata AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, Mumbai - 400013
IRDA Registration No. 108, CIN:U85110MH2000PLC128425, PAN L AABCT3518Q,UIN No. TATHLIP21224V022021
URN No.AH/2017-18/HL-02
Website: www.tataaig.com 24X7 Toll Free No: 1800 266 7780 Email: customersupport@tataaig.com

UIN No. TATHLIP21224V022021

 Name: Mr AKSHAY CHOUKSEY
Age: 28
Gender: Male
Policy No.: 0288647483
From: 27/05/2021 To 26/05/2022
Member IID: 798775774501028

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluded a sale..
Tata AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, Mumbai - 400013
IRDA Registration No. 108, CIN:U85110MH2000PLC128425, PAN L AABCT3518Q,UIN No. TATHLIP21224V022021
URN No. AH/2017-18/HL-02
Website: www.tataaig.com 24X7 Toll Free No: 1800 266 7780 Email: customersupport@tataaig.com

UIN No. TATHLIP21224V022021

Annexure to customer information sheet(CIS)- Benefit illustration in respect of
policies offered on individual and family floater basis

Age of Coverage opted on Coverage opted on individual basis Coverage opted on family floater basis
the individual basis covering multiple members of the family with overall Sum Insured(only one sum
members covering each under a single policy(Sum insured insured available for entire family)
insured member of the available for each member of the family)
family separately(at
a single point of
time)
Premium Sum Premium Discount Premium Sum Premium Floater Premium Sum
(Rs) Insured( (Rs) if any(%) after Insured( or discount after Insured(
Rs) Discount Rs) consolid if any(%) Discount Rs)
(Rs.) ated (Rs.)
premium
for all
members
of the
family
(Rs)
28 4785.00 300000
Total Premium for Total Premium for all members of the Total Premium when policy is opted on
all members of the family is Rs_______________ when they floater basis is Rs_______________
family is Rs 4785.00 are covered under a single policy
when each member
is covered
separately
Sum Insured Sum Insured available for each family Sum Insured of Rs_______________ is
available for each member is: As mentioned in above table available for the entire family
individual is Rs (Rs.)
300000
Note: Premium rates specified in the above illustration shall be standard premium rates without considering any
loading. Also, the premium rates shall be exclusive of taxes applicable.

UIN No. TATHLIP21224V022021