Navi Health Insurance Policy

Policy Schedule

Policyholder Name Srinivas K

Policyholder Id PH00007417

Policy Issued On 11/09/2021

UIN No NAVHLIP22133V012122

Policy No RA0005DT

Policy Valid Upto 10/09/2022

Insurance Agent/Intermediary Details

Name Direct Digital

Code P040203000

Contact No. 1800-123-0004

 Insured Person Details

Member ID: RA0005DT-01

Insured Person Name SRINIVAS K

Relation with Policyholder Self

Date of Birth (DD/MM/YYYY) 01/04/1987

Age(Years) 34

Gender MALE

First Enrolment Date 11/09/2021

 Premium Details

Premium ₹ 11,842

Loading ₹0

Discounts ₹ 1,776.3

Total Premium ₹ 10,065.7

GST @ 18% ₹ 1,811.85

Total Amount (inlc GST) ₹ 11,877.55

 Premium Certificate

This is to certify that Srinivas K has paid a total

amount of ₹ 989.83 towards premium for this
policy effective from 12:26 Hrs on 11/09/2021.

Monthly Instalment amount 989.83

Monthly instalment due date 11th of every month

First instalment paid date 11/09/2021

Last instalment due date 11/08/2022

For the purpose of deduction under section 80 D of

Income Tax Act, 1961 and any amendments
thereafter
 Scope of Cover

Type Individual

Plan Plan 2

Base Sum Insured ₹ 10000000

Sum Insured (Base + Cumulative Bonus)

₹ 10000000

Emergency Road Transportation Covered up to SI

Pre-existing Disease Waiting Period 1 Year

Online Doctor Consultations Unlimited

Organ Donor Expenses Covered up to SI

Domiciliary Hospitalisation Covered up to SI

Automatic Restoration of Sum Insured

Unlimited Number of Times

Daily cash for shared room occupancy

₹ 1000 per day

Additional Sum Insured for Accidental injury

Covered up to SI

Post-Hospitalisation 90 Days

Cumulative (No Claim) Bonus

25% of SI per year up to 100%

Wellness Benefits Covered

Pre-Hospitalisation 60 Days

In-patient Hospitalisation Covered up to SI

Specified disease/procedure waiting period 1 Year

30 days waiting period Applicable

 Policy Service Office

Name Navi General Insurance Limited

Date of Signature of Proposal 11/09/2021

Receipt Number

Place of Supply Bangalore

State Code

HSN No 997133

Stamp Duty

The Stamp Duty of Rs. 0.50 paid vide defaced no.

0003525202201819 dated 27/09/2018
Address

Navi General Insurance Limited

Registered & Corporate Office: NAVI GENERAL
INSURANCE LIMITED, 4th Floor, Salarpuria
Business Center, 93, 5th A Block, Koramangala,
Industrial Layout, Bangalore- 560095

Policy Servicing Office : NAVI GENERAL

INSURANCE LIMITED, 4th Floor, Salarpuria
Business Center, 93, 5th A Block, Koramangala,
Industrial Layout, Bangalore - 560095
 Claim Service Office

TPA Name

MEDI ASSIST INSURANCE TPA PRIVATE LIMITED

Toll Free Number 809-584-0012

Email claim.help@navi.com

TPA Address

Tower D, 4th Floor, IBC Knowledge Park, 4/1,

Bannerghatta Road, Bangalore- 560 029
Important Note
This Schedule, Policy terms and conditions and Endorsement
shall be read together and word or expression to which a
specific meaning has been attached in any part of Navi
Health Insurance policy or of the Schedule shall bear the
same meaning wherever it may appear. Any amendments/
modifications/ alterations made on this system generated
policy document is not valid and Company shall not be liable
for any liability whatsoever arising from such changes. Any
changes required to be made in the policy once issued, would
be valid and effective, only after written request is made to
the Company and Company accepts the requested
amendments/modifications/alterations and records the same
through separate endorsement to be issued by the Company.
Our policy wordings, grievance redressal procedure and
details about ombudsman is also available on our website.
Please note that any misrepresentation, non-disclosure or
withholding of material facts will lead to cancellation of policy
ab initio with forfeiture of premium and non-consideration of
claim, if any. Document is digitally signed

Signer: Sugandha Sharma

Date: Sat, Sep 11, 2021 12:28:32 IST
Location: MUMBAI
 Transcript of Navi Health Proposal Form

This Insurance policy has been issued on the basis

of the information provided by you. In case of
discrepancy in the below information, you may
please write to us on insurance.help@navi.com
within 15 days of the receipt of the Policy,
otherwise below information will be deemed as
correct.
 Proposer Details

Name Srinivas K

Date of Birth 01/04/1987

 Plan Details

Tenure 1 Year

Period 11/09/2021 to 10/09/2022

Type Individual

Sum Insured ₹ 10000000

Plan Plan 2
 Insured Details - Member

Name SRINIVAS K

Gender MALE

Date of Birth (DD/MM/YYYY) 01/04/1987

Relation with Proposer Self

 Nominee Details

Name KRISHNA

Relation with Proposer Father

Date of Birth (DD/MM/YYYY) 01/10/1965

 Medical & Health Information

1. Are your currently suffering from any

symptoms or ever consulted a doctor or got
hospitalized for any illness/injury or health
condition?

No

✓ I/We hereby declare that I have read and understood the

mentioned Terms & Conditions. I/We confirm compliance to
AML guidelines
I hereby consent that the Policy Documents shall be sent to
me by e-mail only on my registered e-mail Id. I understand
that this authorisation can berevoked by me at the time of
renewal by contacting your branch office personally or
customer care by writing a mail/ calling your toll-free number.
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
authorised 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.”
Any GST liability and payment for the same is dependent on
the details (viz GSTIN, address, zero-rating entitlement etc)
provided by me. Navi General Insurance Limited will rely on
such information for the purpose of compliance with
applicable GST regulations and shall not be under obligation
to evaluate authenticity/accuracy of the same. Further, in case
any GST liability (in terms of tax, interest, penalty and
associated litigation cost) arises on Navi General Insurance
Limited on account of any incorrect/ incomplete/ non-
compliance on behalf of me. I will be immediately liable to pay
the same on notification by Navi General Insurance Limited.
The said liability shall vest irrespective of the completion of
the insurance period covered within the policy contract.
I hereby consent to and authorize Navi General Insurance
Limited to make welcome calls, service calls or any other
communication (electronic or otherwise) with respect to the
proposed or existing policy of the Company from time to time.
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 MoneyLaundering Act,2002. I
understand that the Company has the right to call for
documents to establish sources of funds. 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.

UIN No.: NAVHLIP22133V012122

IRDAI Registration Number: 155

GSTIN: 29AAFCD7985H1Z0
CIN: U66000KA2016PLC148551
Registered & Corporate Office: NAVI GENERAL INSURANCE
LIMITED, 4th Floor, Salarpuria Business Center, 93, 5th A
Block, Koramangala, Industrial Layout, Bangalore- 560095
Policy Servicing Office : NAVI GENERAL INSURANCE
LIMITED, 4th Floor, Salarpuria Business Centre, 93, 5th A
Block, Koramangala Industrial Layout, Bangalore - 560095
Toll-Free No: 1800-123-0004
Web: www.naviinsurance.com
Email: insurance.help@navi.com
Navi Health(by Navi General Insurance) is the Trademark
used by Navi General Insurance Ltd. for its digital platform.