HDFC ERGO General Insurance Company Limited

2952202105182501000

Mr Prasenjit Ray
102 N D Kayem Lane Near Kundu Pukur
Burdwan . Bardhaman, 713101
West Bengal
Contact No : 7602352485

Date : 15/02/2020

Dear Mr Prasenjit Ray

Thank you for choosing HDFC ERGO as your preferred insurance partner. We welcome you to be a part of our family !
Your Health insurance policy reference no 2952202105182501000 is confirmed on the basis of the information and declaration given by you.
The details of coverage are mentioned in the enclosed policy schedule of insurance.
We value your relationship with us and assure you our best services at all times and we look forward to serve you.

Now you can view your policy details and health card at your fingertips. Download our Mobile App now and experience convenience today!!
For HDFC ERGO General Insurance Company Ltd.

Ankur Bahorey
Head - Retail Business Group

HDFC ERGO General Insurance Company Limited 2952202105182501000

TAX CERTIFICATE

Dear MR PRASENJIT RAY

Subject : Certificate for the purpose of deduction under section 80 D of Income Tax (Amendment) Act, 1986

This i s to certify that we have received an amount of ` 16958 towards premium for Health Suraksha Policy , Policy No. 2952202105182501000 issued to for the
period 16/02/2020 to 15/02/2022.

Note : This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended from time to time.

For HDFC ERGO General Insurance Company Ltd.

Date : 15/02/2020

Policy Issuing Office: Mumbai

Duly Constituted Attorney

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
POLICY SCHEDULE Health Suraksha Policy
SILVER PLAN

2952202105182501000

Policy No. :2952 2021 0518 2501 000 Issuance Date :15/02/2020
Period of Insurance :From 16/02/2020 00:01 hrs To 15/02/2022 Midnight
Invoice No. :202105182501000 Premium Frequency :Single
0

HSN Code :997133 Policy Type :Family Floater

Mr Prasenjit Ray Proposer Name :Mr Prasenjit Ray PAN
102 N D Kayem LaneNear Kundu Pukur Burdwan
Customer Id :101136166607
.Bardhaman
West Bengal, 713101, Contact No : 7602352485
EIA No.
Payment Details : ERGO_CC_15022020 , Date: 15/02/2020, Bank Name:HDFC Bank Ltd
Email ID : prasenjitpsy@yahoo.com
Insured Person’s Details & Sum Insured
Insured's Name Relationship Date of Birth Member ID 1st Policy Portability Pre Existing
Inception Sum Insured (`) Disease

Prasenjit Ray Self 30/11/1977 16/02/2018 NO

Amrita Chakraborti Wife 26/06/1978 16/02/2018 NO
Oishi Ray Daughter 08/02/2017 16/02/2018 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 Amrita Chakraborti Relationship Spouse
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 Enhanced Cumulative Bonus 10% of Sum Insured; Maximum
years) 5000/- 100%
Regain Benefit 100% of basic Sum Insured
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 14,371.00
Loadings 0.00
GST 18% : Central Tax 9% ( `1293.5 ) + State Tax 9% ( `1293.5) 2,587.00
Total Premium 16,958.00
For Claim/Policy related queries call us at +91- 22 6234 6234/+91- 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim.
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 CSD/293/2020/385/2020 dated 24/01/2020
as prescribed in Government of Maharashtra Order No. Mudrank-2017/CR.97/M-1, dated the 09th January 2018". GST Registration No: 19AABCL5045N1Z5. GST for this invoice is not payable under reverse
charge basis.
Branch :4th floor, block- c, 22 camac street kolkatta Write to us : feedbackgeneral.insurance@in.hdfcbank.com
For HDFC ERGO General Insurance Company Ltd.
Agent Name :HDFC BANK LTD Agent Code :201587086428 Tel No. : 91-22-61606161

Duly Constituted Attorney

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited

HDFC ERGO General Insurance Company Limited 3

Policy No.:2952202105182501000 This card is for identification purpose only.
Valid From: 16/02/2020 Renewal Date: 15 February
Card has to be presented to the Network Service Provider at the time of admission/ availing
Insured Name Date Of Birth Gender cashless hospitalization o r any other services. Insurance claim will be processed in accordance
OISHI RAY 08/02/2017 Female with the policy term & conditions. Card does not guarantee cashless hospitalization or any other
AMRITA CHAKRABORTI 26/06/1978 Female service. For more details and updated list of Network Service Provider please refer our website or
PRASENJIT RAY 30/11/1977 Male call our call centre. This card is valid till the time policy is active.

Customer Service No : 022 - 6234 6234 / 0120 - 6234 6234

Fax Number : 022 - 6234 6234/0120 - 6234 6234
Email : healthclaims@hdfcergo.com
Processing Centre : HDFC ERGO General Insurance Company Ltd. 5th floor,
Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
Website : www.hdfcergo.com

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com