Shri K.V.O.

Seva Samaj Sanjeevani Swasthya Yojna 2020

Address: 99/101,CVOD Jain Mahajan Wadi, 3rd Floor, Keshvaji Naik Road, Chinchbunder, Mumbai - 400009.
Help Line No.- 022-23715050/022-23715151
STANDARD INDIVIDUAL MEDICLAIM WITH National Insurance Company Limited(A Govt. of India undertaking)
RECEIPT CUM PROPOSAL FORM

Membership No. : 5437 Receipt Dt : 23-07-2020

Proposer Name : RIDDHI MANOJ GALA
Address : 6, SAI PALACE, IIND FLOOR, OPP JANKI,STORE, SHIVAJI NAGAR RABODI NO-2
THANE (WEST),
Area : 400601 - Thane (West) Phone No. : 9987060522
Old Policy No. : 240201501910008136 Village : Chhasara

Name Date Of Birth SEX Relation Sum Isured Year Prem Amount
RIDDHI MANOJ GALA 21-05-1997 F SELF F 200000 1999 2576.00
KOMAL MANOJ GALA 13-03-1973 F MOTHER F 200000 1999 6100.00

T O T A L ------------> 2 MEMBER(S) 8676.00

Payment Mode : NEFT UTR No : KVOSSS/UTR/001950

Eight Thousand Six Hundred Seventy Six Only

This is Computrized Generated Transaction Receipt.Signature Not Required