VOLUNTARY TOP UP PLAN FOR HOSPITALISATION INSURANCE

Policy Period: 1st April 2021 to 31st March 2022

NOTE: The below insurance is OPTIONAL for employees and is an addition to the coverage already
provided by CSS CORP to employees and their dependents (spouse and 2 children). This is provided as an
additional enhancement for employees who want to avail the benefit on their own discretion.

Employee Particulars
Employee Id
Employee Name
Contact number

• Premium Table for the Top UP insurance (select any one only)

Including Tax GST 18% Select your Top up

Top-Up Sum Insured Sum Insured
Premium
1,00,000 5,428 ☐
2,00,000 6,490 ☐
3,00,000 7,764 ☐
4,00,000 9,294 ☐
5,00,000 11,129 ☐

Conditions: -
✓ Dependent details as available in HRMS within 7 days from your joining data will be considered for
insurance coverage.
✓ Once enrolled, the premium will be deducted in current month Salary.
✓ The coverage is a mirror image of the base med claim policy, except for capped ailments such as
maternity and cataract.
✓ The Mid-term enrolments would NOT be allowed.
✓ The premium paid will be qualified for Income Tax Deduction Under Section 80D

Declaration:
➢ I hereby declare that the particulars given above are true to the best of my Knowledge.
➢ I agree that the premium applicable to the Top up sum insured can be deducted from my salary.

Employee Signature

Date: