HAPPY FAMILY FLOATER-2015 POLICY SCHEDULE

UIN: IRDAI/HLT/OIC/P-H/V.II/450/15-16

Policy No. : 172300/48/2017/3888 Prev. Policy No. : 172300/48/2016/4289

Cover Note No. : - Cover Note Date : -
Insured's Code : 56317636 Issue Office Code : 172300
Insured Name : JIGAR H. SHAH Issue Office Name : DO CHANNI

Address : 482, VAIKUNTH - 1, NR. BAPOD Address : 1st Floor,Divya Jyoti Complex,
JAKAT NAKA, WAGHODIA ROAD, Ramakaka Road, Chhani
BARODA - 390019 -
- -
VADODARA GUJARAT 390003
-

Tel./Fax/Email : 9879938919 / / 9879938919 / Tel./Fax/Email : 0265-2771023 / 0265-2775553 /

jigar.shah2013@gmail.com 172300@orientalinsurance.co.in
Agent/Broker Details
Dev.Off.Code : NA0000007581 MR. K.R. PATEL
Agent/Broker : BA0000096424 MR. RITESH H.SHAH
Address : 13, BANSARI DUPLEX, NEAR BHAILALBHAI PARK,BEHIND RELIANCE FRESS, AJWA
VAGHODIYA RING ROAD,VADODARA,BARODA,GUJARAT,390019
Tel/Fax/Email : 2652520463/9825083520//setu4ritu2010@yahoo.com

Period of Insurance : FROM 00:00 ON 23/07/2016 TO MIDNIGHT OF 22/07/2017

Collection No. & Dt. : CSH 9930007257 - 20/07/2016
Gross Premium : 9,737 Service Tax : 1461 Stamp Duty : .5 Total : 11,198

Co-insurance Details : Nil

TPA Details :
TPA ID YA0000000334
TPA Name M/S MD INDIA HEALTHCARE SERVICES TPA PVT. LTD.
Address : MD INDIA HOUSE, SURVEY NO.147/8 Sr. Bo. 46/1, Espace, A2 Blg, 4th floor, Pune
Nagar Road, Vadgaonsheri, Pune 411014 customercare@mdindia.com,
info@mdindia.com
Telephone No :
PUNE 411038 Toll Free No. : 18002331166, 18002334446
FAX No. :

Number of persons covered 4 Plan Type SILVER Plan Sum Insured 200000
Particulars of the Persons covered :

Sr. Name of The Relationship Pre-Existing

Gender Date of Age Co-Pay PA Capital
No. Persons With Diseases
Birth (%) Sum Insured (INR)
Proposer

1 JIGAR H. SHAH M 20/12/1982 33 Self / 10

2 ANJALI SHAH F 09/06/1983 33 Spouse / 10
Place : VADODARA For and on behalf of
Date : 20/07/2016 The Oriental Insurance Company Limited

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupee Page 1 of 4
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
Attached to and forming part of policy number 172300/48/2017/3888

Unemployed
3 VRUSHANK M 01/12/2009 6 Dependant / 10
Child
4 BHAVNABEN F 09/10/1959 56 Dependant 10
Parents
Nominee Details
Name Of the Nominee Relationship With the Insured Age Of the Nomine M/F/TG*

Optional Cover
Value
LIFE HARDSHIP BENEFIT NO
RESTORATION OF SI NO

Total Premium in words : Indian Rupees Eleven Thousand One Hundred Ninety-Eight Only

The insurance under this policy is extended to cover risks of Domiciliary Hospitalisation up to 10 % of sum insured subject to maximum Rs
50000 only ( Fifty Thousand Only).
The insurance under this policy is extended to cover risks of :
Domiciliary Hospitalisation Limit, Personal Accident Cover, Daily cash allowance.
Deductible : Nil
The insurance under this policy is subject to conditions, clauses, warranties,endorsements as per forms attached.
The policy shall pay for hospitalisation expenses for medical/surgical treatment taken as an in-patient at any Nursing
Home/Hospital in INDIA as defined in the policy.

Warranted that in case the person covered under the policy has lodged any claim under the previous policy and the sum
insured is enhanced under the current policy, for a further claim for the same disease during the current policy, the earlier
limit of Sum Insured shall be applicable and not the enhanced sum insured.

Warranted that in case of dishonour of premium cheque(s) the Company shall not be liable under the policy and the policy
shall be void abinitio (from inception).

"We at Oriental continuously strive to ensure that you get the best possible treatment from our network hospitals.
Please contact your TPA or any of the Oriental offices for our preferred hospitals in your area before going for a
treatment. This will help us serve you in the best possible manner"

In witness whereof the undersigned being authorised by and on behalf of the Company has/have herein to set his/their hands
at DO CHANNI on 20-JUL-16.

Place : VADODARA For and on behalf of

Date : 20/07/2016 The Oriental Insurance Company Limited

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupee Page 2 of 4
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 Attached to and forming part of policy number 172300/48/2017/3888

1.Claim to be reported within 48 hrs of admission but before discharge.

2.Claim documents to be submitted within 15 days of discharge.

For complete details please refer to policy condition.

Policy History Data

Policy No. Period From Period To Insured Name Sum Insured

171302/48/2014/4197 23-JUL-13 22-JUL-14 The Oriental Insurance Company Ltd. 300000

172300/48/2015/4432 23-JUL-14 22-JUL-15 The Oriental Insurance Company Ltd. 300000

172300/48/2016/4289 23-JUL-15 22-JUL-16 The Oriental Insurance Company Ltd. 300000

Claim History Data

Policy no. Claimant Nam Claim No. Claim OS Claim Paid

171302/48/2014/4197 JIGAR H. SHAH 172300/48/2015/000012 .00 74,63.00

172300/48/2016/4289 JIGAR H. SHAH 172300/48/2016/002473 .00 3,34,24.00

172300/48/2016/4289 JIGAR H. SHAH 172300/48/2016/002574 .00 3,32,08.00

Place : VADODARA For and on behalf of

Date : 20/07/2016 The Oriental Insurance Company Limited

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupee Page 3 of 4
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
Attached to and forming part of policy number 172300/48/2017/3888

For and on behalf of

The Oriental Insurance Company Limited
Entered By : Rajan Desai
Examined By : H V VASAVA

Authorised Signatory

Place : VADODARA For and on behalf of

Date : 20/07/2016 The Oriental Insurance Company Limited

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupee Page 4 of 4
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in