Certificate of Insurance

Policyholder Details
Policy Number/Certificate: 131592128451001022 Proposal No: Y073121009371
Name: SATYENDER KUMAR CHOUHAN Policy Period: From 00:00 hours on : 13 Aug 2021
To mid-night on : 12 Aug 2022
Correspondence Address & D2A/54B, JANAKPURI NEW DELHI , City : Policy Servicing C-1, 3rd Floor, New Krishna Park,
Place of Supply: New Delhi, State : DELHI, PinCode : Branch: Adjustant to Janakpuri Metro Station
110058, West NEW DELHI DELHI 110018,
INDIA
Email Id: satsat7@rediffmail.com Tax Invoice No. & Y073121009371 & 31-Jul-2021
Date:
Contact No: 9205675258 GSTIN/UIN of NA
Policyholder:
Date of Birth: 28 May 1956 Customer ID: 004871485

Plan Details
Master Policy No. 920292028450000441 Previous Policy No. 131592028451001073
A/C No. PAN Card No. ABRPC7891D
Occupation 0 Application Sign Date 13 Aug 2021

Cover Details
Cover Type No. of Lives covered Tenure (Sum Insured) In Premium Payment
Lakhs Mode
Floater 2 1 500000 Single
Certificate Start Date/Joining Date 13 Aug 2021 Certificate End Date 12 Aug 2022

Insured Details
Details of Insured
Relationship Name DOB Gender PreExistingDis PreExistingDisease- PreExistingD Date of
ease (Y/N) Name isease-Since Enrollment
Self SATYENDER 28 May 1956 Male No 13 Aug 2016
KUMAR CHOUHAN
Spouse MADHU CHOUHAN 07 Feb 1962 Female No 13 Aug 2016

Nominee details
Name VARUN CHOUHAN DOB 08 Aug 1987
Relationship with Proposer Son

Premium Details $PRXQWൠ

Net Premium : 15150.00
CGST : (9.00%) 1363.50
SGST : (9.00%) 1363.50
TOTAL PREMIUM PAYABLE : 17877.00
GSTIN : 07AABCR6747B1ZI HSN : 997142
Description of Services :Accident and Health Insurance Service

16B31217 BANK OF INDIA 02266684907

Intermediary Code Intermediary Name Intermediary Contact No.

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway , Santacruz (East), Mumbai - 400 055.
Corporate Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway , Santacruz (East), Mumbai - 400 055.
Corporate Identity No.U66603MH2000PLC128300. UIN No.: RELHLGP21515V022021. Page 1 of 5
RGI/MCOM/CO/HL-01/POLICY-SCHEDULE/Ver. 1.0/260319
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License
Coverage Under RGI-BOI Swasthya Product
Coverages
Hospitalization Coverage for medical expenses against illness/injury that requires inpatient and Day Care
Treatment subject to family sum insured.
Domiciliary Hospitalization Domiciliary Hospitalization up to 10% of sum insured.
Day Care Treatment This benefit covers payment of medical expenses incurred for medically necessary treatment
pertaining to Day Care treatment of the Insured/Insured person.
Pre Hospitalization Pre Hospitalization covered up to 30 days respectively.
Post Hospitalization Post Hospitalization covered up to 60 days respectively.
Donor Expenses Donor Expenses covered up to 50% of sum insured. (Excluding Cost of Organ)
Reinstatement Benefit Reinstatement Benefit of 25% of basic Sum insured shall be provided on complete
exhaustion of the existing policy basic Sum Insured during the policy year. The Total amount
(Basic sum insured + Reinstated sum insured) will be available to all Insured Persons for all
claims under In-patient Benefit during the current Policy Year.
Road Ambulance Road Ambulance covered up to Rs. 1000 per hospitalization.
Ayurvedic Hospitalization Expenses incurred for Ayurvedic hospitalization treatment, are admissible upto 10% of the
base sum insured; provided the treatment for illness/disease(s) or accidental injuries, is taken
in the Government Ayurvedic Hospitals / NABH accredited Ayurvedic Hospitals which qualify
the definition of Hospitals, but clearly excluding centers of Spa, Massage and Healt
Rejuvenation Procedures. Treatment like Panchakarma and all the variants of Panchakarma
shall be excluded from the scope of this coverage.
New Born Baby cover New Born baby covered from 91 days within the family sum insured limit subject to availability
of family slot.
Ailment Capping Cataract per eye covered up to 20% of sum insured or Rs. 40,000 whichever is lower.(Pre-
authorization is mandatory for Cataract)
Day Care Procedures Standard Day-Care procedures requiring less than 24hrs of hospitalization - 171 procedures
covered as per RGICL list
Internal Congenital disease Internal Congenital diseases covered.
Terrorism Terrorism Covered.
Room Rent Insured Person's Hospital accommodation for In-patient care shall be limited Up to 1% of the
sum insured for Normal Room and 2% of the sum insured for ICU, ICCU and NICU.
Maternity Any treatment arising from or traceable to pregnancy (including voluntary termination),
miscarriage (unless due to an Accident), childbirth, maternity (including caesarian section),
abortion or complications of any of these are excluded. However, this exclusion will not apply
to ectopic pregnancy, which is proved by diagnostic means and certification by a gynecologist
that it is life threatening.
Pre Existing Diseases Pre-existing diseases covered after 36 months.
Waiting Period 30 day and 1st Year waiting period for treatment of specified illness (Refer Policy Wordings)
and 2 year waiting period for named ailments (Refer Policy Wordings).
Continuity Benefits Continuity benefits allowed as per the duration of policy one is holding in earlier/existing
scheme operated by Bank of India and on renewal wishes to renew the policy with us, then
he/ she shall be given the benefit of continuity on the expiring Policy’s Sum Insured.
• Example 1: If a policy holder of earlier/existing scheme operated by Bank of India joins us
after a continuous coverage in that policy for three years with same Sum Insured as the
policy’s expiring Sum Insured, then in our policy PED will be covered from DAY ONE. It is to
be noted that, barring above mentioned deviations, policy holder will be governed by all the
terms and conditions of our policy once he/ she opts for our policy.
• Example 2: If a policy holder of earlier/existing scheme operated by Bank of India joins us
after a continuous coverage in that policy for three years with higher Sum Insured as
compared to the expiring policy’s Sum Insured, subjected to all the terms and conditions of
the RGI policy then in our policy PED will be covered from DAY ONE for the expiring Sum
Insured and there will be a 36 MONTHS of waiting period on the extra sum Insured (i.e. Sum
Insured Opted with RGI minus Sum Insured of expiring policy).
The policy wording with detailed terms, conditions and exclusions and the Healthcard are available on our website
www.reliancegeneral.co.in.

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway , Santacruz (East), Mumbai - 400 055.
Corporate Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway , Santacruz (East), Mumbai - 400 055.
Corporate Identity No.U66603MH2000PLC128300. UIN No.: RELHLGP21515V022021. Page 2 of 5
RGI/MCOM/CO/HL-01/POLICY-SCHEDULE/Ver. 1.0/260319
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License
Contact details for Policy & Claims Servicing
Contact Details Policy Servicing Claim Servicing
Name Customer Service Team R Care
Correspondence Address Reliance General Insurance, Reliance General Insurance, No. 1-89/3/B/40
2nd & 3rd Floor, Winway Building, 11/12, Block No-4, to 42/ks/301, 3rd floor, Krishe Block, Krishe
Old No-67, South Tukoganj, Near Madhumilan Square Sapphire, Madhapur, Hyderabad-500001.
Indore (M.P) - 452001.
E-mail ID rgicl.services@relianceada.com rgicl.rcarehealth@relianceada.com
Contact No
Fax No 1800 3010 3001
Website www.reliancegeneral.co.in www.reliancegeneral.co.in
Paid No (022)4890 3009 (022)4890 3009
Consolidated Stamp duty Paid vide Receipt No.CSD/318/2021/1294dated 01 Apr 2021(Not applicable for the state of Jammu and Kashmir).
Please Note:
•Attached with this Policy Schedule are the Policy Terms and Conditions, Endorsements, and Annexures. Please ensure that you
(Policyholder) have received, read and understood all these documents. If you (Policyholder) have not received any of these, please
email/write to the Company at rgicl.services@relianceada.com or contact us on (022)4890 3009.
•This Policy Schedule in original must be surrendered to the Company in case of cancellation of the Policy. In the event of any incorrect
representation, the liability shall be upon the Policyholder.
•The Benefits which are mentioned in this Schedule shall only be available under the Policy.
•In witness whereof this Policy has been signed at Mumbai on policy tax invoice date in lieu of Proposal No. as mentioned in the policy.
•TThis document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services Tax Rules 2017
•For complete details of policy coverage ,terms, conditions and exclusions kindly refer to the policy wordings

Authorised Signatory

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway , Santacruz (East), Mumbai - 400 055.
Corporate Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway , Santacruz (East), Mumbai - 400 055.
Corporate Identity No.U66603MH2000PLC128300. UIN No.: RELHLGP21515V022021. Page 3 of 5
RGI/MCOM/CO/HL-01/POLICY-SCHEDULE/Ver. 1.0/260319
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License
 PREMIUM CERTIFICATE
Premium Certificate for the purpose of deduction under Section 80D of Income Tax Act, 1961.
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&+28+$1WRZDUGVSD\PHQWRIKHDOWKLQVXUDQFHSUHPLXPDVSHUWKHGHWDLOVPHQWLRQHGDERYH7KHSUHPLXPSDLGIRUWKLVSROLF\LVHOLJLEOHIRU
DSSOLFDEOHWD[EHQHILWVXQGHUVHFWLRQ'RIWKH,QFRPH7D[$FWDQGDPHQGPHQWVWKHUHRI
Note: - Any amount paid in cash towards the premium would not qualify for tax benefits as mentioned above.
Name of the Policyholder SATYENDER KUMAR CHOUHAN
Correspondence Address D2A/54B, JANAKPURI NEW DELHI , City : New Delhi, State : DELHI, PinCode : 110058,
Policy Number 131592128451001022
Issue Date 31 Jul 2021
Place New Delhi
For Reliance General Insurance Co. Ltd

Authorised Signatory
Please Note:
•Incase of any discrepancy, the Policy holder is requested to let us know immediately. You can write to us at rgicl.services@relianceada.com
or call us on (022)4890 3009 for necessary changes/rectification.
•These documents must be surrendered to the Company in case of cancellation of the Policy or for the issuance of afresh Schedule in the
case of any alteration in the Policy. In the event of incorrect representation of this declaration, the liability shall be upon the Policy holder.

Grievance Clause: For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at
(022)4890 3009 or may write an
email at rgicl.services@relianceada.com. In case the insured is not satisfied with the response of the office, insured may contact the Nodal
Grievance Officer of the
Company at rgicl.grievances@relianceada.com. In the event of unsatisfactory response from the Nodal Grievance Officer, insured may email
to Head Grievance
Officer at rgicl.headgrievances@relianceada.com. In the event of unsatisfactory response from the Head Grievance Officer, he/she may,
subject to vested jurisdiction,
approach the Insurance Ombudsman for the redressal of grievance. Details of Insurance Ombudsman are available at IRDAI website
www.irdai.gov.in or on company
website www.reliancegeneral.co.in or on www.ecoi.co.in.
- Incase of any discrepancy, the policy holder is requested to let us know immediately. You can write to us at rgicl.services@relianceada.com
or call us on (022)4890 3009 for necessary charges/rectification.

- These documents must be surrendered to the Company in case of cancellation of the Policy or for the issuance of afresh schedule in the
case of any alteration in the policy. In the event of incorrect representation of this declaration, the liability shall be upon the policy holder.

Note : The policy wording with detailed terms, conditions and exclusions are available on our website www.reliancegeneral.co.in
Grievance Clause: For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at
(022)4890 3009 or may write an email at rgicl.services@relianceada.com. In case the insured is not satisfied with the response of the office,
insured may contact the Nodal Grievance Officer of the Company at rgicl.grievances@relianceada.com. In the event of unsatisfactory
response from the Nodal Grievance Officer, insured may email to Head Grievance Officer at rgicl.headgrievances@relianceada.com. In the
event of unsatisfactory response from the Head Grievance Officer, he/she may, subject to vested jurisdiction, approach the Insurance
Ombudsman for the redressal of grievance. Details of Insurance Ombudsman are available at IRDAI website www.irdai.gov.in or on company
website www.reliancegeneral.co.in or on www.ecoi.co.in.

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway , Santacruz (East), Mumbai - 400 055.
Corporate Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway , Santacruz (East), Mumbai - 400 055.
Corporate Identity No.U66603MH2000PLC128300. UIN No.: RELHLGP21515V022021. Page 4 of 5
RGI/MCOM/CO/HL-01/POLICY-SCHEDULE/Ver. 1.0/260319
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License
Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway , Santacruz (East), Mumbai - 400 055.
Corporate Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway , Santacruz (East), Mumbai - 400 055.
Corporate Identity No.U66603MH2000PLC128300. UIN No.: RELHLGP21515V022021. Page 5 of 5
RGI/MCOM/CO/HL-01/POLICY-SCHEDULE/Ver. 1.0/260319
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License