HDFC ERGO General Insurance Company Limited 2866204534789900001

Policy Schedule - Endorsed Copy

my: health Medisure Super Top Up Insurance

2866204534789900001

Policy No. : 2866 2045 3478 9900 001 Issuance Date : 26/02/2022 1

Period of Insurance : From 03/03/2022 00:01 hrs hrs To 02/03/2023 Midnight

Invoice No. : 204534789900001 Premium Frequency : Yearly
Dr Nishita Mehta
B/404,Orchid Evershine ParkVeera Desai Road,Near Country Proposer Name : Dr Nishita Mehta Policy Type : Family floater
Club, Andheri Mumbai HSN Code : 997133
Maharashtra, 400053 Customer Id : 100515307471
Contact No : 9833835833
PAN No. : CDLPM4552R
EIA No. : Not provided

Email ID : dr.nishitamehta@gmail.com
Insured Person’s Details & Sum Insured
Insured's Name Relation with Gender Date of Nominee Name Nominee 1st Policy Sum Insured Deductible Pre Existing
policy holder Birth Relationship Inception (`) (`) Disease
Hypertension,
Nikky Chetankumar
Nishita Mehta Self Female 06/05/1985 HUSBAND 03/03/2022 HYPERTENSI
Mehta
1500000 500000 ON,
Nikky Chetankumar Mehta Spouse Male 21/07/1983 Nishita Mehta SPOUSE 03/03/2022 No
Rianna Nikky Mehta Dependent Daughter Female 30/09/2019 Nishita Mehta MOTHER 03/03/2022 No
The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee
Premium Details (`)
Basic Premium 3520.00
Total Premium excluding Taxes 3520.00
Additional Loading 528.00
Tax as Applicable 729.00
Total Premium 4777.00
Endt No List of Endorsements Description Effective Date
001 Correction in insured particulars 03/03/2022
Processing Centre HDFC ERGO General Insurance Company Ltd. 5th floor, Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
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.
I f 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 noLOA/CSD/225/2021/6304 dated 28/12/2021
a s prescribed in Government of Maharashtra Order No. Mudrank-2017/CR.97/M-1, dated the 09th January 2018;. . GST Registration No: 27AABCL5045N1Z8. GST for this invoice is not payable under reverse
charge basis.
Branch :ff, 808(1), boman lodge, dr. amberdkar road dadar ( east) mumbai
Broker Name : GENNEXT INSURANCE BROKERS PVT LTD For HDFC ERGO General Insurance Company Ltd
Broker Code : 200422166802

Duly Constituted Attorney

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"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings."

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 HDFHLIP22021V042122. 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