HDFC ERGO General Insurance Company Limited 3317202579265901000

Policy Schedule
Personal Accident Insurance Policy
(Plan 5)

3317202579265901000

Policy No. :3317 2025 7926 5901 000 Issuance Date : 16/12/2021
Period of Insurance :From 31/12/2021 00:01 hrs To 30/12/2022 Midnight
Invoice No. :202579265901000 Policy Type :Individual
Proposer Name :Mr Bangar Raju G 1st Policy Inception :31/12/2014
3
HSN Code :997133 Territorial Limits :Worldwide
MR BANGAR RAJU G
D NO 1-9 VELLANKI POST ANANDHAPURAM Customer Id :101193902785 Premium Frequency :Single
MANDAL NEAR BY NH 5 PAN
VISAKHAPATNAM, ANDHRA PRADESH, 531163
Contact No : 8985868268 Payment Details : ERGO_CC_15122020, , Bank Name:HDFC BANK LTD
Email ID : raju.gb57@gmail.com
Insured Person’s Details
Insured’s Name Relationship Date of Birth Name of Nominee Relation Benefit
Bangar Raju G Self 10/08/1985 G Gowthami Spouse 100 %
Sum Insured (`)
Coverage

Accidental Death 28,00,000

Ambulance Costs 10,000
Broken Bones 1,00,000
Burns Benefit 3,00,000
Comatose Benefit - Accident Only 10,00,000
Dependent Child Education Benefit 2,50,000
Emergency Medical Expenses (Accident Only) Subject admissible claim under AD/PD/TTD 20,000
10% of the AD/PD/TTD SI or 40% of admissible claim amount or Rs. 50,000 whichever is lower
In-Hospital Medical Expenses - Accident Only 1,00,000
Last Rites Costs - Accident Only 25,000
Permanent Disability (PTD+PPD) (Table D) 25,00,000
Temporary Total Disability (Up to 104 weeks) 5,000/Week
Premium Details ( ` )
Basic Premium 24882.00
Integrated Tax 18% 4479.00
Total Premium 29361.00
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.

Special Condition :
• Under Coverage “Hospital Cash - Accident & Sickness” , per day limit of hospitalization is Rs. 2000.
• Payment of Hospital daily cash benefit is restricted to 30days within a Certificate of Insurance period.
• One day deductible will be applicable for each and every claim.
• Any disease contracted by the Insured Person during the first thirty (30) days from the commencement date of the policy will not be covered.
• Pre existing diseases are covered from 31st day of coverage commencement date.
• 2 year waiting period for specific Illness and treatment is not applicable.
• Maternity related hospitalization is not covered.
• Territorial limit for Hospital Cash - Accident & Sickness is restricted to India only.
• Income proof is required for only Permanent Disablement cover.
I f the premium i s not realised the policy shall be void from inception. Subject otherwise to the terms,exclusions and conditions of this policy. The Maximum Compensation in respect of an Insured Person under
the policy shall not exceed 10 times the Annual Income (as declared in the Proposal Form). Income proof for availing the compensation at the time of claim is mandatory. Income proof shall mean the previous
year’s returns filed with the Income Tax Department.
Consolidated stamp duty for this Insurance Policy i s paid b y Demand Draft, vide Receipt/Challan noCSD/293/2020/385/2020 dated 24/01/2020 as prescribed in Government of Maharashtra Order No. Mudrank-
2017/CR.97/M-1, dated the 09th January 2018;. .GST Registration No: 36AABCL5045N1Z9. GST for this invoice is not payable under reverse charge basis.

Branch :aditya jr towers, 8-2-120/86/9/a&b, 3rd floor road no-2, banjara hills hyderabad

The Policy wording available at www.hdfcergo.com includes all the standard coverage offered by the Company to its customers. Your entitlement for coverage/benefits shall be restricted to the coverage/benefits as
mentioned in this policy schedule.
For HDFC ERGO General Insurance Company Ltd.
Agent Name :HDFC BANK LTD Agent Code :201587086428 Tel No. : 91-22-61606161

Duly Constituted Attorney

"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 UIN:HDFPAIP03002V010203. 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
HDFC ERGO General Insurance Company Limited 331720257926590100

Personal Accident Insurance Policy

(Plan 5)

TAX CERTIFICATE

Dear Bangar Raju G,

Subject : Certificate for the purpose of deduction under section 80 D of Income Tax (Amendment) Act, 1986
This is to certify that we have received an amount of ` 2587 towards premium for In-Hospitalization Medical Expenses (Accident Only) under Personal Accident
Insurance Certificate of Insurance No. 3317202579265901000 issued to Bangar Raju G for the period 31/12/2021 to 30/12/2022.
Note : This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended from time to time.
For HDFC ERGO General Insurance Company Ltd.
Date : 16/12/2021
Policy Issuing Office: Mumbai

Duly Constituted Attorney

CUT HERE

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFPAIP03002V010203. 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
 FREE HEALTH CHECK UP COUPON
This coupon entitles a free health check up to the insured under the Health Insurance Policy

■ Medical Examination ■ Urine Routine ■ Complete Blood Count ■ Fasting Blood Sugar
■ ECG ■ Total Cholesterol ■ Creatinine

Submit this coupon with Hospital / Diagnostic Center

Name of Insured:  □  Bangar Raju G

Policy Number: 3317202579265901000 Policy Start Date: 31/12/2020

Health Check up Date:

Authorization Number:
Customer Contact: Valid upto:

Customer Signature : I am proposor (Hospital seal with sign)

Terms & Conditions

The Free Check Coupon is non-transferable and cannot be clubbed with any other offer from the Service Provider / Hospital / Nursing Home, The offer is valid only if the policy is
in force. HDFC ERGO General Insurance Co. Ltd. (“HDFC ERGO”) is entitled to refer the health check report. This Health Check Coupon can only be availed by any one insured
member under the health insurance policy of HDFC ERGO. The administration of this offer is brought to you by Health Claim Services. To avail this offer, the insured is required
to carry the policy copy along with this coupon while going for the health checkup. Coupon is valid up to 180 days from the below mentioned date on the coupons. In case of
cancellation of the health policies, where health coupons have been issued and also used by the insured, health coupons charges shall be deducted while refunding the premium.
HDFC ERGO is not responsible or liable for medical reports issued by the Service Provider / Hospital / Nursing Home.

Note:
■ Coupon cannot be clubbed with any other offer from the service provider or hospital/nursing home
■ Coupon is valid only if policy is in force
■ Coupon validity period is mentioned on the coupon
■ Tests are fixed for a particular coupon denomination
■ Coupon has one time use meaning it can be used in a single visit
■ Coupon can be used by a single insured

Coupon will be valid for a period of 180 days from the below mentioned date
15/02/2021

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFPAIP03002V010203. 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