KOTAK GROUP HEALTH CARE

For any assistance please call 1800 266 4545, please save the number for your reference

CERTIFICATE OF INSURANCE
Kotak Group Health Care Policy No. KGHC0099 dated 02/07/2019 has been issued at Mumbai by Kotak Mahindra General Insurance Company Limited
to the Policyholder, Kotak Mahindra Bank Ltd as specified in the Policy Schedule and is governed by, and subject to the terms , conditions and exclusions
therein contained or otherwise expressed in the said Policy, but not exceeding the Sum Insured as specified in the Policy Schedule to th e said policy.

This certificate issued under the signature of the authorised signatory of the Company represents the availability of benefits to the Insured person/
persons named below, Customers of Kotak Mahindra Bank Ltd, subject to the terms, conditions and exclusions contained or other wise expressed in
the said Policy, but not exceeding the Sum Insured as specified below.

For the purpose of this document, we consider Kotak Mahindra Bank Ltd as the policyholder and its Customers as the Insured.

DETAILS OF THE INSURED PERSON(S) UNDER THE POLICY

Certificate Number GI20211107671 Date of Issuance 25/06/2021

Certificate Start Date 24/06/2021 Certificate End Date 23/06/2022
Business Type NEW Expiring Policy No
Name of the Customer BIPINBHAI KALUBHAI JASOLIYA
E-501, Panchdev Residency, Bha ktinandan Chowk, Mota Varachha Chorasi SURAT GJ
Correspondence Address
394101,SURAT,GJ,394101
Email ID jasoliya4@gmail.com
Contact Details 919725682269
Account No / Unique ID 231356365 Customer GSTIN
Policy Tenure 1 year

Sum Insured Details

Sum Insured INR 500000

Sum Insured Basis Individual

Date of Pre-existing
Member ID Insured Name Date of Birth Age Gender
Joining Condition
M1000012227 BIPINBHAI KALUBHAI JASOLIYA 13/08/1982 39 M 24/06/2021

INTERMEDIARY DETAILS

Intermediary Code Intermediary Name Intermediary's Mobile No. Intermediary's Landline No.

4171670000 KMGIC_DIRECT1 18002664545

PREMIUM DETAILS

Taxable Value CGST @ 9 %(As UGST @ 9 %(As SGST @ 9% (As IGST@ 18% (As Total Amount
of Services(Rs.) applicable) (Rs.) applicable) (Rs.) applicable) (Rs.) applicable) (Rs.) (Rs.)
5089.83 916.17 6006

Kotak Group Health Care – UIN: IRDAI/HLT/KMGI/P-H (G)/V.I/58/2016-17

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai - 4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg.
21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E), Mumbai – 400097. India. IRDAI Reg. No. 152
Page 1 of 1477
 COVERAGE DETAILS

Sr. No. Base Covers Sum Insured Limits Description/ Remarks

(i) In-patient Treatment Up to Sum Insured
(ii) Pre-Hospitalisation Medical Expenses Up to Sum Insured No of Days : 60
(iii) Post-Hospitalisation Medical Expenses Up to Sum Insured No of Days : 90
(iv) Day Care Treatment Up to Sum Insured
(v) Domiciliary Hospitalisation Up to Sum Insured
(vi) Emergency Ambulance Up to INR 20,000/- per event
(vii) Donor Expenses Up to Sum Insured
Sr. No. Optional Covers Sum Insured Limits
(i) Optional Cover 1 - Alternative Treatment Up to Rs.100,000/-
1% of SI for Normal Rooms and
(ii) Optional Cover 37 - Room Rent Capping
2% of SI for ICU Rooms,
(iii) Optional Cover 30 – Wellness Program NA (b) Health Check-up and Report evaluation
- One free Annual Health Check-up

Important Conditions:

Sr. No. Condition

1 Age Band: 18 years to 55 years
2 Eligibility: Insured should be customer of Kotak Mahindra Bank Ltd.
3 Pre-Existing Disease (Code – Excl01) Waiting Period – Applicable
Any Pre-Existing Disease will not be covered until 48 months of continuous coverage has elapsed for the Insured Person, since the
inception of the first Policy with the Company.
4 30 days Waiting Period (Code – Excl03– Applicable
5 Specified disease/ procedure waiting period (Code – Excl02) - Applicable
6 Maternity Cover – Not Applicable
7 Renewal is Available only if Insured remains a customer of Kotak Mahindra Bank Ltd.
8 Room Rent Capping - If the Insured Person incurs Room Rent that is higher than the eligible Room Rent as per the limits specified under
this Benefit then We will be liable to pay only a rateable proportion of the Associated Medical Expenses incurred in the proportion of the
difference between the eligible Room Rent and the Room Rent actually incurred, provided that Reasonable and Customary costs
incurred on medicines/pharmacy, medical consumables and medical implants will be reimbursed based on the actual amounts incurred.

Permanent Exclusions:

1. Intentional self-injury (whether arising from an attempt to commit suicide or otherwise)

2. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof (Excl12)
3. Expenses related to sterility and infertility.(Excl17)
4. Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breac h of law with
criminal intent. (Excl10)
5. Any treatment taken outside India
6. Any consequential or indirect loss arising out of or related to Hospitalization
7. Any Injury or Illness directly or indirectly caused by or arising from or attributable to war or war like perils
8. Any Illness or Injury directly or indirectly caused by or contributed to by nuclear weapons/materials

For complete details please refer to the Policy wordings available with the Group Master Policyholder. Alternatively, the same can be
downloaded from our website www.kotakgeneralinsurance.com

NOMINEE DETAILS

Relationship with the Appointee Details in case

Insured Name Nominee Name Age
Insured Person Nominee is a Minor
BIPINBHAI KALUBHAI
CHETANABEN Wife
JASOLIYA

Kotak Group Health Care – UIN: IRDAI/HLT/KMGI/P-H (G)/V.I/58/2016-17

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai - 4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg.
21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E), Mumbai – 400097. India. IRDAI Reg. No. 152
Page 2 of 1477
 DISCLAIMER

This Certificate of Insurance shall be read together with Policy Schedule and the Policy Wordings (which are also available on the Company website
i.e. www.kotakgeneralinsurance.com). Any word or expression to which a specific meaning has been assigned in any part of the policy or this certificate
shall bear the same meaning wherever it may appear.

IN THE EVENT OF CLAIM

Contact Us at:
Toll Free Number: 1800 266 4545 (24 * 7) or may write an email at care@kotak.com

Please send the relevant documents to:

Family Health Plan (TPA) Ltd,
Srinilaya – Cyber Spazio, Suite # 101,102,109 & 110, Ground Floor,Road No. 2, Banjara Hills, Hyderabad, 500 034.

GRIEVANCE REDRESSAL DETAILS

In case of any grievance the insured person may contact the company through
Website: www.kotakgeneralinsurance.com
Toll free: 18002664545
E-mail: care@kotak.com
Fax: 022-28401823
Courier: Kotak General Insurance 2nd Floor, Zone II, Building No.21, Infinity IT park, Off Western Express Highway, Goregaon, Mulund Link Road,
Malad (E), Mumbai - 400097

Insured person may also approach the grievance cell at any of the company’s branches with the details of grievance.
If Insured person is not satisfied with the redressal of grievance through one of the above methods, insured person may contact the grievance officer at
grievanceofficer@kotak.com

For updated details of grievance officer, kindly refer the link:

https://www.kotakgeneralinsurance.com/customer-support/grievance-redressal-process

Grievance may also be lodged at IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/

TAX DETAILS

GST Registration No.27AAFCK7016C1ZT Category: General Insurance Service SAC Code: 997133

Description: Accident and Health Insurance Services Invoice No: GI20211107671

The stamp duty of 50 paid in cash or by demand draft or by pay order, Vide Receipt / Challan No.CSD52202119222021 Dated: 08/06/2021

In witness whereof this policy has been signed for and behalf of Ground Flr, Gala No. E-1, 271 Business Park , Model Industrial Colony, Vishweshwar
Nagar, Off Aarey Road, Goregaon East, Mumbai – 400063 on 25/06/2021

For Kotak Mahindra General Insurance Company Ltd.

Authorised Signatory

Kotak Group Health Care – UIN: IRDAI/HLT/KMGI/P-H (G)/V.I/58/2016-17

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai - 4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg.
21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E), Mumbai – 400097. India. IRDAI Reg. No. 152
Page 3 of 1477
 Kotak Group Health Care – UIN: IRDAI/HLT/KMGI/P-H (G)/V.I/58/2016-17
Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai - 4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg.
21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E), Mumbai – 400097. India. IRDAI Reg. No. 152
Page 4 of 1477
 PREMIUM CERTFICATE

For the purpose of Deduction under section 80D of the Income Tax Act, 1961 (as amended from time to time).

To
BIPINBHAI KALUBHAI JASOLIYA
E-501, Panchdev Residency, Bha ktinandan Chowk, Mota Varachha Chorasi SURAT GJ 394101
SURAT GJ 394101
Policy No:- GI20211107671

This is to certify that the company has received the premium of 6006 for Health insurance coverage under the policy no. GI20211107671 vide PAYMENT
AGGREGATOR dated 24/06/2021

The product is eligible for deduction u/s 80D of the Income Tax Act, 1961 and any amendments made thereto subject to satisfac tion of the conditions
mentioned therein.

Deduction under Section 80 D

Lumpsum Benefit:

Financial Year Annual Lumpsum premium allowed for Deduction under Section 80D

2021-22 6006

For Kotak Mahindra General Insurance Company Limited

Authorized Signatory

*Note

This is subject to the provisions of Section 80D of Income Tax Act, 1961 and amendments made thereof.

The year wise deductions mentioned above are as per provisions of Section 80D and this would be subject to the specified annu al provisions as
applicable for respective years as per the Income Tax Act.

Tax benefits are as per the Income Tax Act, 1961 as amended from time to time. Please consult your Tax advisor for details.

Details of the Policy are as per the Part II and III of this Policy.

This certificate must be surrendered to Us in case of cancellation of the Policy. In the event of incorrect representation of this declaration the liability
shall be upon the Policyholder.

In case You find any variations against Your proposal or any discrepancy in the Policy, please contact Us immediately on the numbers available on our
website www.kotakgeneralinsurance.com
The deduction under Section 80D is not applicable for payments made in cash and third party payments.

Kotak Group Health Care – UIN: IRDAI/HLT/KMGI/P-H (G)/V.I/58/2016-17

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai - 4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg.
21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E), Mumbai – 400097. India. IRDAI Reg. No. 152
Page 5 of 1477
 Group Name : Kotak Mahindra Bank Ltd

Member Name: BIPINBHAI KALUBHAI JASOLIYA

Policy No: GI20211107671 Member Id: M1000012227

Date of Birth: 13/08/1982 Gender: M

Valid Till : 23/06/2022

Kotak Group Health Care – UIN: IRDAI/HLT/KMGI/P-H (G)/V.I/58/2016-17

Kotak Mahindra General Insurance Company Ltd.

CIN: U66000MH2014PLC260291; Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai - 4000051. Office: 8th Floor, Zone IV, Kotak Infiniti, Bldg.
21,Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad (E), Mumbai – 400097. India. IRDAI Reg. No. 152
Page 6 of 1477