POLICY SCHEDULE

SmartSuper Health Insurance Policy

Name of the Proposer: JALALUDDIN SHAIKH Policy Number: J9115416512

Address:
F 91 INCOME TAX COLONY
SECTOR 21/22 BELAPUR
CBD NAVI MUMBAI
NAVI MUMBAI
MAHARASHTRA
Mobile No - 9821193417
PinCode - 400614
Branch Code: 24 Intermediary Code: 24089764
Policy taken on: Senior Citizens Floater
Plan and Variant Opted: Value- 500000
Policy Period: 1 Year
Policy Start Date 01/06/2022 00:00hrs Policy End Date 31/05/2023 Midnight

Insured and Coverage Details

Sl.No Name Gender Date of Birth Relationship Cumulative Maternity C.I Cover Hospital
with Insured Bonus Opted Cash
1 MR JALALUDDIN SHAIKH MALE 01/10/1954 SELF Yes NA No No

2 MRS RUKSANA JALALUDDIN FEMALE 03/04/1962 SPOUSE

Special Conditions [Loading and / or Medical Exclusions]

MR JALALUDDIN and MRS RUKSANA Policy is Floater and loaded 20 % in view of personal medical history of Hypertension. This Policy excludes for the next two years any
claim/s in respectof any disorder, disease, disability or treatment whether directly or indirectly caused by &/or attributed to Hypertension and Heart disease /or its complications
and/or any related ailment existing on or before the commencement date of the policy.
Premium Details
Net Premium : Rs. 48237.4
Loading Premium : Rs. 6012.15
Discount(s) : Rs. 3200.25
GST @ 18% : Rs. 9188.91
Total Premium : Rs. 60238.46
Total Premium in Words Sixty Thousand Two Hundred Thirty Eight.

Name of Nominee for Primary Insured* SAMEERUDDIN SHAIKH

Relationship with Primary Insured Child
Name of Appointee
Relationship of Appointee with Nominee
*Nominee for Insured person(s) other than primary insured shall be primary insured

Warranted that in case of dishonors of premium cheque(s) the Company shall not be liable under the policy and the Policy shall be void ab initio.
The Policy has been issued based on the information provided by you/your representative and the Policy is not valid if any of the information provided is incorrect.
The coverage under this Policy is subject to the terms, conditions and exclusions as mentioned under the policy.
For and on behalf of Bharti AXA General Insurance Company Limited

Authorized Signatory

For redressal of your grievance, if any, you may approach any one of the offices- 1.Policy issuing office 2.Corporate Office. In case, you are not satisfied with our own grievance redressal mechanism; you may also approach Insurance
Ombudsman. Details of Insurance Ombudsman offices are available at IRDA website: www.irda.gov.in, or on the website of General Insurance Council: www.gicouncil.in or on the company website www.bharti-axagi.co.in Bharti AXA
GENERAL INSURANCE COMPANY LTD. Unit 102, 1st Floor, Raheja Titanium, Off Western Express Highway, Goregaon (E), Mumbai - 400063. INDIA. IRDA Regn.No.139 Tel: 91 80 40260100 Fax: 80 40260101 Email:
customer.service@bhartiaxa.com
 Premium statement for the purpose of deduction under
Section 80D of Income Tax Act, 1961

This is to state that we have received from JALALUDDIN SHAIKH a sum of Rs.60238.46 towards premium paid to effect/ keep in effect an insurance on the
health of Proposer for the Period From 00:00 hrs on 01/06/2022 to midnight 31/05/2023. The breakup of the premium paid is as under:

Product Name Policy No Premium (Rs.) GST @ 18% Total (Rs.)

SmartSuper - Value J9115416512 48237.4 9188.91 60238.46

Please note:

The deduction under section 80D is allowable subject to a maximum limit of Rs. 25,000/- Per Annum where the health care insurance has been taken for the
individual/his spouse/ & his dependent children. Similarly, aggregate deduction for health insurance premia and medical expenditure incurred in respect of
parents would be limited to Rs. 30,000/-.

Note: - Above deduction for Self/Spouse/ children & Parents is applicable to an Individual.

This policy is booked via IP at 10.92.89.101 Tue May 31 11:15 IST 2022

For Bharti AXA General Insurance Company Limited

Best Regards,

Rohit Kohli
Vice President – Operations
Date: 31/05/2022

For redressal of your grievance, if any, you may approach any one of the offices- 1.Policy issuing office 2.Corporate Office. In case, you are not satisfied with our own grievance redressal mechanism; you may also approach Insurance
Ombudsman. Details of Insurance Ombudsman offices are available at IRDA website: www.irda.gov.in, or on the website of General Insurance Council: www.gicouncil.in or on the company website www.bharti-axagi.co.in Bharti AXA
GENERAL INSURANCE COMPANY LTD. Unit 102, 1st Floor, Raheja Titanium, Off Western Express Highway, Goregaon (E), Mumbai - 400063. INDIA. IRDA Regn.No.139 Tel: 91 80 40260100 Fax: 80 40260101 Email:
customer.service@bhartiaxa.com