Dear Bharati Das

2809205214129600000
HDFC ERGO General Insurance Company Limited
2809205214129600000
To,
Bharati Das
WARD NO-2 DIST-KHURDA WARD NO-2 DIST-KHURDA KHORDA
ODISHA-, 752056
Contact No : 9090496535
Date :03/02/2023
Dear BHARATI DAS
Thank you for choosing HDFC ERGO as your preferred insurance partner. We welcome you to be a part of our family !
Your Health insurance Certificate of Insurance reference no 2809205214129600000 is confirmed on the basis of the information and declaration given by
you.
The details of coverage are mentioned in the enclosed Certifcate of Insurance .
We value your relationship with us and assure you our best services at all times and we look forward to serve you.
Regards,
Arun Sharma
Senior Vice President Operations and Services Group

Dear Bharati Das,
Subject : Certificate for the purpose of deduction under section 80 D of Income Tax Act, 1961
This is to certify that we have received an amount of ` 21,393.00 (Rupees Twenty-One Thousand Three Hundred Ninety-Three And Zero Paise Only) towards
premium for HDFC ERGO Group Health Insurance Certificate of Insurance no. 2809205214129600000 issued to Bharati Das for the period 06/02/2023 to 05/02/2024.
Note:
1. This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1961 as amended from time to time.
2. This certificate must be surrendered to the company in case of cancellation of this policy. In event of incorrect representation of this declaration
the liability shall be upon the policy holder.
Date : 02/02/2023 For HDFC ERGO General Insurance Company Ltd.

Policy Issuing Office: Mumbai
Duly Constituted Attorney
HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDHHGP21544V012021. 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
2809205214129600000
Certificate of Insurance
Certificate No. 2809 2052 1412 9600 000
HDFC ERGO Group Health Insurance
2809205214129600000
Certificate No. : 2809 2052 1412 9600 000 Issuance Date : 02/02/2023
Period of Insurance : From 06/02/2023 00:01 hrs To 05/02/2024 Midnight
Invoice No. : 205214129600000 Premium Frequency : Single
Proposer Name : Ms Bharati Das Policy Type : Family Floater
HSN Code : 997133 Territory Limit : India
MS BHARATI DAS Customer Id:100308165808 PAN No.
WARD NO-2 DIST-KHURDA WARD NO-2 DIST-KHURDA Master Policy Holder Name: BANDHAN BANK LIMITED GST No.
KHORDAODISHA-, 752056
Master Policy No. 2999204621544600000 Customer UIN
Contact No : 9090496535
Residential Status
Payment Details : BBR2407491, Date : 02/02/2023, Bank Name :Bizdirect
Email ID : bharati.das.khordha@gmail.com
Insured Person's Details

Aggregate Base Sum Cumulative Personal Critical Co 1st Policy
Insured's Name Gender Date of Birth Age. Relation Member Id
Deductible Insured (Rs.) Amout Accident- SI Illness-SI Payment% Inception Date
BHARATI DAS F 01/01/1971 Self NA NA 0 EA01613410 06/02/2019
MR MR MR 0 750000 0
M 08/04/1968 Husband NA NA 0 EA01613411 06/02/2019
KARUNAKAR DAS
Nominee Details
Insured's Name Nominee Name Nominee Relationship Appointee Name Appointee Relation
BHARATI DAS RAJESH KUMAR DAS DEPENDENT SON
MR MR MR KARUNAKAR DAS RAJESH KUMAR DAS DEPENDENT SON
The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee
Coverage Details & Sum Insured (`)
Benefit Details
Medical Expenses 750000
Pre-Hospitalization Medical Expenses Cover 90 days
Post-Hospitalization Medical Expenses Cover 180 days
Domiciliary Hospitalization Covered Upto Sum Insured
Organ Donor Expenses Covered Upto Sum Insured
Day Care Treatment Covered Upto Sum Insured
Road Ambulance Cover Rs.2000
Hospital Daily Cash 1000 per day upto15 days
Preventive Health Check-Up 1% of sum insured per policy at each renewal irrespective of claim subject to max of Rs.7500
Alternative Treatment 100 % of Sum Insured Covered
Second Opinion for Major illness Applicable
Double Restore Benefit Applicable
Maternity Expenses Normal Delivery 25000
Maternity Expenses C-Section Delivery 25000
Maternity Expenses cover Waiting Period 36 Months
Double Sum Insured for Critical Illness Applicable
Preexisting disease waiting period 36 months
Specific Illness Waiting Period 24 months
30 days Waiting Period Applicable
Cumulative Bonus 10 % Subject to Max 100 %
Please read the Policy Wording in conjunction with the Certificate of Insurance. For any clarification, please call our Customer service number.
Premium Details(`)
Basic Premium 18,130.00
GST 18% : Central Tax 9% ( `1631.5 ) + State Tax 9% ( `1631.5) 3,263.00
Total Premium 21,393.00

Special Condition :
1. Alternative Treatment : Alternate Medical expenses incurred for in-patient treatment taken under Ayurvedic Unani ,Sidha,Homeopathy Provided that
the treatment has been undergone in a Ayush Hospital and is prescribed by Medical Practitioner
2. Second Opinion for Major illness : Critical Illness includes Cancer of specified severity, Open Chest CABG, Myocardial Infarction (First Heart Attack
of specific severity), Kidney Failure requiring regular dialysis, Major Organ/Bone Marrow Transplant, Multiple Sclerosis with persisting symptoms,
Permanent Paralysis of Limbs and Stroke resulting in permanent symptoms
3. Double Sum Insured for Critical Illness : Critical Illness includes Cancer of specified severity Myocardial Infarction (First Heart Attack of specific
severity) Stroke resulting in Permanent Symptoms Major Organ/Bone Marrow Transplant
General Exclusion
1. Congenital external diseases, defects or anomalies
2. Expenses related to any admission primarily for diagnostic and evaluation
3. OPD treatment War or any act of war, invasion, act of foreign enemy, Nuclear, Chemical or Biological attack or weapons, radiation of any kind.
4. Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of Medically
Necessary Treatment.
5. Any Insured Person committing or attempting to commit intentional self-injury or attempted suicide or suicide
2809205214129600000
Certificate of Insurance
HDFC ERGO Group Health Insurance
6. Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof
Adress 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri(E), Mumbai 400 059.
For any other query call 022 - 6234 6234 / 0120 - 6234 6234 or write to us at healthclaims@hdfcergo.com to register & track claim.
If the premium is not realised the policy shall be void from inception.
Consolidated stamp duty for this Insurance Policy i s paid by Demand Draft, vide Receipt/Challan noNO.LOA/CSD/477/2022/4252 dated 29/09/2022 as prescribed in
Government of Maharashtra Order No. Mudrank-2017/CR.97/M-1, dated the 09th January 2018". . Goods & Services Tax Registration No: 21AABCL5045N1ZK
GST for this invoice i s not payable under reverse charge basis. I/ We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18
onwards is more than the aggregate turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule
Branch :3rd flr, hotel pal regency, j-7,jayadev vihar, on jaideb behar khorda
For HDFC ERGO General Insurance Company Ltd
Agent Name : BANDHAN BANK LTD

Agent Code : 200217232247 Tel No. : 91-33-66090909
Duly Constituted Attorney
The Policy wording attached herewith 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 detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings
2809205214129600000
e-Enrollment Form for HDFC ERGO Group Health Insurance
Certificate No. : 2809 2052 1412 9600 000 Issuance Date : 02/02/2023
Period of Insurance : From 06/02/2023 00:01 hrs To 05/02/2024 Midnight
Invoice No. : 205214129600000 Premium Frequency : Single
Proposer Name : Ms Bharati Das Policy Type : Family Floater
HSN Code : 997133 Territory Limit : India
MS BHARATI DAS Customer Id:100308165808 PAN No.
WARD NO-2 DIST-KHURDA WARD NO-2 DIST-KHURDA
Master Policy Holder Name: BANDHAN BANK LIMITED GST No.
KHORDAODISHA-, 752056
Contact No : 9090496535 Master Policy No. 2999204621544600000 Customer UIN
Residential Status
Payment Details : BBR2407491, Date : 02/02/2023, Bank Name :Bizdirect
Email ID : bharati.das.khordha@gmail.com
Insured Person's Details

Date of Aggregate Base Sum Cumulative Personal Critical Co 1st Policy
Insured's Name Gender Age. Relation Member Id
Birth Deductible Insured (Rs.) Amout Accident- SI Illness SI Payment% Inception Date
BHARATI DAS F 01/01/1971 Self NA NA 0 EA01613410 06/02/2019
MR MR MR 0 750000 0
M 08/04/1968 Husband NA NA 0 EA01613411 06/02/2019
KARUNAKAR DAS
Nominee Details
Insured's Name Nominee Name Nominee Relationship Appointee Name Appointee Relation
BHARATI DAS RAJESH KUMAR DAS DEPENDENT SON
MR MR MR KARUNAKAR DAS RAJESH KUMAR DAS DEPENDENT SON
The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee
Coverage Details & Sum Insured (`)
Benefit Details
Medical Expenses 750000
Pre-Hospitalization Medical Expenses Cover 90 days
Post-Hospitalization Medical Expenses Cover 180 days
Domiciliary Hospitalization Covered Upto Sum Insured
Organ Donor Expenses Covered Upto Sum Insured
Day Care Treatment Covered Upto Sum Insured
Road Ambulance Cover Rs.2000
Hospital Daily Cash 1000 per day upto15 days
Preventive Health Check-Up 1% of sum insured per policy at each renewal irrespective of claim subject to max of Rs.7500
Alternative Treatment 100 % of Sum Insured Covered
Second Opinion for Major illness Applicable
Double Restore Benefit Applicable
Maternity Expenses Normal Delivery 25000
Maternity Expenses C-Section Delivery 25000
Maternity Expenses cover Waiting Period 36 Months
Double Sum Insured for Critical Illness Applicable
Preexisting disease waiting period 36 months
Specific Illness Waiting Period 24 months
30 days Waiting Period Applicable
Cumulative Bonus 10 % Subject to Max 100 %
Please read the Policy Wording in conjunction with the Certificate of Insurance. For any clarification, please call our Customer service number.
Premium Details(`)
Basic Premium 18,130.00
GST 18% : Central Tax 9% ( `1631.5 ) + State Tax 9% ( `1631.5) 3,263.00
Total Premium 21,393.00
Declaration & Warranty on behalf of all Persons Proposed to be insured

“I/We hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are true and complete in all respects to the best of my
knowledge and that I/We am/are authorized to propose on behalf of these other persons.
I/We understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurance company and that the policy will come into force
only after full receipt of the premium chargeable.
I/We further declare that I/we will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been submitted but before communication of the
risk acceptance by the company.
I/We declare and consent to the company seeking medical information from any doctor or from a hospital who at anytime has attended on the life to be insured/proposer or from any past or present employer
concerning anything which affects the physical or mental health of the life to be assured/proposer and seeking information from any insurance company to which an application for insurance on the life to be
assured/proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Governmental
and/or Regulatory authority.”
Declaration & Warranty on behalf of Insurance Company
Note: The liability of the company does not commence until the acceptance of the proposal has been formally intimated to the insured and full premium has been realized by the company.
2809205214129600000
e-Enrollment Form for HDFC ERGO Group Health Insurance
We are under no obligation to accept any proposal for insurance. The Proposer agrees that the receipt of the Proposal Form by HDFC ERGO General Insurance Company Limited along with the premium
payment does not tantamount to the acceptance of the Proposal for insurance by HDFC ERGO General Insurance Company Limited and does not result in a concluded contract of insurance. The acceptance of
the Proposal for insurance shall be at the Company's sole and absolute discretion and upon full realization of the premium payment .In the event of acceptance of the Proposal for insurance by HDFC ERGO
General Insurance Company Limited, such acceptance shall be specifically intimated to the Proposer by HDFC ERGO General Insurance Company Limited along with the date from which the insurance Cover
shall become effective. HDFC ERGO General Insurance Company Limited shall not be liable for any claim in respect of an event giving rise to a claim covered under the Policy of Insurance that has occurred
prior to policy issuance is not covered under this policy(Your proposal form will be considered after HDFCERGO General Insurance Company Limited receives premium payment.).
Fraud Warning: This policy shall be voidable at the option of the Company in the event of mis-representation, mis-description or non-disclosure of any material particulars by the Proposer. Any person who,
knowingly and with intent to fraud the insurance company or any other person, files a proposal for insurance containing any false information, or conceals or the purpose of misleading, Information concerning any
fact material thereto, commits a fraudulent insurance act, which will render the policy voidable at the sole discretion of the insurance company and result in a denial of insurance benefits
Anti-Rebating Warning: As per Section 41 of the Insurance Act 1938,as amended, the practice of rebating is prohibited, as follows: No person shall allow or offer to allow, either directly or indirectly, as an
inducement to any person to take out or renew or continue an insurance policy in respect to any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any
rebate of the premium shown on the policy, nor shall any person taking out o r renewing o r continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published
prospectus or tables of the insurer. Violation of Section41 of the Insurance Act 1938, as amended, shall be punishable with a fine which may extend to`10Lakhs.
Disclaimer : Proposal Form and Policy Schedule have been generated basis details authenticated b y proposer / insured on Online Platform of HDFC ERGO General Insurance Co Ltd. For Changes if any, kindly
visit URL https://www.hdfcergo.com/customer-care/customer-support.html and register.

Dear Bharati Das

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2809205214129600000

HDFC ERGO General Insurance Company Limited

Dear BHARATI DAS

HDFC ERGO General Insurance Company Limited

Date : 02/02/2023 For HDFC ERGO General Insurance Company Ltd.

Duly Constituted Attorney

Insured Person's Details

Coverage Details & Sum Insured (`)

GST 18% : Central Tax 9% ( `1631.5 ) + State Tax 9% ( `1631.5) 3,263.00

Total Premium 21,393.00

For HDFC ERGO General Insurance Company Ltd

Agent Name : BANDHAN BANK LTD

e-Enrollment Form for HDFC ERGO Group Health Insurance

Insured Person's Details

Coverage Details & Sum Insured (`)

GST 18% : Central Tax 9% ( `1631.5 ) + State Tax 9% ( `1631.5) 3,263.00

Total Premium 21,393.00

Declaration & Warranty on behalf of all Persons Proposed to be insured

e-Enrollment Form for HDFC ERGO Group Health Insurance

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