PAYMENT RECEIPT

Dear Samrat Mazumder,

A504 sector 12A
Ramchandra Niwas
Navimumbai - 400709

We acknowledge the receipt of payment towards the premium of the following health insurancepolicy:

Policy Holder’s Name Mr. Samrat Mazumder Policy Number 30436062201601

Corporate Silver 05 Lacs
Plan Opted for Sum Insured (₹) 5,00,000
2Adult +1 Child
Commencement
28/06/2022 Expiry Date 27/06/2023
Date*
Base Premium (₹) 21150
GST @18%(₹) 3807
Gross Premium (₹) 24957

*Insurance of policy is subject to clearance of premium paid

Details of persons Insured:

Individual cover
Name of the Person Relationship to (₹) (only in case
insured Age Gender policy holder of Family First)
Mr.Samrat Mazumder 34 Male Applicant N/A
Mrs.Kritika Mazumder 30 Female Wife N/A
Miss Tanishka Mazumder 1 Female Daughter N/A

Upon issuance of this receipt, all previously issued temporary receipts, if any, related to this policy are
considered null and void. For the purpose of deduction under section 80D, the benefit shall be as per the
provisions of the Income Tax Act,1961 and any amendments made thereafter.

In the event of non-realization of premium, Tax benefits cannot be obtained against the premium receipt.

For your eligibility and deductions please refer to provisions of Income Tax Act 1961 as modifies and consult
your tax consultant.

Goods and Service Tax Registration number: 27AACCM3201E1Z3

For and on behalf of Max Bupa Health Insurance Co. Ltd.

Ashish Mehrotra

Managing Director and Chief Executive Officer

Location: Mumbai
Date: 28/06/2022