Premium Receipt

Dear MR. ROHIT BALKRISHNA KEDARE

J-901, RAHEJA VISTAS, RAHEJA VIHAR, CHANDIVALI, POWAI.
MUMBAI - 500072

We acknowledge the receipt of payment towards the premium of the following health insurance policy:

Policyholder Name Mr. ROHIT BALKRISHNA KEDARE Policy Number 31694234208892

Product Name ReAssure Plan Opted Family Base Sum Insured 15,00,000

Policy Commencement Date # 29/04/2023 Policy Expiry Date 28/04/2024

Premium Calculation:

(A) Premium (Rs.) - Base Product 36,135.00

(B) Premium (Rs.) - Personal Accident Cover 0.00

(C) Premium (Rs.) - Safeguard 2,710.00

(D) Premium (Rs.) - Hospital Cash 0.00

Underwriting Loading (Rs.) 0.00

Total Discount (Rs.) 1,942.00

Net Premium / Taxable value (Rs.) 36,903.00

Integrated Goods and Service Tax (18.00 %) 6,642.54

Central Goods and Service Tax (0.00 %) 0.00

State/UT Goods and Service Tax (0.00 %) 0.00

Gross Premium (Rs.) 43,546.00

#Issuance of policy is subject to clearance of premium paid

Details of Persons Insured

Name of person Insured Age Insured Taxable Benefit Premium* Gender Relationship**

Mr. Balkrishna Haribhau Kedare 72 Female Father

Mrs. Asha Balkrishna Kedare 68 43,546.00 Female Mother

*Amount is including taxes applied. Any mismatch in the total summation of premium of each member from the gross premium is result of
rounding.

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. For your eligibility and deductions, please refer to provisions of Income Tax Act 1961 as modified and consult your tax consultant. In the
event of non-realization of premium, tax benefits cannot be obtained against this premium receipt.

Upon issuance of this receipt, all previously issued temporary receipts, if any, related to this policy are considered null and void.

GSTI No.: 09AAFCM7916H1Z6 SAC Code / Type of Service : 997187 / General Insurance Services

Niva Bupa State Code: 4 Customer State Code / Customer GSTI No.: 38 /NA

Policy issuing office: Mumbai, Consolidated Stamp Duty deposited as per the order of Government of National Capital Territory of Mumbai.

Location: Mumbai Director - Operations & Customer Service

Date: 03/04/2023 For and on behalf of Niva Bupa Health Insurance Company Limited
(formerly known as Max Bupa Health Insurance Co. Ltd.)

Product Name: ReAssure | Product UIN: MAXHLIP21060V012021