Servicing Office Address: Mangalabag, Cuttack, Odisha, Pin : 753001

aa
RECEIPT

Customer Details

Collection Details

Name : DIPTI PRAKASH BHANJA

Address : AT/PO-KHANKIRA, VIA-GANDIA
DHENKANAL Dist. : DHENKANAL,
Odisha,KHANKIRA,DHENKANAL, Odisha, PIN 759016,Dhenkanal,DHENKANAL, Odisha, PIN 759016
Pin : 759016

Agent Code :303

Collection Number :
163100/81/16/9100000009
Collection Date : 01/10/2016
Bank Account : 9151

Sl.
No

Policy
Number

TR
Code

1 163100/48/16/8565000002

16

2 163100/48/16/8565000002

16

3 163100/48/16/8565000002

16

4 163100/48/16/8565000002

16

End/Ren/Dec/Clm End/Ren/Dec/Clm
A/C
Year
Number
Particulars
PREMIUM
CONTROL
PREMIUM
CONTROL
PREMIUM
CONTROL
PREMIUM
CONTROL

A/C Head
(General
Ledger)

A/C Head
(Sub
Ledger)

Credit
Amount

Debit
Amount

5083

1,854.00

1,854.00

5443

260.00

260.00

5664

9.00

9.00

5667

9.00

9.00

TOTAL :

2,132.00

0.00

Amount
Received

2,132.00

Particulars : CCARD

.
.
.
For National Insurance Company Ltd.,

Authorised Signatory
.
.
.
1.Please quote collection no. and date in all correspondeces.
2.The stamp has been defaced and retained at the office against the
issued policy.

National Insurance Company Limited

3, Middleton Street, Post Box No. 9229, Kolkata - 700 071
Policy Issuing Office
Office Code : 163100
Mangalabag, Cuttack, Odisha, Pin : 753001
Tel:0671 2614052 (G) Fax: 06712614740 Email:

Schedule For National Mediclaim

Proposer & Policy Details

.

Reference Number
Proposer Name
.
Phone
.
Previous Policy Expiry Date
.
E-mail
.
Department Name
.
Nominee Name
blank line

16310070000001
DIPTI PRAKASH BHANJA

Reference Date
Policy Number
.
Policy Start Date
.
Policy Expiry Date
.
Previous Policy Number
.
Pan Number
.
Nominee Relation
blank line

02/10/2016
dipti5457@yahoo.co.in
.
Misc - Non Traditional Business
.

blank line

01/10/2016
16310048168565000002
.
03/10/2016
.
02/10/2017
.
16310048158565000003
.
ALKPB6965A
.

blank line

Proposer Address
.
.
.

Proposer Name
Address

DIPTI PRAKASH BHANJA

AT/PO-KHANKIRA, VIA-GANDIA DHENKANAL Dist. : DHENKANAL, Odisha,KHANKIRA,DHENKANAL, Odisha,
PIN - 759016,Dhenkanal,DHENKANAL, Odisha, PIN - 759016
.

Business Channel Details

.
.

Channel Code
IRDA License Number

163100 / 303
58

Channel Name
Contact Number

MR TARAPRASAD PRAHARAJ
portal.support@nic.co.in

Details of Insured Persons

Srl No
Name
1
DIPTI PRAKASH BHANJA

Date oF Birth Age

01/05/1978
38

Relation

Gender
M

Self

Existing Disease

Cover Details of Insured Persons

Srl No
Name
1
DIPTI PRAKASH BHANJA

Relation
Self

Occupation
Engineer

Sum Insured
100000

CB
50000

Inception Date
03/10/2006

Premium Details
.
.
.

Total Premium Computed

Net Premium Payable
Service Tax Code

2132
1854
.

AAACN9967EST099

.
.
.

Add Service Tax

Swach Bharat Cess
Krishi Kalyan Cess(KKC)

260
9.00
9.00

TPA Details
TPA Code : 890301
Tpa Name & Address : Medi Assist India Pvt. Ltd. Annapoorna, No. 797, 10th Main, 4th Block, Opp: Hande Hall, Jayanagar, Bangalore Pin
Code : 560011 Tel : 080 26538790,080 26538791
Terms & Condition

Visit us at www.nationalinsuranceindia.com for information on Products, Services and Grievance Redressal. Mail us at portal.support@nic.co.in

This insurance shall be extended after 48 months of continuous coverage has elapsed since inception of the first policy to pay any
expenses incurred relating to the disease(s)/sickness/injury mentioned in the row "Pre-existing Disease/Exclusions" and for
consequences attributable thereto or accelerated thereby or arising therefrom, in respect on the respective insured person
INWITNESS WHEREOF, the undersigned being duly authorized hereunto set his/ her hand at the office address mentioned above, this date
[03/10/2016]. This schedule, the attached policy, the clauses, the endorsements and the policy wordings as available in the website shall be
read together as one contract and any word or expression to which the specific meaning has been attached in any part of this policy or the
schedule shall bear the same meaning wherever it may appear.
It is warranted that IN CASE OF DISHONOR OF THE PREMIUM CHEQUE, THIS DOCUMENT STANDS AUTOMATICALLY CANCELLED.
Blank

Blank

Photographs Of Insured Persons: For and on behalf of

National Insurance Company Limited

Authorised Signatory

-2-

blank line

Premium Certificate For The Purpose of Deduction u/s 80-D of Income Tax (Amendment) Act, 1986.
This is to certify that DIPTI PRAKASH BHANJA
has paid
2,132.00 (RUPEES TWO THOUSAND ONE HUNDRED THIRTY TWO ONLY)
towards Premium for NATIONAL MEDICLAIM Policy for the period from
03/10/2016 To 02/10/2017
Policy No. : 16310048168565000002
Net Premium :
1854
Service tax:
278
Place: Kolkata
blank line
blank line
blank line
For and on behalf of
National Insurance Company Limited

Authorised Signatory
blank line
Note - This Certificate must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation of the policy or
any alteration in the Insurance affecting the policy.
blank line

Visit us at www.nationalinsuranceindia.com for information on Products, Services and Grievance Redressal. Mail us at portal.support@nic.co.in

National Insurance Company Limited

3, Middleton Street, Post Box No. 9229, Kolkata - 700 071

Proposal Form For National Mediclaim

Proposer & Policy Details

.

Reference Number
Phone
.
Previous Policy Expiry Date
.
E-mail
.
Department Name
.
Nominee Name
blank line

16310070000001

01/10/2016
03/10/2016
02/10/2017
.
16310048158565000003
.
ALKPB6965A

Reference Date
Policy Start Date
.
Policy Expiry Date
.
Previous Policy Number
.
Pan Number
.
Nominee Relation
blank line

02/10/2016
dipti5457@yahoo.co.in
.
Misc - Non Traditional Business
.

blank line

blank line

Proposer Address
.
.
.

Proposer Name
Address

DIPTI PRAKASH BHANJA

AT/PO-KHANKIRA, VIA-GANDIA DHENKANAL Dist. : DHENKANAL, Odisha,KHANKIRA,DHENKANAL, Odisha,
PIN - 759016,Dhenkanal,DHENKANAL, Odisha, PIN - 759016
.

Business Channel Details

.
.

Channel Code
IRDA License Number

163100 / 303
58

Channel Name
Contact Number

MR TARAPRASAD PRAHARAJ
portal.support@nic.co.in

Details of Insured Persons

Srl No
Name
1
DIPTI PRAKASH BHANJA

Date oF Birth Age

01/05/1978
38

Relation

Gender
M

Self

Existing Disease

Cover Details of Insured Persons

Srl No
Name
1
DIPTI PRAKASH BHANJA

Relation

Occupation
Engineer

Self

Sum Insured
100000

CB
50000

Inception Date
03/10/2006

TPA Details
TPA Code : 890301
Tpa Name & Address : Medi Assist India Pvt. Ltd. Annapoorna, No. 797, 10th Main, 4th Block, Opp: Hande Hall, Jayanagar, Bangalore Pin
Code : 560011 Tel : 080 26538790,080 26538791

.
.
.

Phone
Email
CIN

.
.
.

033-22831705/06
portal.support@nic.co.in
U10200WB1906GOI001713

.
.
.

Fax Number
Website

.
.
.

033-22831712
www.nationalinsuranceindia.com

Visit us at www.nationalinsuranceindia.com for information on Products, Services and Grievance Redressal. Mail us at portal.support@nic.co.in

National Insurance Company Limited

3, Middleton Street, Post Box No. 9229, Kolkata - 700 071

Address And Contact Details of Ombudsmen Centres

Office of The Governing Body of Insurance Council
(Monitoring Body for Offices of Insurance Ombudsman)
3rd Floor, Jeevan Seva Annexe, Santacruz(West), Mumbai - 400054. Tel no: 26106671/6889.
Email id: inscoun@gbic.co.in
website: www.gbic.co.in
If you have a grievance, approach the grievance cell of Insurance Company first.
If complaint is not resolved/ not satisfied/not responded for 30 days then
You can approach The Office of the Insurance Ombudsman(Bimalokpal)
Please visit our website for details to lodge complaint with Ombudsman.

Office of the Insurance Ombudsman,

2nd Floor, Ambica House, Ashram Rd,
AHMEDABAD - 380 014.
Tel.:- 079-27545441/27546840
Fax : 079-27546142
Email: bimalokpal.ahmedabad@gbic.co.in

Office of the Insurance Ombudsman,

2nd Floor, Janak Vihar Complex, 6, Malviya Nagar,
BHOPAL - 462 003.
Tel.:- 0755-2769201/9202
Fax : 0755-2769203
Email: bimalokpal.bhopal@gbic.co.in

Office of the Insurance Ombudsman,

62, Forest Park,
BHUBANESHWAR - 751 009.
Tel.:- 0674-2596455/2596003
Fax : 0674-2596429
Email: bimalokpal.bhubaneswar@gbic.co.in

Office of the Insurance Ombudsman,

SCO No.101-103,2nd Floor, Batra Building, Sector 17-D,
CHANDIGARH - 160 017.
Tel.:- 0172-2706468/2772101
Fax : 0172-2708274
Email: bimalokpal.chandigarh@gbic.co.in

Office of the Insurance Ombudsman,

Fathima Akhtar Court, 4th Floor, 453 (old 312),
Anna Salai, Teynampet,
CHENNAI - 600 018.
Tel.:- 044-24333668 /24335284
Fax : 044-24333664
Email: bimalokpal.chennai@gbic.co.in

Office of the Insurance Ombudsman,

2/2 A, Universal Insurance Bldg.,Asaf Ali Road,
NEW DELHI - 110 002.
Tel.:- 011-23234057/23232037
Fax : 011-23230858
Email: bimalokpal.delhi@gbic.co.in

Office of the Insurance Ombudsman,

Jeevan Nivesh, 5th Floor, S.S. Road,
GUWAHATI - 781 001 .
Tel.:- 0361-2132204/5
Fax : 0361-2732937

Office of the Insurance Ombudsman,

6-2-46, 1st Floor, Moin Court, A.C. Guards,
Lakdi-Ka-Pool,
HYDERABAD-500 004.
Tel.:- 040-65504123/23312122
Fax : 040-23376599
Email: bimalokpal.hyderabad@gbic.co.in

Email: bimalokpal.guwahati@gbic.co.in
Office of the Insurance Ombudsman,
2nd Floor, CC 27/2603, Pulinat Bldg., M.G. Road,
ERNAKULAM - 682 015.
Tel.:- 0484-2358759/2359338
Fax : 0484-2359336
Email: bimalokpal.ernakulam@gbic.co.in

Office of the Insurance Ombudsman,

Hindustan Building. Annexe, 4th Floor, C.R.Avenue,
KOLKATA - 700072
Tel.:- 033-22124339/22124346
Fax : 22124341
Email: bimalokpal.kolkata@gbic.co.in

Office of the Insurance Ombudsman,

Jeevan Bhawan, Phase-2,
6th Floor, Nawal Kishore Road,Hazaratganj,
LUCKNOW - 226 001.
Tel.:- 0522 -2231331/2231330
Fax : 0522-2231310
Email: bimalokpal.lucknow@gbic.co.in

Office of the Insurance Ombudsman,

3rd Floor, Jeevan Seva Annexe,S.V. Road, Santacruz(W),
MUMBAI - 400 054.
Tel.:- 022-26106960/26106552
Fax : 022-26106052
Email: bimalokpal.mumbai@gbic.co.in

Office of the Insurance Ombudsman,

Ground Floor, Jeevan Nidhi II, Bhawani Singh Road,
JAIPUR - 302005.
Tel.:- 0141-2740363
Email: bimalokpal.jaipur@gbic.co.in

Office of the Insurance Ombudsman,

3rd Floor, Jeevan Darshan, N.C. Kelkar Road, Narayanpet
PUNE - 411030.
Tel.:- 020-32341320
Email: Bimalokpal.pune@gbic.co.in

Office of the Insurance Ombudsman,

24th Main Road, Jeevan Soudha Bldg.,
JP Nagar, 1st Phase, Ground Floor
BENGALURU - 560025.
Tel.:- 080-26652049/26652048
Email: bimalokpal.bengaluru@gbic.co.in

Office of the Insurance Ombudsman,

4th Floor, Bhagwan Sahai Palace,
Main Road, Naya Bans, Sector-15,
NOIDA - 201301.
Tel.:- 0120-2514250/51/53
Email: bimalokpal.noida@gbic.co.in

Office of the Insurance Ombudsman,

1st Floor, Kalpana Arcade Building,
Bazar Samiti Road, Bahadurpur,
PATNA - 800006.
Tel.:- 0612-2680952
Email: bimalokpal.patna@gbic.co.in.

-1Visit us at www.nationalinsuranceindia.com for information on Products, Services and Grievance Redressal.

Customer Care Toll Free Number : 18002007710; Grievance Cell Toll Free Number : 18003454033