Digitally signed by Bhabatosh Mishra

Date: 2019.01.23 11:58:53 +05:30

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A9059715
Mr AKASH VINAYKUMAR SHAH
44 RAKHIYAL VILLAGE ROAD,
This Policy Kit Contains:
RAKHIYAL STATION
NB-OptimaRestore / 3064 : 2369

1. The Policy Schedule along with income tax (80D)

RAKHIYAL
certificate (wherever applicable)
Gandhinagar, Gandhinagar
2. Cashless Card*
Gujarat - 382315
3. Copy of Proposal form*
India
Contact No.: 9979967627
Policy No.: 190100/11119/AA00999608
Code Intermediary Name Contact No
80098120 NIRENKUMAR PATEL 9909004824

Your Optima Restore Insurance Policy

Dear Mr AKASH VINAYKUMAR SHAH,

Welcome to Apollo Munich Health Insurance Co. Ltd. We are pleased to issue you an Optima Restore Insurance Policy. We advise you to retain
your Policy Kit during the entire term of the Policy (including renewals).

Please note that the Policy has been issued to you based on the declarations, details and documents received from/on behalf of you in/along with
the Proposal Form submitted to us. We request you to kindly review the Copy of the Proposal Form along with all the documents/material
contained in the enclosed Policy Kit carefully. In case you notice any inconsistency or any discrepancy in any of the document/s in the Policy Kit
including the Proposal Form; please write back to us or call us at the email id or toll free number within 15 days of receipt of the Policy Kit.

Please visit our website www.apollomunichinsurance.com to access information about our Company, the customer service touch points
including the Grievance handling process and various forms including Free Look Cancellation that you can use for service support. You will also
get latest updates on products, Policy Wordings which you can download for your reference and record. You may also register yourself at our
website using your unique member ID and policy number as mentioned in the Policy Schedule

To know the updated list of our network hospitals please visit http://www.apollomunichinsurance.com/our-hospital-network.aspx

For Free Look Cancellation Procedure or any assistance you may write to us at customerservice@apollomunichinsurance.com or call us at our
24 hours toll free number 1800-102-0333. We shall be happy to assist you.

Warm Regards,

Location : Gurgaon
Date : 20-Jan-2019
Authorized Signatory

Note:-
- Please update us with your latest contact details (in case of any change) so that same can be updated in our records. You can either
write back to us or call us on our toll free no. 1800-102-0333.

* The copy of the Proposal Form has been sent earlier if the Policy has been issued through our Website.

* Cashless Card as enclosed would be issued only once along with this policy kit and shall remain valid for further renewals.

Page 1 of 4
 SCHEDULE - Optima Restore Individual

Issuing / Servicing Office : Ahmedabad BO, Office No.- 302, 303 & 304, 3rd FloorEventi,
Plot No. 102, Changispur Taluka,District – Sabarmati, Off C.
G. Road,, Gujarat - 380006
PH : 07940049671
GSTIN : 24AAGCA1654H1ZY
Policy Holder's Name : Mr AKASH VINAYKUMAR SHAH
GSTIN/ UIN (if any) of Policy Holder :
Policy Holder's Address : 44 RAKHIYAL VILLAGE ROAD,
RAKHIYAL STATION
RAKHIYAL
Gandhinagar, Gandhinagar
Gujarat - 382315
India
Policy Holder State Name & Code : Gujarat(24)
Intermediary Code : 80098120
Intermediary Name : NIRENKUMAR PATEL
Intermediary Contact No : 9909004824

Policy Number : 190100/11119/AA00999608

First Policy inception date : 18-Jan-2019
Policy Issuance Date : 19-Jan-2019
Description/ Harmonized System Of Nomenclature Code : Accident and Health insurance Services/9971
Policy Period : From 14:33 hrs on 18-Jan-2019 To 24:00 hrs on 17-Jan-2020
Place of Supply : Gandhinagar (Gujarat)

Insured Persons Details :

Critical Critical
Gross
Date of Birth Relationship to Basic Sum Advantage Multiplier Advantage
Member ID Insured Person's Name Age Premium
(DD-MM-YYYY) Policyholder Insured (Rs) Sum Insured Benefit (Rs) Rider
(Rs)
(USD$) Premium (Rs)
Mr AKASH
10018730893 22-Jun-1995 23 Policy Holder 300000 0 0 0 6282.32
VINAYKUMAR SHAH

Nominee Name : Mrs PRITI Relationship to Policyholder : Mother

The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee.

Premium Calculation :-
Net Premium (Rs.) 5324.00
Discounts (Rs.) 0.00
Loadings (Rs.) 0.00
Taxable Premium (Rs.) 5324.00
CGST@9% (Rs.) 479.16
SGST/UTGST@9% (Rs.) 479.16
IGST@0% (Rs.) 0.00
Any other Cess or Taxes (Rs.) 0.00
Gross Premium (Rs.) 6282.32
Gross Premium amount (in words) Rupees Six Thousand Two Hundred Eighty-Two and Paisa
Thirty-Two Only

The stamp duty of Rs. 1.00 /- (Rupees One Only) paid vide No.F.10(783)/COS(HQ)/Con.duty/08. (Not applicable for the state of Jammu & Kashmir).

Original for Recipient/ Duplicate for Supplier

Whether tax is payable on reverse charge basis No

Page 2 of 4
Claim Administrator : Apollo Munich For and on behalf of Apollo Munich Health Insurance Company Limited

Claim Administrator : Not Applicable

(For critical advantage rider)

Location : Gurgaon
Date : 20-Jan-2019 Authorized Signatory

Page 3 of 4
 Certificate for the purpose of deduction under Section 80 D of Income Tax Act, 1961*

This is to certify that MR AKASH VINAYKUMAR SHAH has paid Rs Rs.6282.32 for FY 2018-2019 (Rupees Six Thousand Two Hundred
Eighty-Two and Paisa Thirty-Two Only for Financial year 2018-2019) towards premium for Optima Restore Individual Policy No.
190100/11119/AA00999608 issued to Mr AKASH VINAYKUMAR SHAH for period 18-Jan-2019 to 17-Jan-2020.

For and on behalf of Apollo Munich Health Insurance Company Limited

Location:Gurgaon Authorized Signatory

Date :20-Jan-2019

* Note

1. This is subject to the provisions of Section 80D of Income Tax 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.
3. Please note that this certificate will not be issued if the premium payment has been made in cash.
4. In case of dishonour of the premium instrument, the policy will be deemed cancelled ab initio.
5. 80 D benefit is applicable for only Self, Spouse, Dependent Children and Dependent parents.

Page 4 of 4
 Copy of Proposal form
Member 3:

Name :

Proposal Form w w w. a p o l l o m u n i c h i n s u r a n c e . c o m
Date of Birth :
Height:
Gender:
Weight:
Application No. 7DLZ35H2KP Annual Income: Occupation:
Relationship to Policy Holder: Plan
Product opted : Mobile No :
This is an application for Insurance. Every Information this application seeks is important. Please read all questions and answer them
carefully. You must provide complete and correct information. Incomplete/incorrect/partially correct information may lead to cancellation
of proposal and policy even if it is issued. It is not obligatory for us to accept any risk or issue policy to anyone. Regulations mandate that
the coverage can incept only after we have received the full amount of premium and have explicitly accepted the risk Member 4:

Please fill-up this form in capital letters. (Please leave a space after every word) Name :
Date of Birth : Gender:
Height: Weight:
1. Please tell us about yourself Annual Income: Occupation:
Name : MR. AKASH VINAYKUMAR SHAH Relationship to Policy Holder: Plan
GSTIN/ UIN (if any) of Policy Holder
Product opted Mobile No :
Address : 44 RAKHIYAL VILLAGE ROAD, RAKHIYAL STATION RAKHIYAL

City / District : GANDHINAGAR State : GUJARAT Member 5:

Marital Status : SINGLE Pin Code : 382315
Mobile No. : 9979967627 Country : INDIA Name :
Landline No. : Nationality : INDIAN Date of Birth : Gender:
Height: Weight:
Email id [This is your user id to log in to our customer wellness portal] Annual Income: Occupation:
SHAHAKASH277@GMAIL.COM Relationship to Policy Holder: Plan
Do you want to save Planet Earth? Product opted : Mobile No :
The answer to the question is evident but the irony is we all choose wrong option.Here is chance to do right
I choose to go digital with verified & digitally signed documents accessible anytime, anywhere at my fingertips. Yes No
I choose e-insurance account to view or download policy details from an Insurance Repository & hereby give my
Yes No
consent to share my KYC details including Aadhaar No. & PAN with the Insurance Repository. Member 6:
I choose to have a hard copy as a proof of my policy although it means I am being unprotective to the environment. Yes No
Name :
*The address mentioned is same as the address mentioned in GSTIN registration certificate
Date of Birth : Gender:
Height: Weight:
2. Please tell us more about members you would like to insure in this (Include your details if you would also like to be insured)
Annual Income: Occupation:
Member 1:
Relationship to Policy Holder: Plan
Name : MR. AKASH VINAYKUMAR SHAH Product opted : Mobile No :
Date Of Birth: 22/06/1995 Gender: M
Height: 5.5 FT Weight: 68 Kgs
Annual Income: 350000 Occupation: COMPUTER ANALYST /
Relationship to Policy Holder:POLICY HOLDER Plan Tenure : 1 Year
Product opted : OPTIMA RESTORE Mobile No : 9979967627 3. EXISTING/PREVIOUS INSURANCE DETAILS *
Is the proposer or the persons proposed, already insured under a plan with Apollo Munich Health Insurance Company Limited or any
other insurance company? No
If yes, please indicate below the Policy/ Application number(s) (Please mention application number incase of pending proposal.)
Member 2: Since when are you continuously insured:
Do you want Us to consider these details for continuity*?
Name :
Date Of Birth: Gender: Policy No./ Period of Insurance Sum Insured Claims lodged Status of Previous
Height: Weight: Application No. Previous Insurer application(s) if any
From To (Rs.) during the
Annual Income: Occupation:
Relationship to Policy Holder: Plan Tenure :
Product opted : Mobile No :

1 * Please note that continuity of benefits shall NOT be considered if the details are not provided.
2

4. PLEASE PROVIDE US WITH INFORMATION ON MEDICAL HISTORY AND LIFE STYLE OF ALL MEMBERS INCLUDED IN THIS POLICY
Medical History: Please answer the below mentioned questions individually in Yes(Y)/No (N).
Member Member Member Member Member Member
Section A: In respect of any of the persons proposed to be insured:
1 2 3 4 5 6
Has any application for life, health, hospital daily cash or critical illness insurance ever
been declined, postponed, loaded or been made subject to any special conditions by any N
insurance company?

Section B: Have any of the person proposed to be insured ever suffered from/ are currently suffering from any of the following.
I. Hypertension, Chest pain, Ischemic heart disease or any other cardiac disorder? N
II. Tuberculosis, Asthma, Bronchitis or any other lung/respiratory disorder? N
III.Ulcer(stomach/duodenal), Hepatitis, Cirrhosis or any other digestive or liver/
gallbladder disorder? N

IV. Renal failure, Calculus or any other kidney/urinary tract or prostate disorder? N
V. Dizziness, Stroke, Epilepsy, Paralysis or other brain/ nervous system disorder? N
VI. Diabetes, Thyroid disorder or any other endocrine disorder? N

VII. Tumor-benign or malignant, any ulcer/growth/cyst? N

VIII. Arthritis, Spondylosis or any other disorder of the muscle/bone/joint? N

IX. Diseases of the Nose/Ear/Throat/Teeth/ Eye ( please mention Diopters )? N
X. HIV/AIDS or sexually transmitted diseases or any immune system disorder? N
XI. Anaemia, Leukaemia or any other blood/lymphatic system disorder? N
XII. Psychiatric/Mental illnesses or Sleep disorder? N
XIII. DUB, Fibroid, Cyst/Fibroadenoma or any other Gynaecological/Breast disorder? N
XIV. Been addicted to alcohol, narcotics, habit forming drugs or been under detoxication
therapy? N
Section C: Have any of the persons proposed to be insured:
I. Been under any regular medication (self/ prescribed)? N
II. Undertaken any lab/blood tests, imaging tests viz. scans/MRI in the last 5 years? N
III. Undertaken any surgery or been advised surgery in the last 10 years or have a surgery
still pending? N
IV. Suffered from any other disease/illness/accident/injury? N
V. Been informed that they are Pregnant? If yes, please mention the expected date of
delivery____________?
N

VI. Had any complaint of Diabetes, Hypertension or any complication during current or N
earlier pregnancy?

Section D: Name & details of Illness/ Medicine/Test/Surgery/Diopter grade (for questions answered as Yes in Section B & C above) attach
additional sheet, if required.
Diagnosis Date of last
Insured Name Exact diagnosis
date consultation

Section E: Name, address, qualification and contact details of the family doctor, if any
Name :
Address :
Qualification : Phone/Mobile
Email :

Section F: Does any person proposed to be insured Alcohol Pan Masala/

consumes alcohol, smoke or consume gutkha/pan masala or (30ml pegs of Hard Liquor/ Smoker Gutkha Others
alcohol. If yes please indicate the name and quantity per Bottles of Beer/ Glass of (No. of pouches)
week. Wines)
MR. AKASH VINAYKUMAR SHAH No No No

(If there is insufficient space to provide additional relevant information, whether as requested or otherwise, please attach extra sheet duly signed.)

A9059715_AA00999608
 Copy of Proposal form
5. PLEASE TELL US WHO YOU WOULD LIKE TO NOMINATE
In the event of the death of an Insured Person, any payment due under the Policy shall become payable to the nominee in accordance with
the Policy terms and conditions. The nominee must be an immediate relative of the Proposer. Nominee for any of the persons proposed to
be insured shall be the Proposer.

Nominee Name Relationship

MRS. PRITI MOTHER
Address of Nominee : 44 RAKHIYAL VILLAGE ROAD, RAKHIYAL STATION RAKHIYAL GUJARAT 382315

*If the Nominee is minor, Name and Address of Appointee and Relationship with Minor:
Appointee Name Relationship

Address of Appointee :

6. PAYMENT DETAILS
Instrument type : CHEQUE

Instrument No. Name of the Premium Payor Relationship of Payor with Proposer

116554 AKASH VINAYKUMAR SHAH POLICY HOLDER

Bank Details Date Amount (in Rs.)

STATE BANK OF INDIA 18/01/2019 6282.32

Please make a A/c Payee Cheque/DD/Pay Order in favour of ‘Apollo Munich Health Insurance Company Limited’ only.
Section 41 of Insurance Act 1938 (Prohibition of rebates):
1) No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or continue an insurance in
respect of 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
premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate except such rebate as
may be allowed in accordance with the prospectus or tables of the insurers.
2) Any person making default in complying with the provisions of this section shall be punishable with fine which may extend to five
hundred rupees.

7. AGENT’S DECLARATION
I, NIRENKUMAR PATEL in my capacity as an Insurance Advisor/ Specified Person of the Corporate
Agent/Authorised employee of the Broker/Relationship Officer, do hereby declare that I have explained all the contents of this Proposal
Form, including the nature of the questions contained in this Proposal Form to the Proposer including statement(s), information and
response(s) submitted by him/her in this Proposal Form to questions contained herein or any details sought herein will form the basis of
the Contract of Insurance between the Company and the Proposer, if this Proposal is accepted by the Company for issuance of the Policy.
I have further explained that if any untrue statement(s)/ information/response(s) is/are contained in this Proposal Form/including
addendum(s), affidavits, statements, submissions, furnished/to be furnished, the Company shall have the right to vary the benefits which
may be payable and further more if there has been a non-disclosure of any material fact, the policy issued to his/her favour pursuant to this
Proposal may be treated by the Company as null and void and all premiums paid under the Policy may be forfeited to the company.
License No.(Advisor/Corporate Agent/Broker/Relationship Officer : 80098120

Date 18/01/2019 Place: Ahmedabad BO

A9059715_AA00999608
Policy:
190100/11119/AA00999608
Member ID Insured Name
10018730893 Mr AKASH VINAYKUMAR SHAH
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Terms and Conditions
(1) This card would be valid till your relationship with AMHI / This card is invalid if the policy is
cancelled (2) In case of renewal please refer original policy number (3) This card is issued for the
purpose of identification only and does not entail automatic cashless facility at the network hospital.
(4) In case of photo-less card, a photo ID issued by any government authority is to be produced to
avail cashless facility. (5) Please apply for cashless facility 48 hours prior to admission in case of
planned admissions and within 24 hours of admission in case of emergency.(6) All terms and
conditions of the policy would be applicable while processing your cashless request. (7) In case your
cashless facility is denied due to any reason, please submit the claim for reimbursement. Denial of
cashless facility does not indicate rejection of the claim. (8) Please read policy documents carefully
for detailed terms and conditions. For more details on risk factors, terms and conditions please read
sales brochure carefully before concluding a sale.
Apollo Munich Health Insurance Co. Ltd. Central Processing Center, 2nd & 3rd Floor, iLABS Centre,
Plot No. 404/405, Udyog Vihar, Phase-III, Gurgaon-122016, Haryana. Corp. Off. 1st Floor, SCF -19,
Sector - 14, Gurgaon - 122 001, Haryana. Reg. Off: Apollo Hospitals Complex, 8-2 293/82/J
III/DH/900, Jubilee Hills, Hyderabad-500033, Telangana.•Website: www.apollomunichinsurance.com
•Toll Free: 1800 102 0333 • IRDAI Reg. No.: 131• CIN: U66030TG2006PLC051760