Service Office

IFFCO TOKIO General Insurance Co. Ltd

4th & 5th Floor IFFCO Tower
Plot No-3 Sector- 29
GURGAON HARYANA
IFFCO-TOKIO GENERAL INSURANCE CO.LTD 122001 INDIA
Regd. Office: IFFCO Sadan C1 Distt. Centre, Saket, New Delhi – 110017 GSTIN : 06AAACI7573H1ZG
CIN No: U74899DL2000PLC107621 General insurance Service :9971
Phone No:
Agent Name:
Family Health Protector Policy Schedule Agent No: 74 - DIRECT SBU CODE
Agent Mobile No: 74000002 18001035499
Cum Tax Invoice

Insured's Name: RAGHAVENDRA KAMATH

Address: 1st floor, Ocean Side retreat, opp Aquamarina CHS, Policy Invoice No- 1-19YZR0W7
Grande Vanelim, Olva, ,
CRM ID : 1-19YZR0W7
SOUTH GOA GOA INDIA
Policy No : H0225594
Pin Code: 403708 Phone No: 8970076007 Period of Insurance : From: 27/11/2019 13:55:11
Emergency Contact No : 8668444623 To: Midnight on 26/11/2020 00:00:00
Cover Note No:
State Code: 30 GSTIN :
Country : INDIA State :GOA

Nominee name Relationship % Share

Anjali Mehta Spouse 100

Coverage Details
Basic Sum Inusred For Family : 400000 Critical Illness Rider Sum Insured : 400000

Cumulative Bonus : 20000 Total Floater Sum Insured : 820000

Add on Covers Opted

Yes Room Rent Waiver Rider : Yes
Critical Illness Rider :
*( Room Rent Rider Applicable for SI <7 Lac)

Insured Details
No of
PED/
Room Fresh / years of
Relationship Critical Total Medical
Basic Rent ITGI past
Insured DOB Gender With illness Discount Premium History
Premium Waiver Renewal / continu
Insured Premium *(YES/
Premium Portability ous
NO)
Policy
4035.96
01/10/1992 FEMALE Spouse 3636 1090.8 218.16 -909 No ITGI Renewal 1
ANJALI MEHTA
6209.34
RAGHAVENDRA 26/09/1985 MALE Self 5594 1678.2 335.64 -1398.5 No ITGI Renewal 1
KAMATH

Total 9230.00 2769.00 553.80 -2307.50 10245.30

PED (Pre - Existing Diseases) / Medical History Details

Insured person(s) Description of pre-existing/Medical History -Illness/condition Medical History (As Selected in Proposal)

Insured Previous Policy Detail

Insured Previous Insurer Policy Start date End date Type of Sum Cumulative Claim Y/N
Number insurance Insured Bonus
IFFCO TOKIO GEN H0021407 03/11/2018 02/11/2019 Floater 400000.00 0 No
ANJALI MEHTA INS CO LTD

IFFCO TOKIO GEN H0021407 03/11/2018 02/11/2019 Floater 400000.00 0 No

RAGHAVENDRA INS CO LTD
KAMATH

Signature Not Verified

Digitally signed by SUBRATA MONDAL Policy No-H0225594 Page 1 of 2
Date: 2019.11.27 17:39:13 IST
Reason: Valid Policy Copy
Location: IFFCO Tokio General Insurance Company Ltd, India
 GST Details
CGST SGST UGST IGST CESS
Percentage 18
Amount 1844.16

Total Gross Premium (Taxable Value) Rs. 10245.30 Net Payable Premium ( Total Invoice Value) Rs . 12089.45

1. In case of dishonor of cheque for any reason whatsoever, cover provided under this document automatically stands cancelled from the inception irrespective of whether a separate
communication is sent or not.

2. The above records with respect to Pre- Existing illness/condition etc, are declared by the insured. If the nomination given above is found to be either incomplete or incorrect or concealed at
the time of claim the same shall be construed as non disclosure of material fact.

3. DOMICILIARY HOSPITALIZATION: The Maximum aggregate sub-limit for Domicillary Hospitilisation is 20% of Basic Sum Insured.

4. LIST OF NETWORK HOSPITALS AND EXCLUDED HOSPITALS: The policy provides for cashless treatment at Network hospitals. However, it does not pay for cost of any
treatment (both cashless & reimbursement) in specified excluded hospital(s). list of network hospitals And excluded hospitals is given in the enclosed booklet "LIST OF NETWORK
HOSPITALS AND EXCLUDED HOSPITALS". This list is dynamic and may change from time to time. You are advised to check our website or contact our call centre for updated list of
such excluded hospitals/medical practitioners before hospitalisation/treatment.

5. NON PAYABLE ITEMS: The policy does not cover certain non payable items, list of which is given as an annexure "LIST OF NON PAYABLE ITEMS" in this booklet.

6. FOR EMERGENCY SERVICE PROVIDER: Assist America medical service (India) private limited. :Toll Free: 1800-425-2955(for BSNL/MTNL landline as well as cellular callers ).
For Other Callers : 040-23321204 (call Charges applicable )

7. In case of exports of services invoice shall carry an endorsement "Supply meant for export on payment of integrated tax"

Claim Serviced by : IFFCO TOKIO General Insurance Co. Ltd. Call Centre : 1800-103-5499(Toll Free); (0124) 4285499 (Local /STD Charges will be applicable ); SMS 56161

Premium Certificate for the purpose of Deduction under Section 80D of Income Tax Act 1961.

Premium Details as per Receipt Particulars are given below:

Receipt Particulars: S.Tax.No. AAACI7573HST001

Pay Method Receipt Amount Instrument No. Instrument Date Bank
ONLINE BANKING 12089.46 530243 27/11/2019
Amount Received 12089.46
This is to certify that Shri/Smt RAGHAVENDRA KAMATH has paid Rs. 12089.45 by ONLINE BANKING towards premium for Family Health
Protector policy H0225594, for period from 27/11/2019 to 26/11/2020
In witness whereof, the undersigned being duly authorized has hereunto set his/her hand at Gurgaon at this 27/11/2019.
For IFFCO-TOKIO General Insurance Co. Ltd
Policy issuing office : Delhi
Consolidated Stamp duty deposited as per order of Government of national
capital Territory of Delhi Subrata Mondal
Authorised Signatory

Steps to validate digital signature on Policy Document:

Open Digitally signed pdf document -->Click on the Digital signature-->Go to 'Show Signature Properties' -->Click on 'Show signer's Certificate'-->Go to Tab 'Trust'--
>Click on 'Add to Trusted Certificates'-->Click on 'OK'-->Click on 'Close'.

Reopen the Pdf, you will see a right symbol on the signature.

Signature Not Verified

Digitally signed by SUBRATA MONDAL Policy No-H0225594 Page 2 of 2
Date: 2019.11.27 17:39:13 IST
Reason: Valid Policy Copy
Location: IFFCO Tokio General Insurance Company Ltd, India