UNITED INDIA INSURANCE COMPANY LIMITED

Divisional Office : 010500

Catholic Centre, 64, Armenian Street, Chennai 600001
POLICY-CUM-CERTIFICATE FOR AROGYA RAKSHA
UIN NO. IRDA/NL-HLT/UII/P-H/V.1/386/13-14
Policy Particulars
Policy Number 0105002019484100001086226 Bank Reference Number 014477847
Policy Validity Period From Date To Date
01/11/2019 31/10/2020
Policy Plan B Sum Insured 500000

Bank Details
Branch Code Branch Name Account Number Voucher Date
I013 IB BANCASSURANCE 408306913 14/10/2019 18:23:43
SERVICE
Previous Insurance history
Previous Policy From Date To Date
null null null

Premium Overview
Proposer Details Mediclaim PA Premium GST Total Amount (Incl.
Premium GST )
RAMAN SAXENA 9773 296 IGST@18% : 1812 11881
HOUSE NO 12 R P S COLONY;
OPP KHANPUR BUS DEPOT MADANGIR;
NEW DELHI
SOUTH DELHI,Delhi,
Pin:110062,
Mob : 9313881060 / Phone: -
Mail: -
In case you have a policy other than Arogya Raksha, the onus is on you to give the copy of the previous year policy
details as well as the claim details.
NOMINEE DETAILS: Name:SHAGUN, Relation: DAUGHTER

Third Party Administrator Details

GoodHealth TPA Services Good Health TPA Services Ltd , Plot No 49,Nagarjuna Hills
Panjagutta, Hyderabad 500082.
Email:customer.care@ghpltpa.com

TOLL FREE: 18604253232 | Web: http://goodhealthtpa.com

Policy Issuing Office Details

United India Insurance Company Ltd., DO CATHOLIC CENTRE , Office Code 010500 , Catholic Centre, NO.64,
Armenian street, ChennaI - 600001,
OFFICE GST No.: 33AAACU5552C1ZQ,Phone: 044-25389793/25389794 , Fax: 044-25386298,
E-mail: arogyaraksha@uiic.co.in
Download policies/ provisional e-cards at:http://portal.uiic.in/ArogyaSuraksha/renewLandingCustomer.jsp

Details of family members covered (* Pre-Existing Diseases within 36 months prior to the first
policy are not covered.)
Sl. Name Birth Date Sex Relation Medical History Treatment Taken
No
1 RAMAN SAXENA 17/11/1951 M SELF
2 SUNITA SAXENA 25/11/1956 F SPOUSE

Declaration
Policy subject to terms, conditions, exclusion and definitions. Summary of terms and conditions of the policy can be
downloaded from http://portal.uiic.in/ArogyaSuraksha/renewLandingCustomer.jsp. The detailed terms and conditions
can be obtained from Indian Bank branch or United Inda Insurance Company Office . The proposal and declaration
by the insured is the basis of this contract and deemed to be incorporated.

Date 14/10/2019 18:23:43 Authorized signatory

 INDIAN BANK
IB BANCASSURANCE SERVICE
CERTIFICATE OF MEDICAL INSURANCE PREMIUM PAID
(for the purpose of deduction u/s 80 D of the Income Tax Act, 1986)

This is to certify that Mr.RAMAN SAXENA having account number 408306913

with Indian Bank, has paid Rs 9773/- at Indian Bank branch IB BANCASSURANCE
SERVICE
for Medical Insurance as premium for policy no: 0105002019484100001086226 on 14/10/2019 18:23:43
for Indian Bank Arogya Raksha Policy under PLAN B

For Indian Bank

.
Date ____ /____ / _______

Branch Manager