Digitally signed by VINAY JANPAMULA

Date: 2020.06.29 16:15:49 +05:30

Mrs M Madhavi Latha This Policy Kit contains:

Plot No 2 Kalyan Gardens,yapral sainikpuri,,Secunderabad, - 1. The Policy Schedule along with income tax (80 D)
500094,Andhra Pradesh,India certificate (wherever applicable)
Contact No.: 9440845841 2. Cashless card*
Policy No: 110103/11121/AA01151442-01

Renewal of Your Optima Restore Floater Insurance Policy

Dear Mrs M Madhavi Latha,

Thank You for renewing the policy with us.

We are pleased to enclose your renewed Policy Kit for the period 05-Jul-2020 to 04-Jul-2021.

To know more about policy related information and value added offers, you may re-register yourself at our website using
your unique member ID and policy number as mentioned in the policy schedule.

In case of any query, please feel free to write to customerservice@hdfcergohealth.com or call us at our 24 hours toll free
number 1800-102-0333. Our customer care team will be happy to assist you.

Warm Regards,

Location: Gurgaon
Authorized Signatory Date: 29-Jun-2020

Note:-
- Please visit our website www.hdfcergohealth.com to access information about our company, the customer service touch
points including the Grievance handling process and various forms 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.
- 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.
- Coverage is not available for the period for which no premium is received.
* Cashless Card as enclosed would be issued only once along with this policy kit and shall remain valid for further renewa

Intermediary Code Intermediary Name Intermediary Contact No

80189584 POLICYBAZAAR INSURANCE WEB 18001020333
AGGREGATOR PL
 Policy Schedule - Optima Restore Floater
Issuing/Servicing Office Details

Address Gurgaon Sales Office,FF,SCF -19, Sector - 14,Gurgaon,Gurgaon,Haryana-122001,PH : 01244979333

GSTIN 06AAGCA1654H1ZW
Policy Holder Details
Name Mrs M Madhavi Latha
GSTIN/ UIN
Address Plot No 2 Kalyan Gardens,yapral sainikpuri,,Secunderabad, - 500094,Andhra Pradesh,India
State Name & Code Andhra Pradesh(37) Place of Supply Secunderabad (Andhra Pradesh)
Policy Details
Policy Number 110103/11121/AA01151442-01
First policy inception date 05-Jul-2019 Policy issuance date 29-Jun-2020
Policy Period From 00:01 hrs on 05-Jul-2020 To 24:00 hrs on 04-Jul-2021
Intermediary Details
Name POLICYBAZAAR INSURANCE WEB AGGREGATOR PL
Code 80189584 Contact No 18001020333

Member and Product Details

Particulars Member 1 Member 2 Member 3 Member 4 Member 5 Member 6
(Mrs M Madhavi (Baby R Sri Lakshmi
Latha/10021486925) Durga/1002148692
6)
Date of Birth 18/07/1969 25/02/2001 - - - -
(Age) (50) (19)
Relationship with Policy Holder Daughter - - - -
Policyholder
Base Sum Insured Rs. 1500000
(SI)
Multiplier Benefit Rs. 500000
SI/Cumulative
Bonus
Protector Rider: -
Sum Insured
Protector SI
Total Sum Insured Rs. 2000000

Other Riders & Benefits

Protector Rider -
Hospital Daily -
Cash Rider SI
(max 30 Days)
Critical Advantage - - - - - -
Rider SI
IPA Rider SI - - - - - -
Nominee Details

Name Mr Mvs Vidyasagar Relationship Husband

The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee.
Premium Calculation(in INR)

Net Premium 22284.00 CGST@0% 0.00

Discounts 0.00 SGST/UTGST@0% 0.00

Loadings 0.00 IGST@18% 4011.12

Taxable Premium 22284.00 Any other Cess or Taxes 0.00

Gross Premium 26295.12

Gross premium amount (in words) Rupees Twenty-Six Thousand Two Hundred Ninety-Five and Paisa Twelve Only

The stamp duty of Rs. 1.00/- (Rupees One Only) paid vide e-stamp Certificate No. IN-DL-DL42844961502751O. (Not applicable for the state of Jammu & Kashmir)

Original for Recipient/ Duplicate for Supplier

Whether tax is payable on reverse charge basis: No

Description/ Harmonized System Of Nomenclature Code: Accident and Health insurance Services/9971

Exclusion(s) / Special Condition(s) (Refer the leaflet attached in the policy document w.r.t. exclusions) :
Member ID No. Name Exclusion Type Applicable Health Condition Exclusion Portability/
on SI Duration Renewal Benefit
(Years)
10021486925 Mrs M Madhavi Latha For Rs 1000000 (Rupees Ten Lakh)
Sum Insured - Sec 5 A (i) of the
policy wording is waived, Sec 5 A (ii)
is reduced to 1 year and Sec 5 A (iii)
is reduced to 2 years.
10021486926 Baby R Sri Lakshmi Durga For Rs 1000000 (Rupees Ten Lakh)
Sum Insured - Sec 5 A (i) of the
policy wording is waived, Sec 5 A (ii)
is reduced to 1 year and Sec 5 A (iii)
is reduced to 2 years.

Claim Administrator: HDFC ERGO HEALTH INSURANCE LTD. For and on behalf of HDFC ERGO Health Insurance Ltd.

Claim Administrator: HDFC ERGO HEALTH INSURANCE LTD.

(For critical advantage rider:)

Location: Gurgaon

Date: 29-Jun-2020 Authorized Signatory

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

This is to certify that the M Latha has paid Rs 26295.12 (Rupees Twenty-Six Thousand Two Hundred Ninety-Five and Paisa Twelve
Only ) towards premium for Optima Restore Floater Policy No 110103/11121/AA01151442-01 issued to Mrs M Madhavi Latha
for period 05-Jul-2020 to 04-Jul-2021.
Location: Gurgaon For and on behalf of HDFC ERGO Health Insurance Ltd.
Date: 29-Jun-2020

Authorized Signatory

*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. 80D benefit is applicable for only Self, Spouse, Dependent Children and Dependent parents