Office Copy

UNITED INDIA INSURANCE COMPANY LIMITED

133, JEHANGIR BUILDING M.G.ROAD, FORT MUMBAI, MUMBAI, MAHARASTRA
GREATER MUMBAI 400001 MAHARASHTRA
PH: (022) 22673960 FAX: EMAIL:

CORONA KAVACH POLICY, UNITED INDIA

UIN NO. UIIHLIP21085V012021
POLICY NO.: 0206002821P100753912

PERIOD OF INSURANCE
FROM 00:00 Hrs on 25/04/2021
To MIDNIGHT on 03/02/2022

Insured
MR RN LOKESH
T/III/10 N T H COMPLEX PLOT NO F10 ANDHERI EAST CENTRAL ROAD MIDC OPP SEEPZ MUMBAI

400093
MUMBAI
MAHARASHTRA

IMPORTANT NOTICE: KINDLY UPDATE YOUR AADHAAR NO. AND PAN/FORM 60. PLEASE IGNORE IF ALREADY UPDATED.

Agent Name : BHAVNA VISHAL KAMBLI

Agent Code : AGN1010251
8454993314
Mobile/Landline Number/Email :
rahulsawant1975.rs@gmail.com

The genuineness of the policy can be verified through "Verify Your Policy" link at www.uiic.co.in.

For any Information, Service Requests and Grievances please write to 020600@uiic.co.in

For ID Cards & Claim Intimations Please contact the TPA mentioned in the Policy document.

Download Customer App(www.uiic.co.in). REGD. & HEAD OFFICE, 24, WHITES ROAD, CHENNAI - 600014.
Website: http://www.uiic.co.in
Printed By : CUSTOMER @ 19/04/2021 3:21:50 PM

Office Copy

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Office Copy
POLICY NO.:0206002821P100753912
UIN NO. UIIHLIP21085V012021
CORONA KAVACH POLICY, UNITED INDIA

CORONA KAVACH POLICY, UNITED INDIA

Previous
Policy Number 0206002821P100753912
Policy No.
Name/ID MR RN LOKESH /23099776217
Tel.(O) Tel.(R) Fax
Insured Detail
EMail rajupetalokesh@gmail.com Mobile 8097267559
Business/Occupation None
Period Of Insurance From 00:00hrs of 25/04/2021 To Midnight on 03/02/2022
Policy Type Family Floater Basis Daily Cash Benefit Opted Yes

Coinsurance UIIC 020600 : 100%

Insured Details

Sl no Insured Name Date of Birth Gender Relation Occupation Nominee Name Nominee Relation
1 R N LOKESH 01/01/1983 Male Self Salaried KEERTHI J A Spouse
2 KEERTHI J A 20/12/1993 Female Spouse Housewife R N LOKESH Spouse
3 VIKRANTH R L 09/01/2017 Male Dependent Children Student R N LOKESH Father

Family Floater Sum 500,000.00

Insured( )

Total Basic Premium( ) 3,861.00 Premium: 4,356.00

Add Daily Cash Benefit Premium( ) 495.00 CGST(9%): 392.00
Less Health Worker Discount( ) 0.00 SGST(9%): 392.00
Stamp Duty: 1.00
Less Rural Discount( ) 0.00
Total: 5,140.00
Less Online Discount( ) 0.00 Receipt Number : 10102060021100603610
Receipt Date: 19/04/2021

Agent Name BHAVNA VISHAL KAMBLI Agent/Broker Code AGN1010251

Development Officer Name Development Officer Code

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Office Copy
POLICY NO.:0206002821P100753912
UIN NO. UIIHLIP21085V012021
CORONA KAVACH POLICY, UNITED INDIA

Customer GST/UIN No.: Office GST No.: 27AAACU5552C1ZJ

SAC Code: 997133 Invoice No. & Date: 2821I100753912 & 19/04/2021
Amount Subject to Reverse Charges-NIL

Anti Money Laundering Clause:-In the event of a claim under the policy exceeding 1 lakh or a claim for refund of premium exceeding
1 lakh, the insured will comply with the provisions of AML policy of the company. The AML policy is available in all our operating offices as
well as Company's web site.

LET US JOIN THE FIGHT AGAINST CORRUPTION. PLEASE TAKE THE PLEDGE AT https://pledge.cvc.nic.in.

Date of Proposal and Declaration: 25/04/2021

IN WITNESS WHEREOF, the undersigned being duly authorised has hereunto set his/her hand at DO 6 MUMBAI 020600 on this 19th day of
April ,2021.

For and On behalf of

United India Insurance Co. Ltd.
Affix
Policy
Stamp
Here

Authorised Signatory.
Underwritten By - SHI29405 ( DO UW CUM CASHIER )

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 POLICY NO.: 0206002821P100753912
UIN NO. UIIHLIP21085V012021
CORONA KAVACH POLICY, UNITED INDIA

Details of TPA:
Please contact the following TPA for Issue of Identity Cards, Cashless Approvals & Claims Settlement.

Name of TPA M/s Raksha TPA Pvt. Ltd.

Address 15/5, Mathura Road, Faridabad, Pin Code : 121003, Fax No :
Toll Free number 18001801444
Contact Details For General Enquiries For Cashless approval For Claim intimation For Grievances
Telephone Numbers 0129-4289999 0129-4289999 0129-4289999 0129-4289999
Email IDs crcm@rakshatpa.com cashless@rakshatpa.com claimintimation@rakshatpa.com crcm@rakshatpa.com

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 POLICY NO.:0206002821P100753912
UIN NO. UIIHLIP21085V012021
CORONA KAVACH POLICY, UNITED INDIA

UNITED INDIA INSURANCE COMPANY LIMITED

133, JEHANGIR BUILDING, M.G.ROAD, FORT MUMBAI, MUMBAI, MAHARASTRA ,
GREATER MUMBAI - 400001 MAHARASHTRA
PH: (022) 22673960 FAX: EMAIL:
Premium Certificate for the purpose of deduction under Section 80-D of Income Tax
(Amendment) Act, 1986.

This is to certify that MR RN LOKESH has paid 5,140.00 towards Premium for CORONA KAVACH POLICY, UNITED INDIA for the period from
00:00 Hrs on 25/04/2021 To Midnight of 03/02/2022

Policy No: 0206002821P100753912

For and On behalf of

United IndiaInsurance Co. Ltd.

Place: DO 6 MUMBAI 020600

Date:19/04/2021 3:21:50 PM

Authorised Signatory

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 premium.

REGD. & HEAD OFFICE, 24, WHITES ROAD, CHENNAI - 600014

Website: http://www.uiic.co.in, Email - info@uiic.co.in

This is a system generated document and any manual alteration / correction / overwriting in the document will make it invalid.

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