HDFC ERGO General Insurance Company Limited 3317202456391100002

Policy Schedule - Endorsed Copy

Personal Accident Insurance Policy
(Plan 5)

3317202456391100002

Policy No. :3317 2024 5639 1100 002 Issuance Date : 04/02/2019
Period of Insurance :From 16/10/2018 20:09 hrs To 15/10/2021 Midnight
Invoice No. :202456391100002 Policy Type :Individual
Proposer Name :Mr Rana Biswas 1st Policy Inception :16/10/2018
1
HSN Code :997133 Territorial Limits :Worldwide
MR RANA BISWAS
18 ANANTA HARI MITRA ROAD,NEADIAR Customer Id :101182363589 Premium Frequency :Single
PARA,P.O.- KRISHNANAGAR, DIST- NADIA PAN
KRISHNAGAR, WEST BENGAL, 741101
Contact No : 9475362724 ,
Email ID : mechanical.rana98026@gmail.com
Insured Person’s Details
Insured’s Name Relationship Date of Birth Name of Nominee Relation Benefit
Rana Biswas Self 20/06/1979 Adrija Rana Biswas C 100 %
Sum Insured (`)
Coverage

Accidental Death 25,00,000

Ambulance Costs 10,000
Animal Attack 50,000
Assault 1,25,000
Broken Bones 1,00,000
Burns Benefit 3,00,000
Comatose Benefit - Accident Only 10,00,000
Dependent Child Education Benefit 2,50,000
Dependent Girl Child Wedding Benefit 1,00,000
Emergency Medical Expenses (Accident Only) Subject admissible claim under AD/PD/TTD 20,000
10% of the AD/PD/TTD SI or 40% of admissible claim amount or Rs. 50,000 whichever is lower
Evacuation 1,00,000
Family Counselling 50,000
Hospital Cash - Accident Only (Payable Max upto 30 days) 1,000/day
In-Hospital Medical Expenses - Accident Only 1,00,000
Last Rites Costs - Accident Only 25,000
Medical Insurance Premium Indemnity 20,000
Parental Care Benefit 50,000
Permanent Disability (PTD+PPD) (Table D) 25,00,000
Temporary Total Disability (Up to 104 weeks) 5,000/Week
Premium Details ( ` )
Basic Premium 7813.00
Tax as Applicable 1406.00
Total Premium 9219.00
List of Endorsements
Endt No Description Effective Date End Date Premium (In ` )
001 Change in Insured Name 16/10/2018
002 General Endorsement 16/10/2018
For Claim/Policy related queries call us at +91- 22 6234 6234/+91- 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim.

Special Condition :
• Under Coverage “Hospital Cash - Accident & Sickness” , per day limit of hospitalization is Rs. 2000.
• Payment of Hospital daily cash benefit is restricted to 30days within a Certificate of Insurance period.
• One day deductible will be applicable for each and every claim.
• Any disease contracted by the Insured Person during the first thirty (30) days from the commencement date of the policy will not be covered.
• Pre existing diseases are covered from 31st day of coverage commencement date.
• 2 year waiting period for specific Illness and treatment is not applicable.
• Maternity related hospitalization is not covered.
• Territorial limit for Hospital Cash - Accident & Sickness is restricted to India only.
• Income proof is required for only Permanent Disablement cover.
I f the premium i s not realised the policy shall be void from inception. Subject otherwise to the terms,exclusions and conditions of this policy. The Maximum Compensation in respect of an Insured Person under
the policy shall not exceed 10 times the Annual Income (as declared in the Proposal Form). Income proof for availing the compensation at the time of claim is mandatory. Income proof shall mean the previous
year’s returns filed with the Income Tax Department.
Consolidated stamp duty for this Insurance Policy i s paid b y Demand Draft, vide Receipt/Challan noCSD/362/2020/1302 dated 20/03/2020 a s prescribed in Government of Maharashtra Order No. Mudrank-
2017/CR.97/M-1, dated the 09th January 2018;. .GST Registration No: 24AABCL5045N1ZE. GST for this invoice is not payable under reverse charge basis.

Branch :206, sec fl. shopper plaza iv,opp. bsnl tel exch rd, navarangpura ahmedabad

The Policy wording available at www.hdfcergo.com includes all the standard coverage offered by the Company to its customers. Your entitlement for coverage/benefits shall be restricted to the coverage/benefits as
mentioned in this policy schedule.

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFPAIP03002V010203. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited 331720245639110000

Personal Accident Insurance Policy

(Plan 5)

For HDFC ERGO General Insurance Company Ltd.

Agent Name :HDFC BANK LTD Agent Code :201587086428 Tel No. : 91-22-61606161

Duly Constituted Attorney

"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings."

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFPAIP03002V010203. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited 331720245639110000

Personal Accident Insurance Policy

(Plan 5)

TAX CERTIFICATE

Dear Rana Biswas,

Subject : Certificate for the purpose of deduction under section 80 D of Income Tax (Amendment) Act, 1986
This is to certify that we have received an amount of ` 923 towards premium for In-Hospitalization Medical Expenses (Accident Only) under Personal Accident
Insurance Certificate of Insurance No. 3317202456391100000 issued to Rana Biswas for the period 16/10/2018 to 15/10/2021.
Note : This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended from time to time.
For HDFC ERGO General Insurance Company Ltd.
Date : 04/02/2019

Policy Issuing Office: Mumbai

Duly Constituted Attorney

CUT HERE

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFPAIP03002V010203. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com