Group Medicare Certificate of Insurance

Group Medicare
Certificate of Insurance
Renewal Business-0239157260-00047908-SpeedPost-1-2920722
Intermediary Name : CANARA BANK
Issuing Office : GULBARGA
Name of the Policy Holder (Master Policy) : CANARA BANK Intermediary Code : CA0045
Intermediary Contact No : 18004250018
Name of Insured Person : MRS UMADEVI MALLINATH MATH .
Address : CO HOLKUNDA
GULBARGA
GULBARGA
KARNATAKA
585313 Branch Code : 90947
Business Type : Renewal Business
GSTIN No :
Master Policy No : 0239157260
Renewal No: 01
Endorsement No: 00
Certificate No : 00047908
Insured Person ID : CANARA2889196008
Place of Supply : KARNATAKA
State Code : 29
Contact details of Insured Person :
• Phone/Mobile No.: 9663444519 • Email id : cb1071@canarabank.com
Certificate Period : From 00:01 Hrs 06/04/2023 (Commencement date) To 23:59 Hrs 05/04/2024 (Expiry Date)
Date of First Policy inception with us : 26/03/2022
Type of Plan : Individual
Details of Insured Persons Covered :
Name Of The Insured Relationship With Date Of Bi Member Unique Sum Insured
Member ID Age
Person Insured Person rth Since ID (Rs.)
CANAR
0239157260/CANARA28 UMADEVI MALLINATH
Self 01/06/1958 64 17/03/2018 A28891 200,000.00
89196008/01 MATH
96008
Nominee Details :
Nominee Name Relationship With Insured Person
MAHADEV MATH Son
Details of Cover :
Covers Cover Details
In-Patient Treatment Upto Sum Insured, Rs.2,00,000
Pre/Post Hospitalization Expenses, 60/90 60 days pre hospitalisation and 90 days post hospitalisation, Rs.2,00,000
Day Care Procedures 541 Day Care Procedures Covered, Upto 100% of In-Patient Treatment Sum Insured
Domiciliary Treatment Covered, Upto 100% of In-Patient Treatment Sum Insured
Organ Donor Covered, Upto 100% of In-Patient Treatment Sum Insured
Ambulance Cover Covered up to Rs 2000 per hospitalisation, Upto Rs. 2,000
Family Transportation Benefit Covered within In-Patient Treatment Sum Insured Upto, Rs.2,00,000
Details of Additional Covers :
Additional Cover Cover Details
SI Rs 1lac benefit Rs 1500 & SI Rs 2lac benefit Rs 2000 & SI Rs 3lac benefit Rs 2200 & SI Rs
5lac benefit Rs 2500 & SI Rs 6lac benefit Rs 2800 & SI Rs 7.5 lac benefit Rs 3000 & SI Rs 10
lac benefit Rs 3500 & SI Rs 12 lac benefit Rs 3700 & SI Rs 15 lac benefit Rs 4000 & At the end
of each year We will pay upto the amount mentioned below towards the cost of a preventive
Health Check-up
medical check-up & This benefit is available ONLY to those Insured Persons who were
insured in the previous Policy Year & Any claim made in respect of this benefit will not be
subject to In-patient Sum Insured and will not affect entitlement to a Cumulative bonus,
Applicable for All Members,Upto Rs.4,000
Upto 5 lacs INR 500 for a max upto 30 days and Above 5 lacs INR 1000 for a max upto 30
Hospital Cash Benefit
days, Applicable for All Members, Per day amount Rs.500 Above SI Limit,No. Of Day :30
Automatic restore full sum insured if executed within same policy year, Applicable for All
Restore Sum Insured Benefit
Members,Upto Rs.200,000
Insurance is the subject matter of the solicitation.For more details on risk factors, terms and conditions, please read salesbrochure carefully before concluding a sale.
TATA AIG General Insurance Company Limited
Registered office : Peninsula Business Park, Tower A,15th Floor, G.K Marg,Lower Parel, Mumbai-400013
24*7 Toll free Number : 1800 266 7780 Email : customersupport@tataaig.com website : www.tataaig.com
IRDA of India Registration No : 108 CIN : U85110MH2000PLC128425 PAN:AABCT3518Q UIN :TATHLGP21248V022021
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Group Medicare
Details of Additional Covers :
Additional Cover Cover Details
Covered covered upto Rs 100000, Applicable for All Members,Maximum Amount Payable:
Emergency Air Ambulance Cover
Rs.100,000
Covered for Primary Insured Member & equal to 100% inpatient sum insured which is above SI
Accidental Death
limit, Applicable for Self,AD Sum Insured : Rs.0 Above SI Limit
Psychiatric Ailment Covered upto Rs 25000 on Inpatient basis, Applicable for All Members
Covered upto 100% of the SI in government hospital or in any institute recognized by
AYUSH Cover government and/or accredited by Quality Council of India, Applicable for All Members,100% of
In-Patient Treatment Sum Insured
Limit on Room Rent No Capping, Amount Mentioned/day Rs.
Covered for Primary Insured Member & equal to 100% inpatient sum insured which is above SI
Permanent Total Disability
limit, Applicable for Self, Permanent Total Disability SI : Rs.200,000
Details of Waiting Period :
Waiting Period Waiting Period Details Applicable To
Fresh Policy Not Waived Off (Applicable) and
30 Days Waiting Period Applicable for All Members
Renewal Policy Waived Off (Not Applicable)
Fresh Policy Covered after waiting period of
24 Months and First Renewal Covered after
Specified Disease Waiting Period waiting period of 12 Months and Second Applicable for All Members
Renewal Waived Off (Renewal include
portability with continuity)
Fresh Policy Covered after waiting period of
36 Months and First Renewal Covered after
waiting period of 24 Months and Second
PED Waiting Period Applicable for All Members
Renewal Covered after waiting period of 12
Months and Third Renewal Waived Off
(Renewal include portability with continuity)
Section 3 (General Exclusions – i, ii & iii) of the policy gets deleted and superseded by Section B12 – Waiting Period (B12.1, B12.2 & B12.3) of
Appendix II: Endorsements of this policy
Premium rates and/or scope of covers are subject to revision at the time of renewal under this policy
Important Exclusions
1.Investigation & Evaluation : (Code-Excl 04)
a) Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
b) Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded
2.Obesity/ Weight Control : (Code-Excl 06)
Expenses related to the surgical treatment of obesity that does not fulfill all the below conditions:
1) Surgery to be conducted is upon the advice of the Doctor
2) The surgery/Procedure conducted should be supported by clinical protocols
3) The member has to be 18 years of age or older and
4) Body Mass Index (BMI);
a) greater than or equal to 40 or
b) greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of
weight loss:
I. Obesity-related cardiomyopathy
II. Coronary heart disease
III. Severe Sleep Apnea
IV. Uncontrolled Type2 Diabetes
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Group Medicare
3.Cosmetic or plastic Surgery: (Code-Excl 08)
Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burns or
Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a
medical necessity, it must be certified by the attending Medical Practitioner.
4.Sterility and Infertility: (Code-Excl 17)
Expenses related to sterility and infertility. This includes:
i.Any type of contraception, sterilization
ii.Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
iii.Gestational Surrogacy
iv.Reversal of sterilization
5.Hazardous or Adventure Sports (Code Excl 09) : Expenses related to any treatment necessitated due to participation as a professional in
hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or
scuba diving, hand gliding, sky diving, deep-sea diving
6.Breach of law (Code Excl10): Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting
to commit a breach of law with criminal intent.
7.Intentional self-injury or attempted suicide while sane or insane.
8.Items of personal comfort and convenience like television (wherever specifically charged for), charges for access to telephone and
telephone calls, internet, foodstuffs (except patient’s diet), cosmetics, hygiene articles, body care products and bath additive, barber or beauty
service, guest service
9.Provision or fitting of hearing aids, spectacles or contact lenses including optometric therapy unless explicitly stated and covered in the
policy
10.Any treatment or part of a treatment that is not of a reasonable charge, not medically necessary; drugs or treatments which are not
supported by a prescription
Important Conditions.
1. Condition Precedent to Admission of Liability
The terms and conditions of the policy must be fulfilled by the Insured Person for the Company to make any payment for claim(s) arising under
the Policy.
2. Disclosure of Information
The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of mis-representation, mis-description or
non-disclosure of any material fact by the Policyholder (Explanation: "Material facts" for the purpose of this policy shall mean all relevant
information sought by the company in the proposal form and other connected documents to enable it to take informed decision in the context of
underwriting the risk)
3. Fraud
If any claim made by the Insured Person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support
thereof, or if any fraudulent means or devices are used by the Insured Person or anyone acting on his/her behalf to obtain any benefit under
this policy, all benefits under this policy and the premium paid shall be forfeited.
Any amount already paid against claims made under this Policy but which are found fraudulent later shall be repaid by all recipient (s)/
Policyholder(s), who has made that particular claim, who shall be jointly and severally liable for such repayment to the Insurer.
For the purpose of this clause, the expression "fraud" means any of the following acts committed by the insured person or by his agent or the
Hospital / Doctor, any other party acting on behalf of the Insured Person with intent to deceive the insurer or to induce the insurer to issue an
insurance policy:
a) the suggestion, as a fact of that which is not true and which the insured person does not believe to be true;
b) the active concealment of a fact by the insured person having knowledge or belief of the fact;
c) any other act fitted to deceive; and
d) any such act or omission as the law specially declares to be fraudulent
The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of Fraud, if the insured person / beneficiary can
prove that the misstatement was true to the best of his knowledge and there was no deliberate intention to suppress the fact or that such mis-
statement of or suppression of material fact are within the knowledge of the insurer.
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Group Medicare
4. Multiple Policies
i. In case of multiple policies taken by an insured person during a period from one or more insurers to indemnify treatment costs, the insured
person shall have the right to require a settlement of his/her claim in terms of any of his/her policies. In all such cases the insurer chosen by
the Insured Person shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen Policy.
ii. Insured person having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed under any other
policy / policies even if the sum insured is not exhausted. Then the Insurer shall independently settle the claim subject to the terms and
conditions of this Policy.
iii. If the amount to be claimed exceeds the sum insured under a single Policy, the Insured person shall have the right to choose insurer from
whom he/she wants to claim the balance amount.
iv. Where an insured person has policies from more than one insurer to cover the same risk on indemnity basis, the insured person shall only
be indemnified the hospitalization costs in accordance with the terms and conditions of the chosen Policy.
5. Possibility of Revision of Terms of the Policy Including the Premium Rates

The Company, with prior approval of IRDAI, may revise or modify the terms of the Policy including the premium rates. The Insured Person shall
be notified three months before the changes are effected.
6. Migration
The insured person will have the option to migrate the policy to other health insurance products/plans offered by the company policy by
applying for migration of the policy atleast 30 days before the policy renewal date as per IRDAI guidelines on Migration. If such person is
presently covered and has been continuously covered without any lapses under any health insurance product/plan offered by the company,
the insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on Migration.
For Detailed Guidelines on Migration, kindly refer Guidelines issued by IRDAI (Insurance Regulatory and Development Authority of India) on
Migration and Portability of Health Insurance policies – Ref: IRDAI/HLT/REG/CIR/194/07/2020) dated 22nd July 2020 and subsequent
amendments thereof.
7. Withdrawal of Policy
i. In the likelihood of this product being withdrawn in future, the Company will intimate the Insured Person about the same 90 days prior to
expiry of the Policy.
ii. Insured Person will have the option to migrate to similar health insurance product
Proportionate deductions are not applicable in respect of the hospitals which do not follow differential billing or for those expenses in respect
of which differential billing is not adopted based on the room category.
Claims Procedure Details :

Details of TPA/Claims Administrator:
For any claim related assistance, notification of claim and submission of claim related documents, insured person can contact:
Name of TPA : Tata AIG Health Claim

Website: www.tataaig.com
Email: healthclaimsupport@tataaig.com
Toll Free: 18002667780

1800229966 (For Senior Citizens)
Submit claim: TAGIC Health Claims,

5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A,
GHMC no - 615,616, Ameerpet, Hyderabad – 500016,
Telangana.
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Group Medicare
1.Notification of Claim
Treatment, Consultation or Procedure: We or Our TPA* must be informed:
1 If any treatment for which a claim may be made and that At least 48 hours prior to the Insured Person’s admission.
treatment requires planned Hospitalisation:
2 If any treatment for which a claim may be made and that Within 24 hours of the Insured Person’s admission to Hospital.
treatment requires emergency Hospitalisation
Failure to furnish such intimation within the time required shall not invalidate nor reduce any claim if You can satisfy us that it was not
reasonably possible for You to give proof of such delay within such time. The Company may relax these timelines only in special
circumstances and for the reasons beyond the control of the insured.
2.Cashless Service
Treatment, Consultation or Treatment, Consultation or Cashless Service is Available: We must be given notice that the
Procedure: Procedure Taken at: Insured Person wishes to take
advantage of the cashless
service accompanied by full
particulars:
If any planned treatment, Network Hospital We will provide cashless service At least 48 hours before the
consultation or procedure for by making payment to the extent planned treatment or
which a claim may be made: of Our liability directly to the Hospitalisation
Network Hospital.
If any treatment, consultation or Network Hospital We will provide cashless service Within 24 hours after the
procedure for which a claim may by making payment to the extent treatment or Hospitalisation
be made, requiring emergency of Our liability directly to the
hospitalisation Network Hospital.
3. Procedure for Cashless Service

i.Cashless Service is only available at Network Hospitals.
ii.In order to avail cashless treatment, the following procedure must be followed by You:
a. Prior to taking treatment and/or incurring Medical Expenses at a Network Hospital, You must call our designated TPA/Us and request pre-
authorization.
b. For any emergency Hospitalization, our designated TPA/We must be informed no later than 24 hours of the start of Your hospitalization/
treatment.
c. For any planned hospitalization, our designated TPA/We must be informed atleast 48 hours prior to the start of your
hospitalization/treatment.
d. Our designated TPA/We will check your coverage as per the eligibility and send an authorization letter to the provider. You have to provide
the ID card issued to You along with any other information or documentation that is requested by the TPA/Us to the Network Hospital.
e. In case of deficiency in the documents sent to TPA/Us for cashless authorization, the same shall be communicated to the hospital by
TPA/Us within 6 hours of receipt of the documents.
f. In case the ailment /treatment is not covered under the policy or cashless is rejected due to insufficient documents submitted, a rejection
letter would be sent to the hospital within 6 hours.
g. Rejection of cashless in no way indicates rejection of the claim. You are required to submit the claim along with required documents for us
to decide on the admissibility of the claim.
h. If the cashless is approved, the original bills and evidence of treatment in respect of the same shall be left with the Network Hospital.
Pre-authorization does not guarantee that all costs and expenses will be covered. We reserve the right to review each claim for Medical
Expenses and accordingly coverage will be determined according to the terms and conditions of this Policy.
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Group Medicare
4. Documents for claims :
Claim documentation will include but is not limited to the following :
i. Our claim form -duly completed and signed for on behalf of the Insured Person.
ii. Original Bills (pharmacy purchase bills, consultation bills, diagnostic bills) and any attachments thereto like receipts or prescriptions in
support of any amount claimed which will then become Our property.
iii. All medical reports, case histories, investigation reports, indoor case papers/ treatment papers (in reimbursement cases, if available),
. discharge summaries.
iv.A precise diagnosis of the treatment for which a claim is made.
v.A detailed list of the individual medical services and treatments provided and a unit price for each in case not available in the submitted
...hospital bill.
vi. All pre and post investigation, treatment and follow up (consultation) records pertaining to the present ailment for which claim is being made,
.. . if and where applicable.
Please refer Master policy wordings for details on supporting claims documents.
Redressal of Grievance:
In case of any grievance the Insured Person may contact through
• Website: www.tataaig.com
• Call us 24X 7 toll free helpline 1800 266 7780 or 1800 22 9966 (Senior Citizen)
• Email us at customersupport@tataaig.com
• Write to us at: TAGIC Health Claims,Tata AIG General Insurance Company Limited8th Floor, Romell Tech Park,Cama Industrial Estate,
Western Express Highway,Goregaon(E), Mumbai, Maharashtra400063
Visit the Servicing Branch mentioned in the policy document
lf lnsured person is not satisfied with the redressal of grievance through one of the above methods, Insured person may contact the grievance
officer at manager.customersupport@tataaig.com. For updated details of grievance officer, kindly refer the link
(https://www.tataaig.com/grievance-redressal-policy)
lf lnsured person is not satisfied with the redressal of grievance through above methods, the Insured Person may also approach the office of
lnsurance Ombudsman of the respective area/region for redressal of grievance as per lnsurance Ombudsman Rules 2017. Grievance may
also be lodged at IRDAI lntegrated Grievance Management System - https://igms. irda.gov.in/
Please visit our website or refer to Master Policy for INSURANCE OMBUDSMAN particulars.
Premium Details :
Commencement of risk cover under the policy is subject to receipt of premium by Tata AIG General Insurance Company Limited.
Particulars Amount(Rs.)
Net Premium (Rs.) 10,198.00
UGST/SGST(9%) 917.82
CGST(9 %) 917.82
Total Gross Premium (Rs.) 12,034.00
Total Gross Premium (in words) Rupees Twelve Thousand Thirty-Four And Paise Zero Only
GSTIN: 29AABCT3518Q1ZS-GULBARGA , SAC CODE: 997133
Premium rates and/or scope of covers are subject to revision at the time of renewal under this policy
Stamp duty details :

The stamp duty of 10 (RUPEES AND PAISE) paid by Demand Draft, vide Receipt/Challan no.LOA/CSD/655/2023/1021 dated 21/03/2023
80 D certificate of Income Tax Act, 1986
This is to certify that the MRS UMADEVI MALLINATH MATH . has paid an amount of Rs 12,034.00 towards the premium for Group Medicare
Product Certificate No 0239157260 00047908 for the period From 06/04/2023 To 05/04/2024 and is eligible for a tax exemption under section 80 D
of IT Act.
Page 6 of 12
Group Medicare
This certificate is subject to terms and conditions of the master policy. Please refer the master policy terms and conditions with the master policy
holder.
For Policy wordings, please scan the below QR code :
Policy Servicing Office:

Registered Addres:- OFFICE NO 1-18/A, 5TH FLOOR, MAHAGAONKAR COMMERCIAL,COMPLEX DISTRICT COURT ROAD,VIVEKANANDA NAGAR,,OPPOSITE
IOC PETROL PUMP, KALABURAGI – 585102,GULBARGA,KARNATAKA,GULBARGA-585102
Page 7 of 12
Group Medicare
RECEIPT
Receipt No : 109471046456508 Receipt Date : 10/04/2023
Policy No: 0239157260 00047908
Received with thanks from UMADEVI MALLINATH MAT a sum of `12033( Rupees Twelve Thousand Thirty-Three And Paise Zero
Only)Direct Debit, Branch Bank Branch Name - CANARA BANK , Gulbarga towards
Sl.No. Policy Number Total Premium Utilized from the receipt for policy Balance
1 0239157260 12,034.00 12,033.00 0.00
Note:
1. This is a computer generated receipt and does not require a signature.
2. Upon issuance of this Receipt, all previously issued temporary receipts, if any, related to this Policy shall be considered null and void.
3. Amounts received by cheque shall be subject to realisation.
4. Any amount received in excess of the Premium is being/shall be refunded by the Company.
GSTIN: 29AABCT3518Q1ZS-GULBARGA , SAC CODE: 997133
Revenue (Consolidated) Stamp Duty paid vide challan No. LOA-NO.CSD/507/4491 date 18/10/2022 for applicable cases.

Registered office : Peninsula Business Park, Tower A,15th Floor, G.K Marg, Lower Parel, Mumbai-400013
24*7 Toll free Number : 1800 266 7780 Email : customersupport@tataaig.com website:www.tataaig.com
IRDA of India Registration No : 108 CIN : U85110MH2000PLC128425 PAN:AABCT3518Q UIN : TATHLGP21248V022021
Page 8 of 12
Group Medicare
Group Medicare
Member Id : 0239157260/CANARA2889196008/01
Name : UMADEVI MALLINATH MATH
Age : 64
Gender : FEMALE
Policy No : 0239157260 00 01
Valid from: : 06/04/2023
Valid till : 05/04/2024
TAGIC Health Claims,

5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A,GHMC no - 615,616,
Ameerpet, Hyderabad – 500016,Telangana, Toll Free : 18002667780

Registered office : Peninsula Business Park, Tower A, 15th Floor, G.K Marg, Lower Parel, Mumbai-400013
24*7 Toll free Number : 1800 266 7780 Fax : 022 6693 8170 Email : customersupport@tataaig.com website : www.tataaig.com
Page 9 of 12
Group Medicare
ENROLMENT FORM FOR GROUP HEALTH POLICY
URN NO : URN No. AH/2018-19/HL-06
Partner Reference No. /

Name of the Group Administrator CANARA BANK CANARA2889196008
Application No
Customer ID / Account No 6103076701 Intermediary code CA0045
This is an application for Insurance & will form the basis of the policy certificate that We may issue. Every information, this application seeks is
important & mandatory. Please read all questions and answer them carefully. You must provide complete and correct information.
Incomplete/incorrect/partially correct information may lead to cancellation of proposal and policy certificate even if it is issued. We are under
no obligation to accept any proposal for insurance. If We accept a proposal for insurance, it shall be subject to the Policy terms and
conditions and We shall have no liability to make any payment under the Policy if proposal is not accepted by us or premium is not received by
Us in full and in time, or non-fulfillments of additional information requested by us, if any or if the proposal is under-process & claim arises in the
interim period before the decision on the proposal is given by us.
Commencement of risk cover under the policy is subject to receipt of premium by Tata AIG General Insurance Company Limited.
Please fill-up this form in CAPITAL LETTERS
Section I: Applicant Information
Name: First Name Middle Name Last Name

(Mr/Mrs/Ms)
MRS UMADEVI MALLINATH MATH .
Date Of Birth: 01/06/1958 Gender: FEMALE Nationality: INDIAN RESIDENT

Mobile: 9663444519 Email ID: cb1071@canarabank.com
Address for communication: CO HOLKUNDAGULBARGA Landmark: District: GULBARGA , City: GULBARGA , State: KARNATAKA
, Pin code: 585313
Unique id no. : PAN (incase of premium > Rs.50, 000) :
Group Medicare
Part A: Plan Details:

Sum Insured : 200,000
Deductible :
Tenure (in years) : 1 year
Plan Type : Individual
Part B: Proposed Insured Persons details:
NAME OF THE RELATIONSHIP WITH

S.No Date of BIRTH GENDER OCCUPATION Adhar NO
INSURED PERSON APPLICANT
UMADEVI MALLINATH
1 Self 01/06/1958 FEMALE
MATH

Page 10 of 12
Group Medicare
Part C: Medical & Lifestyle Information:

Note: This section is applicable for all the persons to be insured
• Please read, understand and confirm “Health Details” accurately and truthfully for each of the members to be insured , as this would be
the prime basis for issuance of your policy and subsequent claim admissibility if any.
• If, for any of the members proposed to be insured, the answer to any of the following questions/health statement is YES, then any such
member shall not be eligible to take this policy.
• Any mis-declaration or non-disclosure here will render coverage under the policy NULL & VOID ,ab initio.
Medical Information Yes/No
Have you or any of the persons proposed for insurance, ever suffered from or taken treatment, or No
hospitalized for or have been recommended to take investigations / medication / surgery or undergone a
surgery for any of the following medical condition?
l Cancer/Kidney failure/Stroke/Heart disease/Paralysis

l Any disease of major organs including but not limited to brain, heart, kidney, lungs, liver or any
neurological disorder
l Any joint disorder including restriction in movement or any form of arthritis
Are you or any of the persons proposed for insurance in good health? Yes
Are you or any of the persons proposed for insurance undergoing/awaiting any treatment for any No
illness?
Part D Premium Paid for product (including taxes):

Section V: Nominee Details
Nominee Name: MAHADEV MATH Relationship with the Applicant: Son
In the event of the death of the Applicant any payment due under the Policy shall become payable to the nominee in accordance with the
Policy terms and conditions. Nominee for any of the persons proposed to be insured shall be the Applicant. The nominee must be an
immediate relative of the Applicant. The nominee for all other Insured Persons proposed to be insured shall be the Applicant himself/herself.
Section VI: Declaration & Warranty On Behalf Of All Persons Proposed To Be Insured
I/ We hereby declare, on my behalf and on behalf of all persons proposed to be insured that the above statements, answers and/or
particulars given by me are true and complete in all respects to the best of my knowledge and that I/We am/ are authorized to propose on
behalf of these other persons.
I understand that the information provided by me will form the basis of insurance policy, is subject to the Board approved underwriting
policy of the Insurance company and that the policy will come into force only after full payment of the premium chargeable.
I/ We further declare that I/We will notify in writing any change occurring in the occupation or general health of the life to be insured/
proposer after the proposal has been submitted but before communication of the risk acceptance by the company.
I/We declare and consent to the company seeking medical information from any doctor or hospital who/which at anytime has attended on
the person to be insured/ proposer or from any past or present employer concerning anything which affects the physical or mental
health of the person to be insured/proposer and seeking information from any insurance company to whom an application for insurance
on the person to be insured/ proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
I/ We authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the
sole purpose of proposal underwriting and/or claims settlement and with any Governmental and/or Regulatory Authority.
Signature of the Applicant: UMADEVI MALLINATH MATH . Date: 06/04/2023 Place: GULBARGA
The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained to me. I/we have understood
these and confirm to abide by the policy terms & conditions.
Signature of the Applicant: UMADEVI MALLINATH MATH .
Name & Signature of agent/intermediary/Specified Person: CANARA BANK
Code: CA0045

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Group Medicare
Vernacular Declaration (Certification in case the applicant has signed in vernacular/thumb print)
The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained by me in vernacular to the
applicant who has understood and confirmed the same.
Signature/Thumb impression of the Applicant:________________________________
Name & Signature of agent/intermediary/Specified Person: CANARA BANK
Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015.
1. No person shall allow or offer toallow, either directly or indirectly, as an inducement to any person to takeout or renew or continue an
insurance in respect of any kind of risk relatingto lives or property in India, any rebate of the whole or part of the commissionpayable or
any rebate of the premium shown on the policy, nor shall any persontaking out or renewing or continuing a policy accept any rebate,
except suchrebate as may be allowed in accordance with the published prospectuses or tables of the insurer.
2.
No person shall allow or offer toallow, either directly or indirectly, as an inducement to any person to takeout or renew or continue an
insurance in respect of any kind of risk relatingto lives or property in India, any rebate of the whole or part of the commissionpayable or
any rebate of the premium shown on the policy, nor shall any persontaking out or renewing or continuing a policy accept any rebate,
except suchrebate as may be allowed in accordance with the published prospectuses or tables of the insurer.
For office use only :

Employee ID :
Partner ID :
Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions please read policy
document carefully before concluding a sale.
CUSTOMER ACKNOWLEDGEMENT
Application Number: 282022007645128 Date: 06/04/2023

Name of the Applicant: UMADEVI MALLINATH MATH .
We acknowledge with thanks the receipt of your application and amount by cash/cheque/Demand Draft/others of amount of Rs 12,034.00.
Neither the submission to us of this completed enrollment form for insurance nor any payment towards this application obliges us to agree to
issue a policy, which decision is and always shall be in our sole and absolute discretion. If we accept a proposal for insurance, it shall be
subject to the policy terms and conditions and we shall have no liability to make any payment if proposal is not accepted by us or premium is not
received by us in full and in time, or non-fulfillments of Pre-Policy Checkup (if applicable) and/or additional information requested by us. Failure to
deposit the entire premium or non-fulfillments of pre-policy check up (if applicable) or furnish additional information requested by us within 15
days from the date of proposal, we shall cancel your application and refund the premium paid without any interest subject to deduction of
pre-policy charges (if applicable & conducted). If we do not accept the proposal, we will inform you and refund any payment received from
you, towards this application, without interest within next 10 days.
We shall have no liability to make any payment under the Policy if proposal is under-process & claim arises in the interim period before the
decision on the proposal is given by us.

Page 12 of 12

Group Medicare Certificate of Insurance

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Group Medicare

5. Possibility of Revision of Terms of the Policy Including the Premium Rates

Claims Procedure Details :

Name of TPA : Tata AIG Health Claim

Toll Free: 18002667780

Submit claim: TAGIC Health Claims,

3. Procedure for Cashless Service

Stamp duty details :

80 D certificate of Income Tax Act, 1986

For Policy wordings, please scan the below QR code :

Policy Servicing Office:

Receipt No : 109471046456508 Receipt Date : 10/04/2023

Policy No: 0239157260 00047908

GSTIN: 29AABCT3518Q1ZS-GULBARGA , SAC CODE: 997133

TATA AIG General Insurance Company Limited

TAGIC Health Claims,

TATA AIG General Insurance Company Limited

ENROLMENT FORM FOR GROUP HEALTH POLICY

URN NO : URN No. AH/2018-19/HL-06

Partner Reference No. /

Customer ID / Account No 6103076701 Intermediary code CA0045

Section I: Applicant Information

Name: First Name Middle Name Last Name

Date Of Birth: 01/06/1958 Gender: FEMALE Nationality: INDIAN RESIDENT

Unique id no. : PAN (incase of premium > Rs.50, 000) :

Part A: Plan Details:

Part B: Proposed Insured Persons details:

NAME OF THE RELATIONSHIP WITH

TATA AIG General Insurance Company Limited

Part C: Medical & Lifestyle Information:

Medical Information Yes/No

l Cancer/Kidney failure/Stroke/Heart disease/Paralysis

Part D Premium Paid for product (including taxes):

Nominee Name: MAHADEV MATH Relationship with the Applicant: Son

TATA AIG General Insurance Company Limited

For office use only :

Application Number: 282022007645128 Date: 06/04/2023

TATA AIG General Insurance Company Limited

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