GENERAL

IHSURAHCE
Tech

DETAILS OF INSURED PERSON MEMBER l MEMBER 2 MEMBER 3 MEMBER 4

Name of the lnsured Person : Mrs. Komal Prajapati Mr. Krishna Prajapati
Gender
Date of Birth : 26/04/1992 l9/03/2023
. . . .. . .. .... . .... . .. .... . . . ...G ... . ... .... ... .. . . .. . .. ....... ..... .... .... ... . .... . ........ .. ... ..... ............ ... . .. ...............
Relationship with Policyholder : Self Son
Insured with the Company, since : 13/07/2023 13/07/2023
G G G G G •G • o • GG G G G G • • • o •G G oG Go •G G G G zG •G o G G G G G • • • • G• G G G o oG • G G G G G G G G • G . ..... . .. . ....... . ... ....... ....... ... ...... ....... .... ...................q.......... . .......... ...............
UHiD 28682230525994 28682230525995
Any Pre-existing Disease : No No
... . ... .. ..... .. . ..... . .. . .... .... G....... ..... . ... ...... . . ...... .. .. ....... . .... ...... . ..... .... . ...... .............................................. . . . ...... ...............
Pre-existing Dlsease — Name : NA NA
Pre-existing Disease — Since •
Permanent excluslons (lf any ) as agreed
by the customer
.... ...... ...... .... ... ...... . .... ....... ...G.. .... ... . ...... ...... ........... ...... ... .. ....... ................................. ..... ............. ........... ... ....... ..............
Speclal Remarks/Condiiions
..... ... . ...... ..... . ...... . ... . ..... . . .G.......... ..... . .. ... ..... ..... .. . . ..... .. ...... . ...... . . .................................. ....... . . ........... ............ . .... .... ................
Cumulative Bonus (* ) Noaier ,0
Cumulative Bonus (* ) Ïndividual ’: o ” 0
Insured Person covered under :
Health lnsurance wlth any NA NA
Company. Since (If, yes)

PREMIUM DETAILS AMOUNT Discount Detail.«

Zone •$ Long Term Discount
. .. . ...
...... .... . ..... .. .. . ... .. ...... . G........................................,........................,............
Base Premium 19590 Female Proposer Dlscount

A d d o n Pr e m iu m 0 Di.g...ita.l...D.isc..o..u. nt ..... .....

... . ... . .... .... .... ... ..
.. .. . . .. . .. .. ... .. .. . ..... ...... ....G ...... .....q.. ........... ..... . ... .. . ....
(lf a n y) 0 0 Long Term Fresh Health Llfe Dlscount
.. .. .. . .... ....... .. . .
LoadlHQ (if any) 0
D i s cPremium
Total o u nt t ifexcludlnga ny l ’ 6 349
. . . . .. . . . . . .. . Taxes
....... and...Levies
.. . ...G.. . ... ...... ..... ... .... .. .. ...... 13240.00
. .

GSTO :27AABCR6747B1ZG, H5N : 997133, Description of services : Accident and health insurance services
Consolidated Stamp duty Paid vide lntter of Authofisatló n “NO.LOA/CSD/662/2023/(Vãlldity PeEod Dt.27/03/20?3 to Dt.01/12/2023)/1156 DT.27
MAR 2023” ai General Stamp Offlce, MulTlbGl. *• Not AppliCable for the Staie of Jammu & Kashmir

NOMINEE DETAILS
..N...a...m...e....o..f...N...o..m....i.n...e..e...........................................
A 403, Hari Aaalayam, Opp
Date of Birth Saithak Era Flat,
05/l0/1987 Address of Nomlnee
Sargasan,..GANDHlNAGA9,GAND
HlNAGA9,GUJARAT,382421
Contact No. / Mobile No,
Email lD
APPOINTEE DETALS
Name of Appointee RelationshiJ2 Wlth Nomin'ee

.D....a..t.e....o..f..B...i.r.t..h...............................................G......G...................................................
..................
..C..o...n..t. a..c..t..N...o...:../...M....o..b..i..l.e...N...o..........................G.......,.................................
............................,G.....
NOT'E
The’ maximum liability of the Company to pay the claims under this Policy is limited to Total Liability defined in the Poficy Wordings. Please
refer ie policy wordings for detailed information and understanding of the coverages.
Rellance Health Gain Policy. UIN.
RELHUP22229V032l22. Page 3 of 25

Scanned with CamScanner

Scanned wit CamScanner