CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

Registered Office:2nd Floor,“DARE House”,2,N.S.C.Bose Road,Chennai-600001

Toll free: 1800 208 9100, T: +91 (0) 44 4044 5400, F: +91 (0) 44 4044 5550
E:customercare@cholams.murugappa.com; website:www.cholainsurance.com
IRDA Regn. No.123;PAN AABCC6633K; CIN U66030TN2001PLC047977
Policy Schedule
CHOLA FLEXI SUPER TOPUP INSURANCE

[UIN:CHOHLIP21561V012021]

Policy Details
GST Invoice No.:2872352495370 CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LTD.
DATE: 18/01/2022 ADDRESS: LUCKNOW - BRANCH
PAN: AABCC6633K CYBER HEIGHTS, OFFICE SPACE NO. 313, 314, 315,
SAC Code: 997133 THIRD FLOOR, VIBHUTI KHAND, GOMTI NAGAR
SAC Description: Accident and Health Insurance Services LUCKNOW G.P.O.
CITY: LUCKNOW STATE: UTTAR PRADESH
GSTIN: 09AABCC6633K7ZB
Business Location :LUCKNOW - BRANCH Period of Insurance
Policy Number :2872/00006663/000/00
From : 11:53:01 hrs on 17/01/2022 To : Midnight on 16/01/2023
Name of the Proposer :PRIYANKA SINHA
Customer ID : 1021214060480001
Communication Address :3RD FLOOR, OM SAI TOWER, B - 114, LDA ROAD BEHIND PHOENIX MALL, ALAMBAGH UP 206012 L D A COLONY S.O LUCKNOW UTTAR PRADESH PIN -
226012
Mobile Number:9838100102 GSTIN:0
E-Mail ID : -

Coverage Details
Plan Type: Gold Plan
Type of Policy: Family floater
(In case of floater coverage, the Sum insured and Cumulative bonus mentioned in the Policy Schedule will be represent our maximum liability for any and all claims made by
any and all Insured persons per annum)

Details of Insured Person

Sl.No
1
Name
PRIYANKA SINHA
Age(In Years)
42
Gender
F
Relationship
Self
DOC* Sum Insured(Rs.)

S Deductible(Rs.) Ported Sum Insured(Rs.)

0

M
2 VIPUL KUMAR CHATTERJEE 41 M Spouse 0
3000000 500000
3 GAURANSH CHATTERJEE 12 M Child1 0
4 OMISHA CHATTERJEE 3 F Child2 0
*Date of commencement of coverage for first time

A
ADD on cover opted(on payment of additional premium)
Medical second Opinion, UIN: No

Nominee Details
Nominee Name : Vipul chatterjee

L Relationship: Spouse
Nominee mentioned above is for the proposer. For other members covered under the policy, proposer is deemed to be the nominee.

Additional Conditions or Exclusions, if any

O
H
Name of Insured Additional conditions or Exclusions if any
PRIYANKA SINHA Nil
VIPUL KUMAR CHATTERJEE Nil
GAURANSH CHATTERJEE Nil
OMISHA CHATTERJEE

Premium Summary
Net Premium

(-)Discount
C
Rs. 6186
Rs. 0.00
Nil

CGST

SGST
Rs. 556.50
Rs. 556.50
(+)Loading Rs. 0.00 IGST Rs. 0.00
Total Premium excluding GST Rs. 6186.00 Kerala Flood Cess Rs. 0.00
Total premium including all taxes Rs. 7299.00

Payment Details
Payment ID 1031082402
Payment Date 17/01/2022

Intermediary Details
Intermediary Type : Intermediary Intermediary Name: VIVEK SINGH
Intermediary Code : 201015842652 Contact Number : 8090441167

For Cholamandalam MS General Insurance Company Ltd.

In WITNESS WHEREOF, this Policy Schedule has been signed on 18/01/2022
@CholaSign1
% DSUnknown
q
1G
1g
0.1 0 0 0.1 9 0 cm
0 J 0 j 4 M []0 d
1i
0g
313 292 m
313 404 325 453 432 529 c
478 561 504 597 504 645 c
504 736 440 760 391 760 c
286 760 271 681 265 626 c
265 625 l
100 625 l
100 828 253 898 381 898 c
451 898 679 878 679 650 c
679 555 628 499 538 435 c
488 399 467 376 467 292 c
313 292 l
h
308 214 170 -164 re
f
0.44 G
1.2 w
1 1 0.4 rg
287 318 m
287 430 299 479 406 555 c
451 587 478 623 478 671 c
478 762 414 786 365 786 c
260 786 245 707 239 652 c
239 651 l
74 651 l
74 854 227 924 355 924 c
425 924 653 904 653 676 c
653 581 602 525 512 461 c
462 425 441 402 441 318 c
287 318 l
h
282 240 170 -164 re
B
Q

Digitally signed by:

KANCHIPURAM
SRIDHAR HARISH

Place : Chennai Authorised Signatory

Note: The Certificate of Insurance / Policy Schedule is an important document issued based on your declaration. We request you to verify the details and ensure that
everything is in order. In case of any discrepancies, please contact us within 15 days from the date of issuance of policy.
Consolidated Stamp Duty Paid Vide G.O. Rt No. 453 , Commercial Taxes and Registration (j1) Department, Tamil Nadu dated 21/12/2021

The policy schedule is forming part and parcel of the policy and is governed by the terms and conditions of the policy. Please refer to our website for policy wordings and
detailed Terms, Conditions, Exclusions and Ombudsman list.

Tax Exemption Certificate

This is to certify that a sum of Rs.7299.00 (Rupees SEVEN THOUSAND TWO HUNDRED NINETY-NINE) (Net Premium Rs.6186.00 and GST Rs.1113.00) has been collected from
Mr/Mrs. PRIYANKA SINHA towards Health Insurance policy number 2872/00006663/000/00 for the duration of 11:53:01 hrs on 17-Jan-22 to midnight on 16-Jan-23. This
certificate is issued for the purpose of Income Tax Deduction under section 80D of the Income Tax Act,1961.
For Cholamandalam MS General Insurance Company Ltd.
Date:18/01/2022
@CholaSign1
% DSUnknown
q
1G
1g
0.1 0 0 0.1 9 0 cm
0 J 0 j 4 M []0 d
1i
0g
313 292 m
313 404 325 453 432 529 c
478 561 504 597 504 645 c
504 736 440 760 391 760 c
286 760 271 681 265 626 c
265 625 l
100 625 l
100 828 253 898 381 898 c
451 898 679 878 679 650 c
679 555 628 499 538 435 c
488 399 467 376 467 292 c
313 292 l
h
308 214 170 -164 re
f
0.44 G
1.2 w
1 1 0.4 rg
287 318 m
287 430 299 479 406 555 c
451 587 478 623 478 671 c
478 762 414 786 365 786 c
260 786 245 707 239 652 c
239 651 l
74 651 l
74 854 227 924 355 924 c
425 924 653 904 653 676 c
653 581 602 525 512 461 c
462 425 441 402 441 318 c
287 318 l
h
282 240 170 -164 re
B
Q

Digitally signed by:

KANCHIPURAM
SRIDHAR HARISH

Place:Chennai Authorised Signatory

Regd.&Head Office:Dare House, 2nd Floor, No.2, N.S.C Bose Road, Chennai-600 001, India
CIN: U66030TN2001PLC047977 | IRDAI Reg. No. 123

Whether tax is payable under reverse charge basis - No.

S
M
L A
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