Vghubbhyujhhh

Group Medicare 360
Certificate of Insurance
New Business-0239255823-00920696---
Intermediary Name/Agent Name : AXIS BANK LTD
Issuing Office : BANDRA Intermediary Code/Agent License Code : CA0069
Name of the Policy holder (Master Policy) : AXIS BANK LIMITED
Name of Insured Person : SADIQUE AKHTAR KHAN
Intermediary Contact No/Agent Contact No.: 1800 209
2001
Address : RAMEE CENTER, GAZOHAR BANDH ROAD,
RAMLAKHAN PATEL CHAWL SANTACRUZ,(WEST)
GAZOHAR BANDH ROAD
MUMBAI
MAHARASHTRA Branch Code : 90230
400054 Business Type : New Business
Master Policy No : 0239255823 Proposal No. :202302230207981
Renewal No: 00
Endorsement No:00 GSTIN No :
Certificate No: 00920696 Family id : 01, 02
Partner Application No:506633582
Insured Person ID : 6129897525
Place of Supply : MAHARASHTRA
State Code : 27
Contact details of Primary Insured Person :
• Phone/Mobile No.: 9892637749
• Email id : SADIQAK040@GMAIL.COM
Certificate Period : From 00:01 Hrs. 23/02/2023 (Commencement date) To 23:59 Hrs. 22/02/2024 (Expiry Date)
Date of First Policy inception with us : 23/02/2023
Plan premium code / Customized Premium: PPGMCARE-20220209-8924
Type of Plan : Floater
Details of Insured Persons Covered :
Existing
diseases
Name of Relations which
Pre-exist Sum
Member the hip With Date Of Member are Cumulati
Gender Age ing Insured
Id Insured Insured Birth Since permane ve Bonus
disease (Rs.)
Person Person ntly
Excluded
*
02392558 SADIQUE
23/506633 AKHTAR Self 01/01/1979 MALE 44 23/02/2023
582/01 KHAN
500,000
02392558
HASEENA
23/506633 Spouse 25/07/1984 FEMALE 38 23/02/2023
KHAN
582/02
Nominee Details :
Name of the insured person Nominee Name Nominee Date of Birth Relationship
SADIQUE AKHTAR KHAN HASEENA KHAN 25/07/1984 Wife
Details of Cover :
Covers Cover Details
In-Patient Treatment Up to Sum Insured, Rs.5,00,000
Pre/Post Hospitalization Expenses,
Up to 60 days & up to 90 days respectively, Rs.5,00,000
60/90
Day Care Procedures 541 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
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 Fax : 022 6693 8170 Email : customersupport@tataaig.com website : www.tataaig.com
IRDA of India Registration No : 108 CIN : U85110MH2000PLC128425 UIN :TATHLGP22162V012122
Page 1 of 14
Group Medicare 360
Details of Cover :
Covers Cover Details
1% of sum insured subjected to maximum of Rs.10000 per hospitalisation. Applicable only in case of
Ambulance Cover
emergency, Upto 1% of In-patient Treatment Sum Insured
Family Transportation Benefit Covered within In-Patient Treatment Sum Insured Upto, Rs.5,000
Details of Additional Covers :

Additional Cover Cover Details
15 named critical illnesses (Please refer the policy wording for detailed list), Applicable for All
Critical Illness Cover (Indemnity Basis) Members,Covered on Indemnity Basis,Critical Illness Sum Insured of Rs.500,000, Flat Amount
Rs.0
Nursing Allowance Rs.100 per day for maximum up to 15 days with a deductible of 2 days, Up to Rs.1,500
Health Check-up Applicable only after every 2 claim free years, Applicable for Self,Upto Rs.2,000
Restore Sum Insured Benefit Covered up to base Sum Insured, Applicable for All Members,Upto Rs.500,000
Covered up to Base Sum Insured applicable only for Self, Applicable for Self,AD Sum Insured
Accidental Death
: Rs. Above SI Limit
AYUSH Cover Covered, Applicable for All Members,100% of In-Patient Treatment Sum Insured
Unlimited Tele-consultation with General Practitioners & Health Risk Assessment are covered.
wellness services
These services can be availed through TATA AIG app, All Members
Limit on Room Rent Single Private Room, Amount Mentioned/day Rs.
50% CB per year up to 100% of sum insured for claim free year, 50% CB per year up to
Cumulative Bonus
100% of sum insured for claim free year
Covered up to Base Sum Insured applicable only for Self, Applicable for Self, Permanent Total
Permanent Total Disability
Disability SI : Rs.500,000
Details of Waiting Period :

Waiting Period Waiting Period Details Applicable To
Not waived off. Applicable upto 30 days. Not
applicable for Accidental Hospitalisation. For
30 Days Waiting Period Applicable for All Members
renewal customers the Initial Waiting Period is
not applicable
Covered after a waiting period of 24 Months.
For 1st year Renewals/ migration a waiting
Specified Disease Waiting Period period of 12 months is applicable. For 2nd Applicable for All Members
year and above renewals/ migration no
waiting period applicable
Covered after a waiting period of 24 Months.
For 1st year Renewals/ migration a waiting
period of 12 months is applicable. For 2nd
year and above renewals/ migration no
PED Waiting Period Applicable for All Members
waiting period applicable. For new business
Asthama High BP High Cholesterol Diabetes
covered after waiting period of 12 months
whereas not applicable for renewal.
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
Page 2 of 14
Group Medicare 360
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
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 Excl09) : 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.
Page 3 of 14
Group Medicare 360
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.
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 available with the Company at the time of renewal with all
the accrued continuity benefits such as cumulative bonus, waiver of waiting period as per IRDAI guidelines provided the Policy has been
maintained without a break.
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
Page 4 of 14
Group Medicare 360
Claims Procedure Details :
For any claim related assistance, notification of claim and submission of claim related documents, insured person can contact:
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)
Fax : 022 66938170
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,
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 Treatment, Cashless Service is We must be given notice that the
or Procedure Consultation or Available: Insured Person wishes to take
Procedure Taken at: advantage of the cashless service
accompanied by full particulars:
If any planned treatment, Network Hospital We will provide cashless At least 48 hours before the planned
consultation or procedure for service by making payment to treatment or Hospitalisation
which a claim may be made: the extent of Our liability
directly to the Network
Hospital.
If any treatment, consultation Network Hospital We will provide cashless Within 24 hours after the treatment or
or procedure for which a service by making payment Hospitalisation
claim may be made, requiring to the extent of Our liability
emergency hospitalisation directly to the Network
Hospital.
Page 5 of 14
Group Medicare 360
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.
4. Documents for claims :

Claim documentation will include but is not limited to the following :
i.Details of TPA/Claims Administrator
ii.Notification Of Claim section added as per Wordings
iii.Cashless Service details added as per Wordings
iv.Procedure for Cashless Service addeda

v. Our claim form -duly completed and signed for on behalf of the Insured Person.
vi. 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.
vii. All medical reports, case histories, investigation reports, indoor case papers/ treatment papers (in reimbursement cases, if available),
. discharge summaries.
viii.A precise diagnosis of the treatment for which a claim is made.
ix.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.
x. 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 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
Page 6 of 14
Group Medicare 360
Visit the Servicing Branch mentioned in the policy document
The insured person may also approach the grievance cell at any of the Company’s branches with details of grievance.
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.) 10,300.00
UGST/SGST @ 9% 927.00
CGST @ 9% 927.00
Total Gross Premium (Rs.) 12,154.00
Rupees Twelve Thousand One Hundred Fifty-Four And Paise Zero
Total Gross Premium (in words)
Only
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 Rs.25/- paid in cash or demand draft or by pay order,vide Receipt/Challan no:LOA/CSD/577/2023/335/23 dated the 24/01/2023
80 D certificate of Income Tax Act, 1986
This is to certify that the MR SADIQUE AKHTAR KHAN has paid an amount of Rs 12,154.00 towards the premium for Group Medicare 360 Product
Certificate No 0239255823 00920696 for the period From 23/02/2023 To 22/02/2024 and is eligible for a tax exemption under section 80 D of IT
Act.
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 :
Page 7 of 14
Group Medicare 360
Policy Servicing Office:
SUMIT BUSINESS BAY, UNIT NO.524, ANDHERI KURLA ROAD,, ADJACENT TO CINEMAX AND WEH METRO STATION,GURUNANAK, PETOL PUMP CHAKALA,
ANDHERI EAST, MAHARASHTRA, 400069, MUMBAI, MAHARASHTRA
Page 8 of 14
Group Medicare 360
Group Medicare 360
Member ID : 0239255823/506633582/01
NAME : SADIQUE AKHTAR KHAN
AGE : 44
GENDER : MALE
Policy No : 0239255823 00 00
Valid from : 23/02/2023
Valid till : 22/02/2024
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
Group Medicare 360
Member ID : 0239255823/506633582/02
NAME : HASEENA KHAN
AGE : 38
GENDER : FEMALE
Policy No : 0239255823 00 00
Valid from : 23/02/2023
Valid till : 22/02/2024
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
IRDA of India Registration No : 108 CIN : U85110MH2000PLC128425 UIN : TATHLGP22162V012122
Page 9 of 14
Group Medicare 360
ENROLMENT FORM FOR GROUP HEALTH POLICY
URN NO : URN No. AH/2018-19/HL-06
Partner Reference No. /

Name of the Group Administrator AXIS BANK LIMITED 506633582
Application No
Customer ID / Account No 6129897525 Intermediary code 0015455000
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)
MR SADIQUE AKHTAR KHAN
Date Of Birth: 01/01/1979 Gender: MALE Nationality: INDIAN RESIDENT

Mobile: 1800 209 2001 Email ID: SADIQAK040@GMAIL.COM
Occupation Salaried Self-employed Others (please specify):_______________________________________________
:Address for communication: RAMEE CENTER, GAZOHAR BANDH ROAD,RAMLAKHAN PATEL CHAWL SANTACRUZ,(WEST) GAZOHAR
BANDH ROAD Landmark: District: SANTACRUZ , City: SANTACRUZ , State: MAHARASHTRA , Pin code: 400054
Unique id no. : PAN (incase of premium > Rs.50, 000) :
Group Medicare 360
Part A: Plan Details:

Sum Insured : 500,000
Deductible :
Tenure (in years) : 1 year
Plan Type : Floater
Part B: Proposed Insured Persons details:
NAME OF THE RELATIONSHIP WITH

S.No Date of BIRTH GENDER OCCUPATION Adhar NO
INSURED PERSON APPLICANT
SADIQUE AKHTAR
1 Self 01/01/1979 MALE Salaried
KHAN
2 HASEENA KHAN Spouse 25/07/1984 FEMALE

Page 10 of 14
Group Medicare 360
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.
Sr. No. Has any of the person's proposed to be insured Yes/No
1 Taken any medicine for more than 21 days consistently except for high cholesterol, asthma, diabetes and hypertension NO
Been diagnosed in the past or currently suffering from and/or currently undergoing treatment for Hypertension, Diabetes
Mellitus, Asthma, dyslipidemia (raised blood cholesterol levels) wherein,
a) taken or currently taking injectable medication /insulin to control blood sugar level as a treatment of Diabetes Mellitus
2 NO
b) taken or currently taking more than one medication to control high blood pressure, more than once a day
c) ever undergone or currently taking systemic/oral steroid therapy for Asthma
d) ever been hospitalized for dyslipidemia/raised cholesterol or its related complications
undergone any surgery other than cataract in either or both eyes, appendicectomy/ cholecystectomy/ hysterectomy/
3 tonsillectomy, renal stone removal, fracture surgeries (not leading to any disability) or surgeries for family planning/ C- NO
section (applicable for females) or have been hospitalised for more than 07 continuous days in the last 10 years
4 any history of spinal or joint disorders like but not limited to arthritis, slip disc (prolapsed intervertebral disc) in the last 5
NO
years
ever been diagnosed with but not limited to Tumor or cancer anywhere in the body, stroke, epilepsy, Chronic liver disease,
5 NO
schizophrenia, Hepatitis B or C, auto-immune disorders, sexually transmitted diseases.
6 Have been diagnosed for any illness and undergoing/ awaiting any treatment, medical/ surgical or attending any follow up
for any disease/ condition/ ailment/ injury/ addiction other than high cholesterol, asthma, diabetes and hypertension NO
Part D Premium Paid for product (including taxes):

Section V: Nominee Details
Nominee Name: HASEENA KHAN Relationship with the Applicant: Wife
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.

Page 11 of 14
Group Medicare 360
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: SADIQUE AKHTAR KHAN Date: 23/02/2023 Place: BANDRA
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: SADIQUE AKHTAR KHAN
Name & Signature of agent/intermediary/Specified Person: AXIS BANK LTD
Code: 0015455000
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: SADIQUE AKHTAR KHAN
Name & Signature of agent/intermediary/Specified Person: AXIS BANK LTD
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. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh
rupees.
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.
Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel,
Mumbai 400013
24X7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) Fax: 022 6693 8170 Email:customersupport@tataaig.com Website:
www.tataaig.com IRDA of India Registration No: 108 CIN: U85110MH2000PLC128425

Page 12 of 14
Group Medicare 360
CUSTOMER ACKNOWLEDGEMENT
Application Number: 282023001458265 Date: 23/02/2023

Name of the Applicant: SADIQUE AKHTAR KHAN
We acknowledge with thanks the receipt of your application and amount by cash/cheque/Demand Draft/others Debit Authorization of amount of
Rs 12,154.00. 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 13 of 14
Group Medicare 360
RECEIPT
Receipt No : 102301044217707 Receipt Date : 23/02/2023
Policy No: 0239255823 00920696
Received with thanks from MR SADIQUE AKHTAR KHAN a sum of Rs.12154( Rupees Twelve Thousand One Hundred Fifty-Four And
Paise Zero Only)vide Credit / Debit Card No 1003XXXXXXXX dated 23/02/2023 Name as in credit/debit card - SADIQUE AKHTAR
KHANdrawn on HSBC BANK , KOCHI branch towards
Utilized from the receipt for

Sl.No. Policy Number Total Premium Balance
policy
1 0239255823 12,154.00 12,154.00 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: 27AABCT3518Q1ZW-BANDRA , 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 Fax : 022 6693 8170 Email : customersupport@tataaig.com website:www.tataaig.com
Page 14 of 14

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Group Medicare 360

Details of Insured Persons Covered :

Details of Additional Covers :

Details of Waiting Period :

2.Obesity/ Weight Control (Code- Excl 06)

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

Details of TPA/Claims Administrator:

Name of TPA : Tata AIG Health Claim

Treatment, Consultation or Procedure: We or Our TPA* must be informed:

i. Cashless Service is only available at Network Hospitals.

4. Documents for claims :

ii.Notification Of Claim section added as per Wordings

iii.Cashless Service details added as per Wordings

iv.Procedure for Cashless Service addeda

In case of any grievance the Insured Person may contact through

Particulars Amount (Rs.)

80 D certificate of Income Tax Act, 1986

For Policy wordings, please scan the below QR code :

Group Medicare 360

Group Medicare 360

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 6129897525 Intermediary code 0015455000

Section I: Applicant Information

Name: First Name Middle Name Last Name

Date Of Birth: 01/01/1979 Gender: MALE Nationality: INDIAN RESIDENT

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

Group Medicare 360

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:

Sr. No. Has any of the person's proposed to be insured Yes/No

c) ever undergone or currently taking systemic/oral steroid therapy for Asthma

d) ever been hospitalized for dyslipidemia/raised cholesterol or its related complications

Part D Premium Paid for product (including taxes):

Nominee Name: HASEENA KHAN Relationship with the Applicant: Wife

TATA AIG General Insurance Company Limited

For office use only :

Tata AIG General Insurance Company Limited

TATA AIG General Insurance Company Limited

Application Number: 282023001458265 Date: 23/02/2023

TATA AIG General Insurance Company Limited

Receipt No : 102301044217707 Receipt Date : 23/02/2023

Policy No: 0239255823 00920696

Utilized from the receipt for

GSTIN: 27AABCT3518Q1ZW-BANDRA , SAC CODE: 997133

TATA AIG General Insurance Company Limited

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