Policy Servicing Branch Office : Reliance General Insurance Co. Ltd, Reliance General Insurance Co Ltd 202-21 2nd Floor MERCANTILE HOUSE KASTURBA GANDHI MARG New Delhi New Delhi 110001
Policy Issuing Office : Reliance General Insurance Co. Ltd., 570, Naigaum Cross Road, Next to Royal Industrial Estate, Wadala (W), Mumbai – 400031
Reliance Reliance Individual Mediclaim Policy Schedule Name and Address of the Proposer : KOUSHIK DUTTA F-93, GROUND FLOOR, SECTOR - 54 GURGAON, HARYANA 122001 India Mobile No: 7838080811 Policy Number 1301812821000291 Details Details of previous poli cy (in case of renewal) Previous policy No.
: NA
Date of expiry
: NA
Sum Insured
: As Indicated Below
Period of Insurance
: From 00:01 on 25/05/2016 to mid-night on 24/05/2017
Name of Insured Person
KOUSHIK DUTTA APARNA GAWAS
Gender
Male Female
Date of Birth
Relationship with the Proposer
28/12/1980 Self 21/10/1986 Spouse
Occupation
Pre-Existing Illness
Others Others
Sum Domiciliary Insured (Rs) Hospitalisation Limit (Rs) 50000.00
500000.00
Amo un t of CB (Rs)
Loading (%)
555000.00
Premium (Rs) 0 18110.00
* Where an Insured Person is added to this P olicy, either by way of endorsement or at the ti me of renewal, the pre-existing disease clause,first year exclusion and 30 days waiting period is applicable considering such policy period as th e first policy with us. * Policy would be considered as a fresh policy if there would be break of fift een or more days between the prevoius policy expiry date and current policy start date. * Any enhanced Sum insured during subsequent policy r enewals will not be available for an illness, dis eases, injury already contracted under the preceding policy periods.All Waiting periods as defined in the policy shall apply for this enhanced limit from the effective date of enhancement of such Sum Insured. * This Insurance is subject to the t erms and conditions of policy attached .The polic y wordings with detailed terms , conditions and exclusio ns is available on our website www.reliancegeneral.co.in www.reliancegeneral.co.in Special Conditions, if any : Premium Details
Amo un t (Rs.)
Gross Premium
18,110.00
Service Service Tax (12% of Net Net Premium) Premium)
2173.20
Education Cess (2% of Service Tax)
43.46
Secondary and Higher Education Cess (1% of Service Tax)
21.73
Total Premium
20,348.00
(Service Tax Registration No: AABCR6747BST001) Consolidated Stamp duty Paid vide Receipt No.20984 dated 25/05/2016 ** ** Not applicable for the the State of Jammu and Kashmir Kashmir Note: In the event of dishonor of cheque, this policy document automatically stands cancelled from inception, irrespective of wh ether a separate communication is sent or not. In witness whereof this policy has been signed at Mumbai on 25/05/2016 For any assistance with claims, please contact us on 1 800 3002 8282 (toll free) free) and 3989 8282 (local charges apply) or email us at services.rgicl@reliancea
[email protected] da.com TPA/Service Provider Details TPA/Service Provider Name
Paramount Health Services Pvt. Ltd.
Add ress Please Log on to www.paramounttpa.com f or locating the nearest office for submission of claim d ocuments 24X7 Customer Helpline Number 022-66620880/ Number 022-66620880/ (022) 6662 0880(TollFree) Fax Number (022) 2825 9543 /9743 Email id
[email protected] [email protected] ( F or Insured Grievances & for any other queries)
Premium Certificate Premium Certificate for the purpo se of deductio n under Section 80-(D 80-(D)) of Income Tax (Amendment) Act 1986. This is to certify that KOUSHIK DUTTA has paid Rs.20348 (TWENTY THOUSAND T HREE HUNDRED FOURT Y EIGHT) towards premium for Health Insurance for the Period Period From From 00:01 on 25/05/201 25/05/2016 6 to Midnight Midnight of 24/05/ 24/05/2017 2017 on May 25 2016 Policy Number : 13018128 1301812821000 21000291 291 Date : 25/05/201 25/05/2016 6
Place : Mumbai
Note: This certificate must be surrendered to the Insurance Comp any for issuance of fresh certificate in case of c ancellation of policy or any alteration in the insurance affecting the premium.
Registered Office: Reliance Centre, 19, Walchand Hirachand Marg,Ballard Estate ,Mumbai - 400 001
