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To, The Manager, E-MEDITEK (TPA) SERVICE LTD. 577, Udyog Vihar Phase V Gurgaon, Haryana Date: 20th March 2013 Through the E-Meditek (TPA) Service Ltd. Guwahati Branch, Assam Ref.: Intimation for Mediclaim vide Policy No. 322102/48/2013/898 Valid from: 12-02-2010 Period of Policy 12-02-2013 to 11-02-2014 In the name of Mrs. Jyotirmoyee Phukan Puzari Dear Sir, With due respect I would like to inform you that, I have admitted at Barua Surgical Centre, Jorhat on 26-02-2012 due my Appendix surgery. The Medical expenses incurred during hospitalization are enclosed for favour of your kind disposal. By mistake there are three names of myself on policy and hospitalization papers, so I enclose a court affidavit in the application for favour of you. It is my kind information and take necessary effective action immediately please. Thanks, Enclosed: 1. Xerox 3 years continued policy copies. 2. Xerox Court Affidavit copy 3. Xerox Bank Passbook of SBI Jorhat 4. Original claim form. 5. Original first consultation paper by the treating doctor. 6. Original visiting Specialist paper of Baruah Surgical Centre. 7. Original Discharge certificate of Baruah Surgical Centre. 8. Original Money Receipt of Baruah Surgical Centre Rs. 23490/9. Original Advance Money Receipt of Baruah Surgical Centre Rs. 5000/10. Original Registration Card of Baruah Surgical Centre. 11. Original Hospital Bill of Borua Surgical Centre Rs. 7500/12. Original Ward Cabin Bill of Boruah Surgical Centre Rs. 1500/13. Original Doctors Bill Boruah Surgical Centre Rs. 13,600/-

2 of 3 14. Original summarized statement of Surgicl Centre Rs. 9890/15. Original Medicine Bill of Barua Surgical Centre Rs. 4247.48/16. Original Medicine Bill of Barua Surgical Centre Rs. 743.90 17. Original Medicine Bill of Barua Surgical Centre Rs. 430.00 18. Oiginal Pathology Bill of Barua Surgical Centre Rs. 2720.00 19. Original Pathology Bill of Barua Surgical Centre Rs. 660.00 20. Original Radiology Bill of Barua Surgical Centre Rs. 230.00 21. Original 5 copies of Laboratories papers of Barua Surgical Centre 22. Original 9 copies of Requisition slips of Barua Surgical Centre 23. Original ECG Report of Barua Surgical Centre. 24. Original Digital X-Ray report with film & treating doctors paper with Money Receipt of Sanjivani Diagnostics. 25. Original surgery photo copy of Barua Surgical Centre 26. Original Ultra Sound Report copy and Money Receipt of Sanjivani Diagnostics. 27. Original X-Ray report with film of Barua Surgical Centre.

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PARTICULARS IN THE NAME OF MRS. JYOTIRMOYEE PHUKAN PUZARI 1. Name of the patient/Insured 2. Name of Hospital & Address : JYOTIRMOYEE PHUKAN PUZARI Age: 55 Years : Barua Surgical Centre, Borbheta, Jail Road Jorhat-785004 : SHA/47 : 26-02-2013 : 01-03-2013

3. Regd. No. of Hospital 4. Date of Admission Date of Discharge PARTICULARS OF BILL Hospital Bill Ward Cabin Bill (500.00 X 3 days) Doctors Bill Medicine Bill of Barua Surgical Centre Medicine Bill of Barua Surgical Centre Medicine Bill of Barua Surgical Centre Pathology Bill of Barua Surgical Centre Pathology Bill of Barua Surgical Centre Radiology Bill of Barua Surgical Centre Digital X-Ray of Sanjivani Diagnostics Ultrasound of Sanjivani Diagnostics

(a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k)

Total Bill

: Rs. 7,500.00 : Rs. 1500.00 : Rs. 13,600.00 : Rs. 4247.48 : Rs. 743.90 : Rs. 430.00 : Rs. 2720.00 : Rs. 660.00 : Rs. 230.00 : Rs. 600.00 : Rs. 1100.00 :Rs. 33331.38

(Rupees Thirty Three Thousand Three Hundred Thirty One and Thirty Eight Paisa only)

Yours faithfully

Jyotirmoyee Phukan Puzari