INDIVIDUAL HEALTH INSURANCE

INTERMEDIARY NAME

Direct
NA PHONE NO.

INTERMEDIARY CODE
POLICY NO
COVERNOTE
NUMBER

E-MAIL

NA

SUB IMD CODE

NA

2815/52643333/03/B00

POLICY TYPE

NA
RENEWAL
BUSINESS

NA
CUSTOMER ID

101074314085

NAME OF THE
PROPOSER

PROPOSER DETAILS
SAMPATH VITTAL AMIN

PERIOD OF INSURANCE

FROM 00:00 OF 17/11/2015 TO MIDNIGHT OF 16/11/2016

ADDRESS OF THE
PROPOSER

B4/206, EKTA LOKMILAN ,

NAHAR AMRIT SHAKTI , SAKI
VIHARROAD , CHANDIVALI
MUMBAI
MUMBAI
MAHARASHTRA
PIN - 400072
MOB NO: 9869909834
Email Address samincrindia@gmail.com

POLICY ISSUED AT

ANDHERI POLICY ISSUE DATE

(MUMBAI)
BRANCH

TYPE OF COVER

Health-Basic Cover

TOTAL SUM INSURED Rs.

30/11/2015

300000.00

PREMIUM (AMOUNT IN Rs.)

TOTAL PREMIUM

5715.00

SERVICE TAX (Including Swachh Bharat Cess)

828.68

EDUCATION CESS

0.00

TOTAL AMOUNT PAYABLE

6544.00

TOTAL AMOUNT PAYABLE(IN WORDS)

Rupees Six Thousand Five Hundred Fourty Four Only

TYPE OF POLICY

COMPOSITION

NO OF PARENTS

FAMILY

2 ADULT

NA

DETAILS OF INSURED
CUMULATIVE BONUS(Rs.)

PRE-EXISTING DISEASE DECLARED

SAMPATH VITTAL AMIN

NAME OF INSURED

DATE OF BIRTH GENDER RELATIONSHIP WITH PROPOSER

19/10/1978

SELF

15000

NO

MAMATHA SAMPATH AMIN

11/06/1983

WIFE

NO

NOMINEE DETAILS
NOMINEE NAME

RELATIONSHIP WITH PROPOSER

PADMAVATI V AMIN

SELF

NA

WIFE
PREVIOUS POLICY DETAILS

COMPANY NAME

POLICY NUMBER

POLICY YEAR

POLICY START DATE

POLICY END DATE

CLAIM STATUS

UNIVERSAL SOMPO

2815/52643333/01/000

2013

31/10/2013

30/10/2014

NO

UNIVERSAL SOMPO

2815/52643333/00/000

2012

31/10/2012

30/10/2013

NO

UNIVERSAL SOMPO

2815/52643333/02/B00

2014

04/11/2014

03/11/2015

NO

Policy subject to the following Special Condition(s) :

NO CLAIMS REIMBURSEMENT FOR EXPENSES INCURRED FOR HOSPITALIZATION COMMENCING DURING THE PERIOD OF BREAK TIME GAP IN RENEWAL.
2815/OL/000014

Clauses/Endorsements attached to the policy: NA

In Witness whereof the undersigned being duly authorised by and on behalf of the company has/have here onto set his/their hands
Collection No

1015602410

SERVICE TAX REGISTRATION NO.: AAACU8917FST001

Dated

30/11/2015
FOR UNIVERSAL SOMPO GENERAL INSURANCE CO. LTD.

IRDAI UIN NO: IRDA/NL-HLT/USGI/P-H/V.I/52/13-14

USGI IRDAI REGISTRATION NO: 134

DULY CONSTITUTED ATTORNEY(S)

Consolidated stamp duty Rs 0.50 paid towards Insurance policy stamp vide receipt no. 52014 dated 17/06/2015 of General Stamp Office Mumbai.
DISCLAIMER: This Policy is null and void ab initio,if the cheque/any valid negotiable Instrument as receipted by this company via this receipt is dishonoured by the
bank. Issuance of the receipt is not a proof of risk acceptance.
CLAIMS DISCLAIMER: In the unfortunate event of any loss or damage to the insured property resulting into a claim on this policy, please intimate the mishap
IMMEDIATELY to our Call Centre at Toll Free Numbers: 1800-200-5142, Chargeable Numbers: 02239635200, Fax Toll Free Numbers: 1800-200-9134.
Email at contactclaims@universalsompo.com. Please note that no delay should be allowed to occur in notifying a claim on the policy as the same may prejudice
liability.
RESOLVING ISSUES
Please read your policy and policy schedule:
The policy and policy schedule set out the terms of your contract with us. please read this carefully to ensure that the cover
meets your needs.
In case of any discrepancy,complaint or grievance, please feel free to contact us within 15 days of receipt of the policy.
Universal Sompo General Insurance Co. Ltd.

Express IT Park,Plot No. EL - 94,T.T.C. Industrial Area,M.I.D.C., Mahape,Navi Mumbai- 400710

Toll Free Numbers: 1800-200-5142, Chargeable Numbers: 022 39635200, Fax Toll Free Numbers: 1800-200-9134.
E-mail Address: contactus@universalsompo.com.
Note : Please include your policy number for any communication with us.
Universal Sompo General Insurance Co.Ltd. shall abide by Insurance Regulatory and Development Authority (Protection of Policyholder's Interests) Regulations 2002 .
under this regulation and with an objective to provide a forum to personal lines policy holders for resolution of claims related complaints, Insurance Ombudsman has
been constituted under the aegis of Governing Body of Insurance Council. For further information you could refer to www.irdaindia.org/ins_ombusman.htm.
TPA DETAILS : The details of the TPA and our network providers and diagnostic centers can be found at our website www.universalsompo.com.
Cashless claims facility is extended under the policy and your Third Party Administrator (TPA) is UNIVERSAL SOMPO-HEALTH SERVE. Contact number
of TPA for registering claims for Pre-authorization is 1800 200 5142 (Toll Free)

Premium Certificate for the purpose of deduction under Section 80 D of Income Tax Act
This is to certify that Shri/Smt SAMPATH VITTAL AMIN has paid Rs. 6544.00 (Rupees Six Thousand Five Hundred Fourty Four Only) towards premium for INDIVIDUAL
HEALTH INSURANCE POLICY under Policy No. 2815/52643333/03/B00 for the period from 17/11/2015 TO 16/11/2016 vide Collection No. 1015602410 Collection Date
30/11/2015.

USGI IRDAI REGISTRATION NO: 134

FOR UNIVERSAL SOMPO GENERAL INSURANCE CO. LTD.

Authorized Signatory