HDFC ERGO General Insurance Company Limited 3317100439250500000

Policy Schedule
Policy No. 3317 1004 3925 0500 000
Individual Personal Accident Policy
(Plan 3)
331
00
0
Proposer Name MR SOMU SAI KUMAR PAN No. Premium frequency Yearly
Corr. Address/ 2-87 VANDANAM NEAR HANUMAN TEMPLE Permanent 2-87 VANDANAM NEAR HANUMAN TEMPLE
Place of Supply KHAMMAM, TELANGANA, 507318 Address KHAMMAM, TELANGANA, 507318
0
Mobile 9121807534 Phone - E Mail SAIKUMARSOMU8@GMAIL.COM Territorial Limits Worldwide Policy Type Individual

Period of Insurance From Date & Time 02/04/2019 16:04 hrs To Date & Time 01/04/2020 Midnight 1st Policy Inception 02/04/2019 Policy Issuance Date 02/04/2019

Insured Person’s Details

Insured’s Name Relationship with Proposer Date of Birth
SOMU SAI KUMAR Self 28/07/1997
Nominee Details
Insured’s Name Name of Nominee Relation Benefit
SOMU SAI KUMAR VIJAYALAXMI Parent 100 %
Coverage Details
Sum Insured (`)
Coverage
Self
Accidental Death 1000000.00
Dependent Child Education 100000.00
Medical Insurance Premium Indemnity 100000.00
Permanent Disablement 1000000.00
Premium Details ( ` )
Basic Premium 977.00
Integrated Tax 18% 176.00
Total Premium 1153.00
Payment Details
Cheque No./DD/Fund Transfer Date Bank Name
PI1904000283 02/04/2019 BizDirect
Invoice No. 100439250500000 HSN Code 9971
For Claim Services Phone 022-6234 6234/0120-6234 6234 Fax no. +91 22 66383699 E-mail care@hdfcergo.com
Processing Centre 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri(E), Mumbai 400 059.
For any other query call toll-free 1800 2 700 700 (Accessible from India only) or email us at care@hdfcergo.com or log on to www.hdfcergo.com

We shall not be liable to make any payment under this policy in connection with or in respect of any Illness or injury directly or indirectly caused by or contributed to by nuclear weapons/materials or contributed to
by or arising from ionising radiation or contamination by radioactivity by any nuclear fuel or from any nuclear waste or from the combustion of nuclear fuel.
If the premium is not realised the policy shall be void from inception.Subject otherwise to the terms,exclusions and conditions of this policy.The Maximum Compensation in respect of an Insured Person under the
policy shall not exceed 5 times the Annual Income. Income proof for availing the compensation at the time of claim is mandatory. Income proof shall mean the previous year’s returns filed with the Income Tax
Department.
2004/4125/CR690/M-1Goods and Service Tax Registration No: 27AABCL5045N1Z8. Goods and Service Tax for this invoice is not payable under reverse charge basis.

Branch :LEELA BUSINESS PARK, 6TH FLR, ANDHERI - KURLA RD, MUMBAI, 400059. Phone No. :+91-22-66383600

The Policy wording attached herewith includes all the standard coverage offered by the Company to its customers. Your entitlement for coverage/benefits shall be restricted to the coverage/benefits as mentioned in this
policy schedule. For any clarification please call our toll free number.
Agent Name :HDFC BANK LTD For HDFC ERGO General Insurance Company Ltd.
Agent Code :201587086428 Tel No. :91-22-28561818

Duly Constituted Attorney

HDFC ERGO General Insurance Company Limited.(Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016).CIN:
U66030MH2007PLC177117.Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai - 400 020.Customer Service Address: D-301, 3rd Floor,
Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service no:022-6234 6234/0120-6234 6234 Te.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | care@hdfcergo.com |
www.hdfcergo.com. UIN : HDE-MO-P14-40-V02-14-15 IRDAI Reg No.146
HDFC ERGO General Insurance Company Limited 3317100439250500000

Policy No. 3317 1004 3925 0500 000

Individual Personal Accident Policy
(Plan 3)

Dear Somu Sai Kumar,

Subject : Certificate for the purpose of deduction under section 80 D of Income Tax (Amendment) Act, 1986

This is to certify that we have received an amount of ` ( Only) towards premium for policy no. 3317100439250500000 issued to Somu Sai Kumar for the period
02/04/2019 to 01/04/2020.
Note:

1. This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended from time to time.
2. This certificate must be surrendered to the company in case of cancellation of this policy. In event of incorrect representation of this declaration
the liability shall be upon the policy holder.

Date : 31/12/2004 For HDFC ERGO General Insurance Company Ltd.

Policy Issuing Office: Mumbai

Duly Constituted Attorney

HDFC ERGO General Insurance Company Limited.(Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016).CIN:
U66030MH2007PLC177117.Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai - 400 020.Customer Service Address: D-301, 3rd Floor,
Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service no:022-6234 6234/0120-6234 6234 Te.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | care@hdfcergo.com |
www.hdfcergo.com. UIN : HDE-MO-P14-40-V02-14-15 IRDAI Reg No.146
HDFC ERGO General Insurance Company Limited
3317100439250500000

Proposal No. 3317 1004 3925 0500 000

Health Insurance - Proposal Form For Individual Personal Accident Insurance

(Plan 3)
331 0
0 0
Proposer Name MR SOMU SAI KUMAR Premium frequency Yearly PAN No.
Correspondence 2-87 VANDANAM NEAR HANUMAN TEMPLE Permanent 2-87 VANDANAM NEAR HANUMAN TEMPLE
Address KHAMMAM, TELANGANA, 507318 Address KHAMMAM, TELANGANA, 507318

Mobile 9121807534 Phone - E Mail SAIKUMARSOMU8@GMAIL.COM Territorial Limits Worldwide Policy Type Individual

Period of Insurance From Date & Time 02/04/2019 16:04 hrs To Date & Time 01/04/2020 Midnight 1st Policy Inception 02/04/2019

Insured Person’s Details

Insured’s Name Relationship with Proposer Date of Birth
SOMU SAI KUMAR Self 28/07/1997

Nominee Details
Insured’s Name Name of Nominee Relation Benefit
SOMU SAI KUMAR VIJAYALAXMI Parent 100 %

Premium Details ( ` )

Basic Premium 977.00

Integrated Tax 18% 176.00
Total Premium 1153.00

Payment Details

Cheque No./DD/Fund Transfer Date Bank Name

PI1904000283 02/04/2019 BizDirect
Agent Name :HDFC BANK LTD
Agent Code :201587086428 Tel No. :91-22-28561818
Proposer declaration

“I/We hereby declare, on m y 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.

understand that the information provided by me will form the basis of the 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 receipt 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 from a hospital who at anytime has attended on the life to be insured/proposer or from any past
or present employer concerning anything which affects the physical or mental health of the life to be assured/proposer and seeking information from any insurance company to which an
application for insurance on the life to be assured/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 m y proposal including the medical records for the sole purpose of proposal underwriting and/or claims settlement and
with any Governmental and/or Regulatory authority.”

For Claim Services Phone 022-6234 6234/0120-6234 6234 Fax no. +91 22 66383699 E-mail care@hdfcergo.com
Processing centre 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri(E), Mumbai 400 059.
For any other query call toll-free 1800 2 700 700 (Accessible from India only) or email us at care@hdfcergo.com or log on to www.hdfcergo.com

Disclaimer : Proposal Form and Policy Schedule have been generated basis details entered by proposer / insured on Online Platform (either on HDFCERGO.com or its affiliated Online Channels (IRDAI Licensed
Intermediaries). For any modification, kindly visit URL https://www.hdfcergo.com/customer-care/customer-support.html and register your service request or write to us at care@hdfcergo.com

Customer Name: MR. SOMU SAI KUMAR PAN No. :

HDFC ERGO General Insurance Company Limited.(Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016).CIN:
U66030MH2007PLC177117.Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai - 400 020.Customer Service Address: D-301, 3rd Floor,
Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service no:022-6234 6234/0120-6234 6234 Te.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | care@hdfcergo.com |
www.hdfcergo.com. UIN : HDE-MO-P14-40-V02-14-15 IRDAI Reg No.146