पॉलिसी अनुसूची/ Policy Schedule - GroupMediclaim-Tailormade

पॉलिसी संख्या / Policy Number:

व्यवसाय स्रोत/ Business Source: 910441
240400501810000315
जारीकर्ता कार्यालय/Issuing Office विक्रय चैनल विवरण/
कार्यालय कोड/ Office Code: 240400 Sales Channel Details

कार्यालय पता/ Office Address: MUMBAI कोड/ Code: 91044100000001

DIVISION X Rajeshwar Bhavan, First Floor, नाम/ Name: PREFERRED PARTNERS INSURANCE BROKERS PVT LTD - HO
Above Canara Bank, 51, R,anade Road, संपर्क संख्या/Contact Number: 9599487797
Dadar West, Mumbai, - 400028.
राज्य कोड/State Code: 27 , Maharashtra
जीएसटीएन/GSTIN: 27AAACN9967E1Z3
संपर्क संख्या/Contact Number: 22
24227278
मोबाइल संख्या /Mobile Number: 0

ग्राहक का नाम/Customer Name: STEM WATER DISTRIBUTION ग्राहक आईडी/ Customer ID:
AND INFRASTRUCTURE CO PVT LTD 9701141918
पैन/ PAN: AAPCS1541Q
पता/ Address: VARDAN COMMERCIAL COMPLEX,9TH FLOOR, फोन/ Phone:
MIDC ROAD NO.16 WAGLE INDUSTRIAL ESTATE THANE
WEST, शहर/City: THANE, जिला/District: THANE, राज्य/State: ई-मेल/ E-Mail:
MAHARASHTRA, पिन/ PIN: 400604.

पॉलिसी प्रभावी समय घंटे को Policy Effective from 00:00 hours, on 17/06/2018 की मध्य रात्रि तक प्रभावी/to midnight of

16/06/2019
कवर नोट संख्या तथा तिथि/ Cover
प्रीमियम /Premium ` 38,44,620.00 NA
Note Number and Date
सीजीएसटी/CGST ` 3,46,016.00

एसजीएसटी/यूटीजीएसटी प्रस्ताव संख्या और तिथि /Proposal

` 3,46,016.00 8800180621365166 दिनांक/Dt. 21/06/2018
SGST/UTGST Number and Date
आईजीएसटीIGST ` 0.00
वसूली योग्य स्टाम्प शुल्क
` 0.00 रसीद संख्या और तिथि/ 240400811810000513 दिनांक/Dt.
/ Recoverable Stamp Receipt Number and Date 15/06/2018
Duty
पिछली पॉलिसी संख्या तथा समाप्ति
कुल / Total ` 45,36,652.00 तिथि/ Previous Policy Number and NA
Expiry Date
(रूपए /Rupees Forty Five Lakh Thirty Six Thousand Six Hundred Fifty Two केवल/Only.)

Location Address:VARDAN COMMERCIAL COMPLEX, 9th FLOOR, MIDC ROAD NO.16, WAGALE INDUSTRIAL ESTATE,
THANE(WEST),,Thane,Thane,Maharashtra,400604.
Number of Families :200 Number of Lives covered:868

SL. No Coverage Coverage Description Sum Insured

200 EMPLOYEES COVERED ALONG WITH 668
Standard Cover DEPENDENTS TOTAL LIVES COVERED 868 AS PER ` 3,35,50,000.00
GMC TERMS AND CONDITIONS
1
Excess: AS PER NATIONAL TAILOR MADE GROUP MEDICLAIM POLICY.
Additional Information: NA

TPA Details: HERITAGE HEALTH TPA PVT LTD - MUMBAI MBRO 1, ELITE AUTO HOUSE, 54byA, Aby01, GROUND FLOOR,BESIDE
APPLE HERITAGE BLDG , ANDHERI KURLA ROAD, CHAKALA, ANDHERI E ,MUMBAI - 400093 Contact No : 022 - 28232503 Fax : 022
- 66716299 Email : heritagemumtpa@bajoria.in.

Clauses As per Annexure I

दिनांक को मुद्रित/Printed on 25/06/2018 आईडी द्वारा/by ID: 76302, AID : पृष्ठ सं.Page no: 1
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 पॉलिसी अनुसूची/ Policy Schedule - GroupMediclaim-Tailormade
पॉलिसी संख्या / Policy Number:
व्यवसाय स्रोत/ Business Source: 910441
240400501810000315
जारीकर्ता कार्यालय/Issuing Office विक्रय चैनल विवरण/
कार्यालय कोड/ Office Code: 240400 Sales Channel Details

कार्यालय पता/ Office Address: MUMBAI कोड/ Code: 91044100000001

DIVISION X Rajeshwar Bhavan, First Floor, नाम/ Name: PREFERRED PARTNERS INSURANCE BROKERS PVT LTD - HO
Above Canara Bank, 51, R,anade Road, संपर्क संख्या/Contact Number: 9599487797
Dadar West, Mumbai, - 400028.
राज्य कोड/State Code: 27 , Maharashtra
जीएसटीएन/GSTIN: 27AAACN9967E1Z3
संपर्क संख्या/Contact Number: 22
24227278
मोबाइल संख्या /Mobile Number: 0
जिसकी गवाही में दिन/ माह /वर्ष को उपरोक्त उल्लिखित कार्यालय पते पर अधोहस्ताक्षरी को विधिवत अधिकृत किया जा रहा है उसके हाथ

निर्धारित किए जाएं। यह अनुसूची, संलग्न पॉलिसी, खण्ड, पृष्ठांकन और पॉलिसी शब्दों, जो कंपनी वेबसाईट
www.nationalinsuranceindia.nic.co.in पर उपलब्ध है, को एक अनुबंध के रुप में एक साथ पढ़ा जाए तथा कोई भी शब्द या अभिव्यक्ति जिसके
लिए यह विशिष्ट अर्थ पॉलिसी या अनुसूची के किसी भी हिस्से में संलग्न किया गया हो, एक ही अर्थ वहन करेगा चाहे जहॉ भी उल्लिखित हो। यह

आश्वासन दिया जाता है कि प्रीमियम चेक की अस्वीकृति के मामले में, यह दस्तावेज स्वतः आरंभ से ही निरस्त मानी जाएगी । /IN WITNESS
WHEREOF, the undersigned being duly authorized hereunto set his/ her hand at the office address mentioned above, this 25/June/2018.
This schedule, the attached policy, the clauses, the endorsements and policy wordings as available in the website
www.nationalinsuranceindia.nic.co.in shall be read together as one contract and any word or expression to which the specific meaning
has been attached in any part of this policy or of the schedule shall bear the same meaning wherever it may appear. It is warranted that IN
CASE OF DISHONOUR OF THE PREMIUM CHEQUE, THIS DOCUMENT STANDS AUTOMATICALLY CANCELLED 'AB-INITIO'

स्टांप कृते नेशनल इन्श्योरेन्स कंपनी

लिमिटेड/ For and on behalf of National Insurance
ड्यूटी
Stamp
इंश्योरेन्सइंडियालिमिटेड Company Limited
Duty:
(` 1.00 )
अधिकृत हस्तात्क्षरकर्ता/ Authorized
Signatory

दिनांक को मुद्रित/Printed on 25/06/2018 आईडी द्वारा/by ID: 76302, AID : पृष्ठ सं.Page no: 2
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पॉलिसी अनुसूची/ Policy Schedule - GroupMediclaim-Tailormade
पॉलिसी संख्या / Policy Number:
व्यवसाय स्रोत/ Business Source: 910441
240400501810000315
जारीकर्ता कार्यालय/Issuing Office विक्रय चैनल विवरण/
कार्यालय कोड/ Office Code: 240400 Sales Channel Details

कार्यालय पता/ Office Address: MUMBAI कोड/ Code: 91044100000001

DIVISION X Rajeshwar Bhavan, First Floor, नाम/ Name: PREFERRED PARTNERS INSURANCE BROKERS PVT LTD - HO
Above Canara Bank, 51, R,anade Road, संपर्क संख्या/Contact Number: 9599487797
Dadar West, Mumbai, - 400028.
राज्य कोड/State Code: 27 , Maharashtra
जीएसटीएन/GSTIN: 27AAACN9967E1Z3
संपर्क संख्या/Contact Number: 22
24227278
मोबाइल संख्या /Mobile Number: 0
अनुलग्नक I / ANNEXURE I– लागू खंडों की सूची/ List of Applicable Clauses
• ANNEXURE I- LIST OF APPLICABLE CLAUSES. : TERMS AND CONDITIONS:
1. Family Floater = (1+5) Employee + Spouse + 2 Children + Dependent Parents or Parents in Law.
2. No Age Limit.
3. Pre-Exisiting diseases covered.
4. 30 days waiting period waiver.
5. 1st, 2nd, 3rd and 4th year Exclusion waiver.
6. Maternity Benefit : Rs. 35,000/- for Normal & Rs. 50000/- for Caesarian.
7. Nine months waiting period waiver for all the employee and dependent spouse only.
8. New Born baby cover from Day one under Family Sum Insured.
9. Pre and Post Natal Expenses Covered under Maternity Limit.
10. OPD Cover Inclusive any Dental, Eye care & other Medical expenses/health checkup Limit of Rs. 2000/- ,Rs.
5000/-, Rs. 20000/- & Rs. 75,000/- as per list attached.
11. Day Care Facilities Cover.
12. Pre and Post Hospitalization for 30 and 60 days respectively.
13. Room rent restricted to 1.5% of the Sum Insured for normal hospitalization and 2.5% of the Sum Insured for ICU
and all other charges accordingly room rent.
14. Cashless Facility.
15. Cover for new joinees from date of joining of the employee.
16. Ambulance Charges: Rs. 1000/- per insured person.
17. Congenital Internal Diseases Cover.
18. Terrorism Cover.
19. Ayurvedic treatment hospitalization expenses are admissible 25% only when the treatment is taken as in-patient ,
in the government hospital.
20. Cochlear Implant treatment shall be restricted to 50% of the SI.
21. Corporate buffer of Rs. 1,00,000/- and utilization for all the illness except maternity.
22. Claim Intimation Clause: within 7 days from hospitalization and before discharge from hospital.

कृते नेशनल इन्श्योरेन्स कंपनी लिमिटेड/

For and on behalf of National
Insurance Company Limited

अधिकृत हस्तात्क्षरकर्ता/ Authorized Signatory

दिनांक को मुद्रित/Printed on 25/06/2018 आईडी द्वारा/by ID: 76302, AID : पृष्ठ सं.Page no: 3
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 टैक्स इनवॉयस/TAX INVOICE

इनवॉयस क.सं./Invoice Serial No: 30153O8P00000315 इनवॉयस ितिथ/Invoice Date: 25/06/2018

आपूर्तिकर्ता का विवरण/Details of Supplier:

नेशनल इन्श्योरेन्स कंपनी लिमिटेड/National Insurance Company Limited.,
MUMBAI DIVISION X Rajeshwar Bhavan, First Floor, Above Canara Bank, 51, R,anade Road, Dadar West, Mumbai, - 400028
राज्य/State : 27 , Maharashtra
जीएसटीआएन
नंबर/GSTIN 27AAACN9967E1Z3
No :

प्राप्तकर्ता का विवरण/Details Of Receiver : STEM WATER DISTRIBUTION AND INFRASTRUCTURE CO PVT LTD
पता/Address : VARDAN COMMERCIAL COMPLEX,9TH FLOOR, MIDC ROAD NO.16 WAGLE INDUSTRIAL ESTATE THANE WEST
शहर/City : THANE,
जिला/District: THANE,
राज्य/State: MAHARASHTRA,
पिन/PIN: 400604.

आपूर्ति का स्थान/Place Of
Maharashtra
Supply State :
राज्य कोड/State Code : 27
जीएसटीआईएन नंबर/GSTIN
NA
No :

टैक्स योग्य/ एसजीएसटी/यूटीजीएसटी/

सैक कोड/ सेवा का विवरण/ छूट/ सीजीएसटी की राशि/CGST आईजीएसटी/IGST
कुल/Total(`) मूल्य/ SGST/UTGST
SAC Description of Discou
Taxable दर/ दर/ राशि दर/ राशि/
Code Service nt Amount(`)
Value(`) Rate Rate Amount(`) Rate Amount(`)
Other non-life
insurance services
997139 (excluding 38,44,620 0% 38,44,620 9% 3,46,016 9% 3,46,016 0% 0
reinsurance
services)
TOTAL 38,44,620 38,44,620 3,46,016 3,46,016 0
कुल इनवॉयस मूल्य (अंकों में )Total Invoice Value (In figures) : ` 45,36,652
कुल इनवॉयस मूल्य (शब्दों में)Total Invoice Value (In words) : रूपए/Rupees Fourty Five Lakh Thirty Six Thousand Six Hundred Fifty Two केवल/Only.
रिवर्स चार्ज के अधीन टैक्स की राशि/ Amount of Tax Subject to Reverse Charge : No

E.&.O.E

कृते नेशनल इन्श्योरेन्स कंपनी लिमिटेड/For and on behalf of

National Insurance Company Limited.,

अधिकृत हस्ताक्षरकर्ता/Authorized Signatory

दिनांक को मुद्रित/Printed on 25/06/2018 आईडी द्वारा/by ID: 76302, AID : पृष्ठ सं.Page no: 4
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