Digitally signed by Padmesh Nair

Date: 2019.08.29 11:26:39 +05:30

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N2019082636126
MR Abhishek Jain
House No-2196 Gali No-09
Indian Post / REN /1988 / 1

Kailash Nagar Gandhi Nagar

Delhi -
Delhi - 110031 This Policy Kit Contains:
India 1. The Policy Schedule along with income tax
Contact No. : 9582232379 (80D) certificate (wherever applicable)
Policy No : 110105/11121/6000119019-06 2. Cashless Card*

Code Intermediary Name Contact No

80150337 HARI SHANKER TIWARI 9810352926

Renewal of Your Optima Restore Insurance Policy

Dear MR Abhishek Jain,

Thank You for renewing the policy with us.

We are pleased to enclose your renewed Policy Kit for the period 28-Aug-2019 to 27-Aug-2020

To know more about policy related information and value added offers, you may re-register yourself at our website using your unique member
ID and policy number as mentioned in the policy schedule.

In case of any query, please feel free to write to [email protected] or call us at our 24 hours toll free number
1800-102-0333. Our customer care team will be happy to assist you.

Warm Regards,
Location : Gurgaon
Date : 24-Aug-2019

Authorized Signatory

Note :-
- Please visit our website www.apollomunichinsurance.com to access information about our company, the customer service touch
points including the Grievance handling process and various forms that you can use for service support. You will also get latest
updates on products, policy wordings which you can download for your reference and record.

- Please update us with your latest contact details (in case of any change) so that same can be updated in our records .You can either
write back to us or call us on our toll free no. 1800-102-0333.

*Cashless card issued earlier would be valid till your relationship with Apollo Munich Health Insurance. With HealthJinn app, you can also
access your policy details at your fingertips. To download the app, click on bit.ly/2xeq3ua

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 POLICY SCHEDULE - Optima Restore Floater

Issuing/Servicing Office : Laxmi Nagar Branch Office, 204, Laxmi Deep Building, Laxmi
Nagar District CentreLaxmi Nagar
Delhi -110092
PH : 01143602378
GSTIN of Issuing Office : 07AAGCA1654H1ZU
Policy Holder's Name : MR Abhishek Jain
GSTIN / UIN (if any) of Policy Holder:
Policy Holder's Address : House No-2196 Gali No-09
Kailash Nagar Gandhi Nagar
Delhi -
Delhi - 110031
India
Policy Holder State Name & Code : Delhi(07)
Intermediary Code : 80150337
Intermediary Name : HARI SHANKER TIWARI
Intermediary Contact No : 9810352926
Policy Number : 110105/11121/6000119019-06
First policy inception date : 28-Aug-2013
Policy issuance date : 23-Aug-2019
Description/Accounting Code of Service Accident and Health Insurance Service/ 9971
Policy Period : From 00:00 hrs on 28-Aug-2019 To 24:00 hrs on 27-Aug-2020
Place of supply : Delhi (Delhi)

Insured Persons Details :

Particulars Member 1 Member 2 Member 3 Member 4 Member 5 Member 6
10005913352 10005913353 10005913354 10005913355 - -
Mr Abhishek Jain Mrs Kanika Jain Master Samyak Jain Master Sarthak Jain - -
Date of Birth / (Age) 17-Dec-1977 (41) 01-May-1980 (39) 05-Aug-2002 (17) 15-Apr-2004 (15) - -
Relationship to Policy holder Policy Holder Wife Son Son - -
Base Sum Insured (Rs) 500000.00
Multiplier Benefit Sum Insured (Rs) 250000.00
Protector Rider Sum Insured (Rs) 0
Total Sum Insured (Rs) 500000.00

Other Riders & Benefits

Protector Rider Opted
Hospital Daily Cash Rider SI (max -
30 Days)
Critical Advantage Rider SI - - - - - -
IPA Rider SI (Rs) - - - - - -

Nominee Name : Mrs Kanika Jain Relationship to Policyholder : Wife

The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee.

Premium Calculation :-
Net Premium (Rs.) 17922.00
Discounts (Rs.) 0.00
Loadings (Rs.) 0.00
Taxable Premium (Rs.) 17922.00
CGST@9% (Rs.) 1612.98
SGST/UGST@9% (Rs.) 1612.98
IGST@0% (Rs.) 0.00
Any other Cess of Taxes (Rs.) 0.00
Gross Premium (Rs.) 21147.96
Gross premium amount (in Rupees Twenty-One Thousand One Hundred Forty-Seven and Paisa Ninety-Six Only
words)
The stamp duty of Rs. 1.00 /- ( Rupees One Only ) paid vide No.F.10(783)/COS(HQ)/Con.duty/08. (Not applicable for the state of Jammu &
Kashmir).

Original for Recipient/ Duplicate for Supplier

Whether tax is payable on reverse charge basis No

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EXCLUSION(S) / SPECIAL CONDITION(S)
Member ID Person Name Details
10005913352 Mr Abhishek Jain For Rs 200000 (Rupees Two Lakh) Sum Insured - Sec 5 A (i), Sec 5 A (ii)
and Sec 5 A (iii) of the policy wording is waived.For Rs 300000 (Rupees
Three Lakh) Sum Insured - Sec 5 A (i), Sec 5 A (ii) and Sec 5 A (iii) of the
policy wording is waived.
10005913353 Mrs Kanika Jain For Rs 200000 (Rupees Two Lakh) Sum Insured - Sec 5 A (i), Sec 5 A (ii)
and Sec 5 A (iii) of the policy wording is waived.For Rs 300000 (Rupees
Three Lakh) Sum Insured - Sec 5 A (i), Sec 5 A (ii) and Sec 5 A (iii) of the
policy wording is waived.
10005913354 Master Samyak Jain For Rs 200000 (Rupees Two Lakh) Sum Insured - Sec 5 A (i), Sec 5 A (ii)
and Sec 5 A (iii) of the policy wording is waived.For Rs 300000 (Rupees
Three Lakh) Sum Insured - Sec 5 A (i), Sec 5 A (ii) and Sec 5 A (iii) of the
policy wording is waived.
10005913355 Master Sarthak Jain For Rs 200000 (Rupees Two Lakh) Sum Insured - Sec 5 A (i), Sec 5 A (ii)
and Sec 5 A (iii) of the policy wording is waived.For Rs 300000 (Rupees
Three Lakh) Sum Insured - Sec 5 A (i), Sec 5 A (ii) and Sec 5 A (iii) of the
policy wording is waived.

Claim Administrator: Apollo Munich For and on behalf of Apollo Munich Health Insurance Company Limited

Claim Administrator: Not Applicable

(For critical advantage rider)

Authorized Signatory
Location : Gurgaon
Date : 24-Aug-2019

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 Certificate for the purpose of deduction under Section 80 D of Income Tax Act, 1961*

This is to certify that MR Abhishek Jain has paid Rs Rs.19224.96 for FY 2019-2020 (Rupees Nineteen Thousand Two Hundred Twenty-Four
and Paisa Ninety-Six Only for Financial year 2019-2020) towards premium for Policy No 110105/11121/6000119019-06 issued to
ABHISHEK JAIN for period 28-Aug-2019 to 27-Aug-2020

For and on behalf of Apollo Munich Health Insurance Company Limited

Authorized Signatory
Location : Gurgaon
Date : 24-Aug-2019

* Note

1. This is subject to the provisions of Section 80D of Income Tax Act, 1961 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.
3. Please note that this certificate will not be issued if the premium payment has been made in cash.
4. In case of dishonour of the premium instrument, the policy will be deemed cancelled ab initio.
5. 80 D benefit is applicable for only Self, Spouse, Dependent Children and Dependent parents.

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Copy of Proposal form

5 of 6
Copy of Proposal form

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 Terms and Conditions
(1) This card would be valid till your relationship with AMHI / This card is invalid if the policy is
cancelled (2) In case of renewal please refer original policy number (3) This card is issued for
the purpose of identification only and does not entail automatic cashless facility at the network
hospital. (4) In case of photo-less card, a photo ID issued by any government authority is to be
produced to avail cashless facility. (5) Please apply for cashless facility 48 hours prior to
Policy:
admission in case of planned admissions and within 24 hours of admission in case of
110105/11121/6000119019-06

1988
emergency.(6) All terms and conditions of the policy would be applicable while processing your
Member ID Insured Name cashless request. (7) In case your cashless facility is denied due to any reason, please submit
10005913352 Mr Abhishek Jain the claim for reimbursement. Denial of cashless facility does not indicate rejection of the claim.
10005913353 Mrs Kanika Jain (8) Please read policy documents carefully for detailed terms and conditions. For more details
REN /1988

ë­ÉÉÉ­ël¥Î‹xu–ál×lë­ÉÉÉ­ë on risk factors, terms and conditions please read sales brochure carefully before concluding a
10005913354 Master Samyak Jain
10005913355 Master Sarthak Jain §ˆyˆs†–{Έǎی¨Éؒ‡|¨œ¥z sale.
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Apollo Munich Health Insurance Co. Ltd. Central Processing Center, 2nd & 3rd Floor, iLABS
ätÔÔÔtält¼Ì´tŒlt¤¬´||”Œ¬ä Centre, Plot No. 404/405, Udyog Vihar, Phase-III, Gurgaon-122016, Haryana. Corp. Off. 1st Floor,
SCF -19, Sector - 14, Gurgaon - 122 001, Haryana. Reg. Off: Apollo Hospitals Complex, 8-2
293/82/JIII/DH/900, Jubilee Hills, Hyderabad-500033, Telangana.•Website:
www.apollomunichinsurance.com
•Toll Free: 1800 102 0333 • IRDAI Reg. No.: 131• CIN: U66030TG2006PLC051760