HDFC ERGO General Insurance Company Limited

2952203057411504000

Mr Stephen L
No 25, 1St Floor Palandi Amman Kovil Street
Adambakkam Bank Of Baroda Building .
Kanchipuram, 600088
Tamil Nadu
Contact No : 99XXXXXXX6

Date : 17/08/2023

Dear Mr Stephen L

Thank you for choosing HDFC ERGO as your preferred insurance partner. We welcome you to be a part of our family !
Your Health insurance policy reference no 2952203057411504000 is confirmed on the basis of the information and declaration given by you.
The details of coverage are mentioned in the enclosed policy schedule of insurance.

As a measure of our customer convenience we have implemented a Lifetime Validity Health Card. For you, this simply means that your Health Card is valid for all subsequent
renewals and as long as your policy is active with us. Hence, you need not replace your health card every year

We value your relationship with us and assure you our best services at all times and we look forward to serve you.

Now you can view your policy details and health card at your fingertips. Download our Mobile App now and experience convenience today!!
Proposer details have been updated basis the information present in the KYC documents. If you find any detail which needs to be corrected, request you to create/ modify the
eKYC ID and place a request for endorsement.

Soft copy of the policy is valid for all purposes including claims.

For HDFC ERGO General Insurance Company Ltd.

Arun Sharma
Head - Customer Experience Management

HDFC ERGO General Insurance Company Limited 2952203057411504000

TAX CERTIFICATE

Dear MR STEPHEN L

Subject : Certificate for the purpose of deduction under section 80 D of Income Tax Act, 1961

This i s to certify that we have received an amount of ` 21680 towards premium for my: health Suraksha Policy , Policy No. 2952203057411504000 issued to for
the period 01/10/2023 to 30/09/2024.

Note : This is subject to the provisions of Section 80D of income tax Act, 1961 as amended from time to time.

For HDFC ERGO General Insurance Company Ltd.

Date : 17/08/2023

Policy Issuing Office: Mumbai

Duly Constituted Attorney

Renewal Coupons + 4 Claim Free year coupon

Being our valued customer, you are now eligible for a yearly Free Health Check Up worth Rs. 1000
Additionally, basis your claim history, you are now also eligible for a free Health check Up worth Rs.5000
Call 022 - 6234 6234 / 0120 - 6234 6234 to fix an appointment Visit the selected diagnostic center at the scheduled time. Please carry the photo copy of your policy.
The eligible Insured Person(s), is/are entitled for one time health check up benefit up to an amount of Rs. 6000, which will be valid for 365 days from policy renewal date.

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLIP24079V072324. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
POLICY SCHEDULE my: health Suraksha Policy
Silver

2952203057411504000

Policy No. :2952 2030 5741 1504 000 Issuance Date :17/08/2023
Period of Insurance :From 01/10/2023 00:01 hrs To 30/09/2024 Midnight
Invoice No. :203057411504000 Premium Frequency :Yearly
0

HSN Code :997133 Policy Type :Family Floater

Mr Stephen L Proposer Name :Mr Stephen L PAN :
No 25, 1St FloorPalandi Amman Kovil StreetAdambakkam
Customer Id :100722088689
Bank Of Baroda Building .Kanchipuram
Tamil Nadu, 600088, Contact No : 99XXXXXXX6
EIA No. : Not provided
Payment Details : 3522308143205 , Bank Name:BizDirect
Email ID : [email protected]
Insured Person’s Details & Sum Insured
Insured's Name Relation with Gender DOB Nominee Name Nominee 1st Policy Basic Sum Tier CB Amount Pre
policy holder Relationship Inception Insured (`) (`) Existing
Disease
Stephen L Self Male 03/08/1968 Gnanamary S Spouse 31/08/2010 500000 Tier 2 250000 NO
Preethi Angel S Daughter Female 01/11/2000 31/08/2010 NO
Schedule of Coverage
Section Covers Details/ Applicability of Sum Insured Limit
Base Covers
A Hospitalization Cover up to Basic Sum Insured including cumulative Bonus Basic Sum Insured and CB
Medical Expenses Basic Sum Insured and CB
1B Mental Healthcare Basic Sum Insured and CB
2 Home Healthcare Basic Sum Insured and CB
3 Domiciliary Hospitalization Basic Sum Insured and CB
4 Pre-Hospitalization 60 Days
5 Post-Hospitalization 180 Days
6 Day Care Procedures Basic Sum Insured and CB
7 Road Ambulance cover Sub limited within the Basic Sum Insured including SI 1 to 5 L -2,000
Cumulative Bonus SI 6 to 50 L -3,500
SI Above 50 L -15,000
8 Organ Donor Expenses upto Basic Sum Insured including cumulative Bonus Basic Sum Insured and CB
9 Alternative Treatment upto Basic Sum Insured including cumulative Bonus Basic Sum Insured and CB
* You will have to bear 20% of the admissible claim amount, if you undergo treatment in Delhi, NCR, Mumbai, Thane, Mumbai Suburban, Navi Mumbai, Surat,
Ahmedabad & Vadodara.
Optional Covers
C17 Hospital Cash benefit payable , basis per day of hospitalization Normal / day- <1000>
ICU / day- <2000>
Max Days - <30>
Renewal Benefits
1 Prevent Health Check-up 1% of Sum insured for every 4 claim free years (max upto 5000)
2 Cumulative Bonus Applicable (5% of sum insured , max upto 50%)
3 my:health Active Applicable
Waiting Periods
Sec E 1 i - General waiting period - 30 days from Policy inception date
Section A Hospitalization Cover Sec E 1 ii - Listed illness & procedures - 24 Months
Sec E 1 iii - Preexisting conditions - 48 Months
Premium Details (`)
Basic Premium 17,349.00
Loadings 0.00
Integrated Tax 18% 3,123.00
Total Premium 20,472.00
For Claim/Policy related queries call us at +91- 22 6234 6234/+91- 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim.
If the premium is not realised the policy shall be void from inception.The stamp duty of Rs. 1/- ( Rupees One And Zero Paise Only ) paid vide e-stamp Certificate No.(LOA/ENF-1/CSD/34/2023/ Validity Period
Dt. 28/12/2023 to Dt. 31/12/2026. OW No. 6045 Date 27/Dec/2023 GRN NO. MH011651000202324M Dt. 05/12/2023, SBI Bank & DEFACE No. 0006692260202324 Dt. 21/12/2023) dated 27/12/2023 as
prescribed in Government of Maharashtra Order No. Mudrank-2017/CR.97/M-1, dated the 09th January 2018". GST Registration No: 27AABCL5045N1Z8. GST for this invoice is not payable under reverse charge
basis. I/ We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under sub-rule (4) of rule 48, we are not required
to prepare an invoice in terms of the provisions of the said sub-rule
Branch :leela business park, 6th flr, andheri - kurla rd, mumbai Write to us : [email protected]

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLIP24079V072324. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
POLICY SCHEDULE

my: health Suraksha Policy

MY: HEALTH SURAKSHA POLICY

For HDFC ERGO General Insurance Company Ltd.

Agent Name :HDFC BANK LTD Agent Code :201587086428 Tel No. : 91-22-61606161

Duly Constituted Attorney

"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings."

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLIP24079V072324. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited

HDFC ERGO General Insurance Company Limited 2

Policy No.:2952203057411504000 This card is for identification purpose only.
Valid From: 01/10/2023 Renewal Date: 30 September
Card has to be presented to the Network Service Provider at the time of admission/ availing
cashless hospitalization o r any other services. Insurance claim will be processed in accordance
Insured Name Member ID Date Of Birth Gender with the policy term & conditions. Card does not guarantee cashless hospitalization or any other
service. For more details and updated list of Network Service Provider please refer our website or
STEPHEN L 10010000 03/08/1968 Male call our call centre. This card is valid till the time policy is active.

PREETHI ANGEL S 10010000 01/11/2000 Female Customer Service No : 022 - 6234 6234 / 0120 - 6234 6234
Fax Number : 022 - 6234 6234/0120 - 6234 6234
Email : [email protected]
Processing Centre : HDFC ERGO General Insurance Company Ltd. 5th floor,
Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
Website : www.hdfcergo.com

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLIP24079V072324. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited YES
POLICY SCHEDULE
my:health Koti Suraksha Policy

FH
2952203057411504000
C
Certificate No. :2952 2030 5741 1504 000 Issuance Date :17/08/2023
Period of Insurance :From 01/10/2023 00:01 hrs To 30/09/2024 Midnight 0
Invoice No. :203057411504000 Premium Frequency :Yearly 0
Mr Stephen L HSN Code :997133 Policy Type Individual
No 25, 1St FloorPalandi Amman Kovil StreetAdambakkam Proposer Name :Mr Stephen L PAN
Bank Of Baroda Building .Kanchipuram
Tamil Nadu, 600088, Contact No : 99XXXXXXX6 :2010-08-31
Customer Id :100722088689 1st Policy Inception
00:00:00.0
Annual Income :
Occupation :

Payment Details : 3522308143205 , Bank Name:BizDirect

Email ID : [email protected]
my:health Koti Suraksha Insured details & Sum Insured Details (UIN- HDFHLIP21131V012021)
Insured’s Name Relationship Date of Birth Nominee NameNominee Sum Insured Benefit Occupation Annual Pre Existing
Relationship Income Disease
Stephen L Self 03/08/1968 GNANAMARY S Spouse As mentioned 100% NO
Preethi Angel S Daughter 01/11/2000 below 100% NO

Schedule of Coverage
Section B. Personal Accident
Section B.I Base Coverages
Member 1 Member 3
Self Member 2 Daughter Member 4
Section # Covers
Base Sum Insured / Balance Base Sum Insured / Balance
Sum insured Sum insured
1 Accidental Death 10 Lakhs / 10 Lakhs 2.5 Lakh / 2.5 Lakh
i Disappearance 10 Lakhs / 10 Lakhs 2.5 Lakh / 2.5 Lakh
ii Comatose Benefit 5 Lakh / 5 Lakhs 1.25 Lakh / 1.25 Lakh
2 Permanent Disablement 10 Lakhs / 10 Lakhs 2.5 Lakh / 2.5 Lakh
Section B.II - Value added Services under Section B
1 Health Coach Covered

Waiting Periods Applicable to Temporary Total Disablement Illness and Emergency Medical Expenses under Section.B
Section B.IV Pre-existing Conditions 48months
Section B.IV Listed illness & procedures 24 Months
Section B.IV General Waiting Period 30 days from Policy inception date
The Policy Wording attached herewith includes all the standard coverage’s 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 issued to you. Please read the Policy Wording in conjunction with the Policy Schedule. For any
clarification, please call our toll free number. The Maximum Compensation in respect of an Insured Person under the policy shall not exceed 12 times the Annual Income
(as declared in the Proposal Form). Income proof for availing the compensation at the time of claim i s mandatory. Income proof shall mean the previous year’s returns filed
with the Income Tax Department.

Premium Details ( `)
A Basic Premium 1,024.00
B Optional Cover Premium 0.00
C Net Premium (A+B) 1,024.00
D Integrated Tax 18% 184.00
E Total Premium 1,208.00
Special Conditions :

Address 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri(E), Mumbai 400 059.
For Claim/Policy related queries call us at +91- 22 6234 6234/+91- 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim.
If the premium is not realised the policy shall be void from inception.The stamp duty of Rs. 1/- ( Rupees One And Zero Paise Only ) paid vide e-stamp
Certificate No.(LOA/ENF-1/CSD/34/2023/ Validity Period Dt. 28/12/2023 to Dt. 31/12/2026. OW No. 6045 Date 27/Dec/2023 GRN NO. MH011651000202324M
Dt. 05/12/2023, SBI Bank & DEFACE No. 0006692260202324 Dt. 21/12/2023) dated 27/12/2023 as prescribed in Government of Maharashtra Order No.
Mudrank-2017/CR.97/M-1, dated the 09th January 2018". GST Registration No: 27AABCL5045N1Z8. GST for this invoice is not payable under reverse charge
basis. I/ We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover
notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule
Branch :leela business park, 6th flr, andheri - kurla rd, mumbai Write to us :[email protected]

Agent Name :HDFC BANK LTD For HDFC ERGO General Insurance Company Ltd.

Agent Code :201587086428 Tel No. : 91-22-61606161

Duly Constituted Attorney

"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings."

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLIP24079V072324. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com