HDFC ERGO General Insurance Company Limited

Proposal Form - my:health Koti Suraksha

Proposal No. :3317 1012 3310 8800 000

Period of Insurance :From 05/12/2023 18:27 hrs To 04/12/2024 Midnight
Invoice No. :101233108800000 Premium Frequency :Single
Proposer Name :MR Sahabuddin Policy Type :Individual

MR Sahabuddin HSN Code :9971 PAN No. :BAHPN5950J

SR NO- 112/5, Gala No 02, Sai Shradha Nagar,Sadi Com
Vasai, Nallasopara, Palghar, Maharashtra- 401209 Customer Id
Annual Income : 10 Lakh
Occupation : Self Employed
EIA No. : Not Provided

my:health Koti Suraksha - Insured Details & Sum Insured

Relation with Nominee 1st Policy Annual Pre Existing
Insured's Name Gender DOB Nominee Name Sum Insured Occupation
policy holder Relationship Inception Income Disease
MR Sahabuddin Male 28/08/2017 Rajiuddin Khan Father As mentioned Self 10 Lakh
Self 05/12/2023 NO
below Employed
Schedule of Coverage
Section B. Personal Accident
Section B.I Base Coverages
Member 1
Member 2 Member 3 Member 4
Section # Covers Self
Base Sum Insured / Sum Insured
1 Accidental Death 150000/150000
i Disappearance 150000/150000
ii Comatose Benefit 75000/75000
Optional Cover under Accidental Death
i Burns 0/0
Permanent Disablement (Table
2 50000/50000
D)
3 Temporary Total Disability 0/0
Temporary Total Disability -
I 0/0
Accident Only
Temporary Total Disability -
II 0/0
Accident & Illness
4 Broken Bones 0/0
5 Emergency Medical Expenses 0/0
II Optional Covers under Emergency Medical Expenses
Emergency Medical Expenses -
i 0/0
Global ($100 Deductible)
ii Co-Payment (in percentage) 0/0
6 Hospital Cash - Accident Only 0/0
III Optional Covers under Hospital Cash - Accident Only
i Companion Benefit 0/0
ii Hospital Cash - ICU 0/0
Time Deductible modification
iii 0/0
Option
iv Hospital Cash - Global 0/0
7 Chauffeur Benefit 0/0
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 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 10 times the Annual Income (as declared in the Proposal Form). Income
proof for availing the compensation at the time of claim is mandatory. Income proof shall mean the previous returns filed with the Income Tax Department.
Premium Details ( ` )
Particulars Premium
A Basic Premium 97.00
B Optional Cover Premium 0.00
C Net Premium (A+B) 97.00
D GST 18% : Central Tax 900%(`8.5) + State Tax 900%(`8.5) 17.00
E Gross Premium (C+D) 114.00
Proposer declaration

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN : HDE-MO-P14-40-V02-14-15. Customer Service Address: D 301, 3rd Floor, Eastern Business District
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service No : +91
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited

Proposal Form - my:health Koti Suraksha

I/We hereby declare, on my 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.

I/We understand that the information provided by me/us will form the basis of the insurance policy, is subject to the underwriting policy of the insurance Company and that the policy will come into force only after
full receipt of the premium chargeable under the policy.

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 my proposal including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Go vernmental and/or
Regulatory authority
Declaration & Warranty on behalf of Insurance Company

Note: The liability of the Company does not commence until the acceptance of the proposal has been formally intimated to the insured and full premium has been realized by the Company.
The Company is under no obligation to accept any proposal for insurance. The Proposer agrees that the receipt of the Proposal Form by HDFC ERGO General Insurance Company Limited along with the premium
payment does not tantamount to the acceptance of the Proposal for insurance by the Company and does not result in a concluded contract of insurance. The acceptance of the Proposal for insurance shall be at
the Company's sole and absolute discretion and upon full realization of the premium payment .In the event of acceptance of the Proposal for insurance by the Company, such acceptance shall be specifically
intimated to the Proposer by the Company along with the date from which the insurance Cover shall become effective. The Company shall not be liable for any claim in respect of an event giving rise to a claim
covered under the Policy of Insurance that has occurred prior to policy issuance is not covered under this policy(Your proposal form will be considered after HDFCERGO General Insurance Company Limited
receives premium payment.).
Fraud Warning: This policy shall be voidable at the option of the Company in the event of mis-representation, mis-description or non-disclosure of any material particulars by the Proposer. Any person
who,knowingly and with intent to fraud the insurance Company or any other person, files a proposal for insurance containing any false information, or conceals or the purpose of misleading, Information concerning
any fact material thereto, commits a fraudulent insurance act, which will render the policy voidable at the sole discretion of the insurance Company and result in a denial of insurance benefits.
Anti-Rebating Warning : As per Section 41 of the Insurance Act 1938,as amended, the practice of rebating is prohibited, as follows: No person shall allow or offer to allow, either directly or indirectly, as
aninducement to any person to take out or renew or continue an insurance policy in respect to any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any
rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the publishedprospectus or
tables of the insurer. Violation of Section41 of the Insurance Act 1938, as amended, shall be punishable with a fine which may extend to`10Lakhs.

Disclaimer :: Proposal Form and Policy Schedule have been generated basis details authenticated by proposer / insured on Online Platform of HDFC ERGO General Insurance Co Ltd. For Changes if any, kindly
visit URL https://www.hdfcergo.com/customer-care/customer-support.html and register

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."
Policy Issuing Office : LEELA BUSINESS PARK, 6TH FLR, ANDHERI - KURLA RD, MUMBAI, 400059. Phone No. : +91-22-66383600
COMMON SERVICE CENTRE Name : CSC E GOVERNANCE SERVICES INDIA LIMITED
COMMON SERVICE CENTRE Code :201764376894 Tel No. :+91-22-66383600

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN : HDE-MO-P14-40-V02-14-15. Customer Service Address: D 301, 3rd Floor, Eastern Business District
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service No : +91
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. 22-62346234/+91-120 6234 6234 | www.hdfcergo.com