Ref No.: GHI - 1/WEL/SG/00390.

1/RGI20245453024

Date: 08/10/2024

To,
Mr. Bipin Kumar Singh..
128, MINI MARKET, Shikhargarh
Jodhpur - 342001, District: JODHPUR
RAJASTHAN, India

Policy number: RGI20245453024

Subject: Risk assumption for Group Health Care

Dear Mr. Bipin Kumar Singh..,

We welcome you to Zurich Kotak General Insurance Company (India) Limited and thank you for choosing us as your preferred service
provider.

This is with reference to your above mentioned Policy issued under Group Health Care.

Enclosed please find the Policy Schedule outlining the details of your policy. Kindly note that the proposal is underwritten and policy is
issued based on the information submitted to us by you, as well as acceptance of the terms and conditions. Policy schedule must be read
i n c o n j u n c t i o n w i t h t h e p r o d u c t b r o c h u r e a n d p o l i c y w o r d i n g . P l e a s e v i s i t https://www.zurichkotak.com/customer-
support/downloads or scan above QR code for detailed policy wording.

We request you to carefully go through the same once again and in case of any disagreement, discrepancy or clarifications, please call us
on our toll free number 1800 266 4545 or write to us at [email protected] within 15 days from the date of this letter. Alternatively, you
can also write to us at 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai -
400063. ,Mumbai , Maharashtra

Please note that the information provided by you will be verified at the time of claim and the captioned Policy shall be treated as void in
case of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure in any form whatsoever made by you or by
your agent, on your behalf, at any stage.

Group Health Care UIN: ZUKHLGP21221V032021

In case where premium is not received by us due to cheque dishonour or any other reason, the insurance cover shall be void ab-initio.

As a valued customer, we would like to provide regular updates on your policy through email and SMS. We therefore request you to keep
us updated of any change in your contact details.

Assuring you of our best services at all times.

Thanking you,

Yours sincerely,

For Zurich Kotak General Insurance Company (India) Limited

Authorised Signatory

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 Group Health Care UIN: ZUKHLGP21221V032021

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 Group Health Care
ZUKHLGP21221V032021
For any assistance please call 1800 266 4545, please save the number for your reference

CERTIFICATE OF INSURANCE
Group Health Care Policy No. KGHC0128 dated 21/12/2022 has been issued at Mumbai by Zurich Kotak General Insurance Company (India) Limited Limited to
the Policyholder,Kotak Mahindra Bank Ltd, as specified in the Policy Schedule and is governed by, and subject to the terms, conditions and exclusions therein
contained or otherwise expressed in the said Policy, but not exceeding the Sum Insured as specified in the Policy Schedule to the said policy.

This certificate issued under the signature of the authorised signatory of the Company represents the availability of benefits to the Insured person/ persons named
below, Customers of Kotak Mahindra Bank Ltd, subject to the terms, conditions and exclusions contained or otherwise expressed in the said Policy, but not
exceeding the Sum Insured as specified below.

For the purpose of this document, we consider Kotak Mahindra Bank Ltd as the policyholder and its Customers as the Insured.

DETAILS OF THE INSURED PERSON(S) UNDER THE POLICY

Certificate Number RGI20245453024 Date of Issuance 08/10/2024

Certificate Start Date 17/11/2024 Certificate End Date 16/11/2025

Business Type Roll Over Expiring Policy No 3934288900

Name of the Customer BIPIN KUMAR SINGH..

Correspondence Address 128, MINI MARKET, Shikhargarh, 342001, JODHPUR, RAJASTHAN, AGOLAI

Email ID [email protected]

Contact Details 8604713545

Account No / Unique ID 723455320 / RGI20245453024 Customer GSTIN

Policy Tenure 1 Year Lives Count 4

Sum Insured Details

Sum Insured INR 5,00,000.00 Sum Insured Basis Floater

Co-Pay % Deductible 0

Relation with Date of Pre existing

Insured Name Date of Birth Age Gender Occupation Member ID
Proposer Joining condition
SHOBHA SINGH .. Wife 25/06/1996 28 Female Others 1048697650 17/11/2024

Group Health Care UIN: ZUKHLGP21221V032021

DRISHTI SINGH .. Daughter 13/09/2022 2 Female Others 1048697652 17/11/2024
BIPIN KUMAR SINGH.. Self 15/05/1994 30 Male Others 1048697649 17/11/2024
ANVIKA SINGH .. Daughter 10/11/2019 5 Female Others 1048697651 17/11/2024

ABHA DETAILS

Member ID Insured Name ABHA Account Details ABHA Address

INTERMEDIARY DETAILS

Intermediary Code Intermediary Name Intermediary's Mobile No. Intermediary's Landline No.
1579291461 KMBL-1461-VRM - 811 - THANE 18602662666

PREMIUM DETAILS

Taxable value of Services (Rs) IGST @ 18% (As applicable) (Rs) Total Amount (Rs)
11,357.28 2,044.31 13,402.00

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 COVERAGE DETAILS

Sr. No Base Covers Sum Insured Limits/ Description/ Remarks

1 In patient treatment Covered upto 100% of Sum Insured
2 Post Hospitalisation Medical Expenses No of Days : 90
3 Domiciliary Hospitalisation Covered Upto Sum Insured
4 Day Care Treatment Covered Upto Sum Insured - As per Annexure II of Policy Wordings
5 Emergency Ambulance Up to INR 20,000/- per hospitalization event
6 Pre Hospitalisation Medical Expenses No of Days : 60
7 Donor Expenses Covered Upto Sum Insured
Sr. No Optional Covers Sum Insured Limits/ Description/ Remarks
1 Wellness Program Available - Health Check-up and Report evaluation - One free Annual Health Check-up
2 Room Rent capping Applicable : 1% of Sum Insured per day for Normal Rooms and 2% of Sum Insured per day for ICU Rooms,
3 Alternative Treatment Covered Upto Sum Insured (AYUSH)

Important Conditions
Sr. Condition
No.
1 Eligibility: Insured should be customer of Kotak Mahindra Bank Ltd. Renewal is Available only if Insured remains a customer of Kotak Mahindra Bank Ltd.
Pre­Existing Disease (Code – Excl01) Waiting Period – Applicable ­ Any Expenses related to the treatment of a pre­existing Disease (PED) and its direct
2
complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer.
3 30 days Waiting Period (Code – Excl03) – Applicable
4 Specified disease/ procedure waiting period (Code – Excl02) – Applicable
5 Maternity Cover – Not Applicable
Room Rent Capping - If the Insured Person incurs Room Rent that is higher than the eligible Room Rent as per the limits specified under this Benefit then We
will be liable to pay only a rateable proportion of the Associated Medical Expenses incurred in the proportion of the difference between the eligible Room Rent
6
and the Room Rent actually incurred, provided that Reasonable and Customary costs incurred on medicines/pharmacy, medical consumables, medical
implants and diagnostic costs will be re
7 Alternative Treatment (AYUSH) - Covered Upto Sum Insured

PERMANENT EXCLUSION

1.Intentional self-injury (whether arising from an attempt to commit suicide or otherwise).

2.Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof (Excl12)
3.Expenses related to sterility and infertility.(Excl17)
4.Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.
(Excl10)

Group Health Care UIN: ZUKHLGP21221V032021

5.Any treatment taken outside India
6.Any consequential or indirect loss arising out of or related to Hospitalization
7.Any Injury or Illness directly or indirectly caused by or arising from or attributable to war or war like perils
8.Any Illness or Injury directly or indirectly caused by or contributed to by nuclear weapons/materials

For complete details please refer to the Policy wordings available with the Group Master Policyholder. Alternatively, the same can be downloaded from
our website www.zurichkotak.com

NOMINEE DETAILS

Insured Name Nominee Name Relationship with the Insured Person Age Appointee Details in case Nominee is a Minor
BIPIN KUMAR SINGH.. SHOBHA SINGH Wife 28
SHOBHA SINGH .. BIPIN KUMAR SINGH Husband 30
ANVIKA SINGH .. BIPIN KUMAR SINGH Father 30
DRISHTI SINGH .. BIPIN KUMAR SINGH Father 30

DISCLAIMER

This Certificate of Insurance shall be read together with Policy Schedule and the Policy Wordings (which are also available o n the Company website i.e.
www.zurichkotak.com). Any word or expression to which a specific meaning has been assigned in any part of the policy or this certificate shall bear the same
meaning wherever it may appear.

IN THE EVENT OF CLAIM

Contact Us at:
TOLL FREE NUMBER: 1800 266 4545 (24 * 7) or may write an e- mail at [email protected]

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 Please send the relevant documents to:
Family Health Plan Insurance TPA Limited,
SRINILAYA CYBER SPAZIO, SUITE # 101,102,109 & 110, GROUND FLOOR,ROAD NO. 2, BANJARA HILLS BANJARA HILLS HYDERABAD TS, TELANGANA,
500034

GRIEVANCE REDRESSAL DETAILS

In case of any grievance the insured person may contact the company through
Website: www.zurichkotak.com Toll free: 1800 266 4545 E-mail: [email protected]
Courier: Zurich Kotak General Insurance Company (India) Limited
401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai - 400063. ,Mumbai , Maharashtra

Insured person may also approach the grievance cell at any of the company’s branches with the details of grievance.
If Insured person is not satisfied with the redressal of grievance through one of the above methods, insured person may contact the grievance officer at
[email protected]

For updated details of grievance officer, kindly refer the link: https://www.zurichkotak.com/customer-support/grievance-redressal-process

Grievance may also be lodged at IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/
The updated details of Insurance Ombudsman offices are also available on the website of Council for Insurance Ombudsmen: www.cioins.co.in/ombudsman

TAX DETAILS

SAC
GST Registration No. 2 7 A A F C K 7 0 1 6 C 1 Z T Category : General Insurance Services 997133
Code
Invoice
Description Accident and Health Insurance Services RGI20245453024
Number
DECLARATION

In Witness whereof this Policy has been signed for and behalf of MUMBAI - THANE on 08/10/2024

For Zurich Kotak General Insurance Company (India) Limited

Authorised Signatory
This document is digitally signed, hence counter signature / stamp is not required.

Group Health Care UIN: ZUKHLGP21221V032021

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 Premium Certificate

For the purpose of Deduction under section 80D of the Income Tax Act, 1961 (as amended from time to time).
Note - Applicable only for premium paid towards Health Section/s under the Policy.

To
Mr. Bipin Kumar Singh..

This is to certify that the company has received the premium of ₹ 13,402.00 for Health insurance coverage under the policy no. RGI20245453024 vide
RTGS/NEFT dated 05-10-2024.

The product is eligible for deduction u/s 80D of the Income Tax Act, 1961 and any amendments made thereto subject to satisfaction of the conditions mentioned
therein.
Deduction under Section 80 D
A) Lumpsum Benefit:

Financial Year Annual Lumpsum premium allowed for Deduction under Section 80D
2024-25 13,402.00
OR
B) Year wise proportionate Benefit/Deduction:

Financial Year Year wise proportionate premium allowed for Deduction under Section 80D
2024-25 13,402.00

For Zurich Kotak General Insurance Company (India) Limited

Authorized Signatory
This document is digitally signed, hence counter signature / stamp is not required.

Group Health Care UIN: ZUKHLGP21221V032021

*Note
This is subject to the provisions of Section 80D of Income Tax Act, 1961 and amendments made thereof.
The year wise deductions mentioned above are as per provisions of Section 80D and this would be subject to the specified annual provisions as applicable for
respective years as per the Income Tax Act.
Only one option for deduction under Section 80D (i.e. either A or B above) can be availed by the Proposer/Policyholder as per the provisions of the Income Tax
Act, 1961.
Tax benefits are as per the Income Tax Act, 1961 as amended from time to time. Please consult your Tax advisor for details.
Details of the Policy are as per the Part II and III of this Policy.
This certificate must be surrendered to Us in case of cancellation of the Policy. In the event of incorrect representation of this declaration the liability shall be
upon the Policyholder.
In case You find any variations against Your proposal or any discrepancy in the Policy, please contact Us immediately on the numbers available on our website
www.zurichkotak.com
The deduction under Section 80D is not applicable for payments made in cash and third party payments.

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 1. This card is not transferrable.
2. Use of this card is governed by the terms and conditions of the policy.
3. To avail cashless services,please present a valid photo ID proof along with this
card.
Group Name:Kotak Mahindra Bank Ltd 4. To Speed up the claims process, please reach out to us 3 days prior to planned
admissions. In case of emergencies, kindly contact within 48 hours.
Member Name: Mr. Bipin Kumar Singh..
Service Provider- Family Health Plan Insurance TPA Limited
Policy No. : RGI20245453024 Gender: M
Email: [email protected]
Date of Birth : 15/05/1994 Website: www.zurichkotak.com
Member Toll Free: 1800 266 4545
Valid till : 16/11/2025 Id:1048697649 If found, please return to:
Zurich Kotak General Insurance Company (India) Limited
ABHA Address 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway,
Goregaon (East), Mumbai 400063. Maharashtra, India.
ABHA Account No
CIN:U66000MH2014PLC260291 IRDAI Reg. No. 152

1. This card is not transferrable.

2. Use of this card is governed by the terms and conditions of the policy.
3. To avail cashless services,please present a valid photo ID proof along with this
card.
Group Name:Kotak Mahindra Bank Ltd 4. To Speed up the claims process, please reach out to us 3 days prior to planned
admissions. In case of emergencies, kindly contact within 48 hours.
Member Name: Ms. Drishti Singh ..
Service Provider- Family Health Plan Insurance TPA Limited
Policy No. : RGI20245453024 Gender: F
Email: [email protected]
Date of Birth : 13/09/2022 Website: www.zurichkotak.com
Member Toll Free: 1800 266 4545
Valid till : 16/11/2025 Id:1048697652 If found, please return to:
Zurich Kotak General Insurance Company (India) Limited
ABHA Address 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway,
Goregaon (East), Mumbai 400063. Maharashtra, India.
ABHA Account No

Group Health Care UIN: ZUKHLGP21221V032021

CIN:U66000MH2014PLC260291 IRDAI Reg. No. 152

1. This card is not transferrable.

2. Use of this card is governed by the terms and conditions of the policy.
3. To avail cashless services,please present a valid photo ID proof along with this
card.
Group Name:Kotak Mahindra Bank Ltd 4. To Speed up the claims process, please reach out to us 3 days prior to planned
admissions. In case of emergencies, kindly contact within 48 hours.
Member Name: Ms. Anvika Singh ..
Service Provider- Family Health Plan Insurance TPA Limited
Policy No. : RGI20245453024 Gender: F
Email: [email protected]
Date of Birth : 10/11/2019 Website: www.zurichkotak.com
Member Toll Free: 1800 266 4545
Valid till : 16/11/2025 Id:1048697651 If found, please return to:
Zurich Kotak General Insurance Company (India) Limited
ABHA Address 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway,
Goregaon (East), Mumbai 400063. Maharashtra, India.
ABHA Account No
CIN:U66000MH2014PLC260291 IRDAI Reg. No. 152

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 Group Health Care UIN: ZUKHLGP21221V032021

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 1. This card is not transferrable.
2. Use of this card is governed by the terms and conditions of the policy.
3. To avail cashless services,please present a valid photo ID proof along with this
card.
Group Name:Kotak Mahindra Bank Ltd 4. To Speed up the claims process, please reach out to us 3 days prior to planned
admissions. In case of emergencies, kindly contact within 48 hours.
Member Name: Mrs. Shobha Singh ..
Service Provider- Family Health Plan Insurance TPA Limited
Policy No. : RGI20245453024 Gender: F
Email: [email protected]
Date of Birth : 25/06/1996 Website: www.zurichkotak.com
Member Toll Free: 1800 266 4545
Valid till : 16/11/2025 Id:1048697650 If found, please return to:
Zurich Kotak General Insurance Company (India) Limited
ABHA Address 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway,
Goregaon (East), Mumbai 400063. Maharashtra, India.
ABHA Account No
CIN:U66000MH2014PLC260291 IRDAI Reg. No. 152

Group Health Care UIN: ZUKHLGP21221V032021

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 Group Health Care UIN: ZUKHLGP21221V032021

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 Application Form cum Transcript - Group Health Care

( Kotak Mahindra Bank Ltd - KGHC0128 )

Please note:
* This insurance coverage is subject to the terms, conditions and exclusions of Group Health Care Policy No. KGHC0128 issued to Kotak Mahindra Bank Ltd
covering their customers and based on this Application and payment of content.
* The detailed Policy Wordings are available with Kotak Mahindra Bank Ltd and on our website www.zurichkotak.com.roposal FULLY, AND ACCURATELY AND
CORRECTLY. You may provide us with any and all additional information relevant to risk to be underwritten.
* Issuance of policy is subject to receipt of content, in case the content is not received, the policy shall be void ab-initio
* The policy issuance basis the details provided by you and the underwriting guidelines of the Company. In case of any non-disclosure, the policy is liable to be
cancelled.
* Based on your health declaration(s), you are likely to be contacted by Zurich Kotak General Insurance Company (India) Limited for additional documents and a
pre-policy medical check-up, if applicable.
* Kindly note that we cannot issue a policy until the prescribed formalities are completed, inspite of having received your payment.
* In case of refund of content, the same would be given in the account/card from which the content was received.
PROPOSER INFORMATION

Name: Mr. Bipin Kumar Singh..

Gender: Male Date of Birth: 15/05/1994
Address: 128 MINI MARKET Shikhargarh Jodhpur - 342001 District: JODHPUR RAJASTHAN, India
Mobile: 8604713545 Email: [email protected]
Occupation: Others PAN/ GST : /
POLICY AND CONTENT SUMMARY
Member Unique No: 723455320 / RGI20245453024 Policy Tenure: 1 Year(s)
Policy Start Date: 17/11/2024 Policy End Date: 16/11/2025
Total Members: 4 Policy Type Floater

Sum Insured: 5,00,000 Total content: 13,402.00

Co Pay: % Deductible: 0

Installment Option: No Installment Frequency:

Group Health Care UIN: ZUKHLGP21221V032021

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 INSURED MEMBER INFORMATION

Insured 1 Insured 2 Insured 3 Insured 4

Insured Name Bipin Kumar Singh.. Drishti Singh .. Anvika Singh .. Shobha Singh ..
Relation with the Proposer Self Daughter Daughter Wife
Gender M F F F
Date of Birth 15/05/1994 13/09/2022 10/11/2019 25/06/1996
Occupation Others Others Others Others
Marital Status Unmarried Single Single Married
Nominee Name SHOBHA SINGH BIPIN KUMAR SINGH BIPIN KUMAR SINGH BIPIN KUMAR SINGH
Nominee Relationship Wife Father Father Husband
Nominee DOB 25/06/1996 15/05/1994 15/05/1994 15/05/1994
ABHA Account Number
ABHA Address

HEALTH DECLARATION

Particulars Member 1 Member 2 Member 3 Member 4

Member Name BIPIN KUMAR SINGH.. SHOBHA SINGH .. ANVIKA SINGH .. DRISHTI SINGH ..
Member ID 1048697649 1048697650 1048697651 1048697652
Any major disease / disorder / ailment / deformity
/ surgery or neither awaiting any treatment
medical or surgical nor attending any follow up for
any disease / condition / ailment / injury /
addiction.
Previous Policy / Claims details

COVERS/BENEFITS

Sr. No Base Covers Sum Insured Limits/ Description/ Remarks

1 In patient treatment Covered upto 100% of Sum Insured
2 Post Hospitalisation Medical Expenses No of Days : 90
3 Domiciliary Hospitalisation Covered Upto Sum Insured

Group Health Care UIN: ZUKHLGP21221V032021

4 Day Care Treatment Covered Upto Sum Insured - As per Annexure II of Policy Wordings
5 Emergency Ambulance Up to INR 20,000/- per hospitalization event
6 Pre Hospitalisation Medical Expenses No of Days : 60
7 Donor Expenses Covered Upto Sum Insured
Sr. No Optional Covers Sum Insured Limits/ Description/ Remarks
1 Wellness Program Available - Health Check-up and Report evaluation - One free Annual Health Check-up
2 Room Rent capping Applicable : 1% of Sum Insured per day for Normal Rooms and 2% of Sum Insured per day for ICU Rooms,
3 Alternative Treatment Covered Upto Sum Insured (AYUSH)

IMPORTANT CONDITIONS
Sr. Condition
No.
1 Eligibility: Insured should be customer of Kotak Mahindra Bank Ltd. Renewal is Available only if Insured remains a customer of Kotak Mahindra Bank Ltd.
Pre­Existing Disease (Code – Excl01) Waiting Period – Applicable ­ Any Expenses related to the treatment of a pre­existing Disease (PED) and its direct
2
complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer.
3 30 days Waiting Period (Code – Excl03) – Applicable
4 Specified disease/ procedure waiting period (Code – Excl02) – Applicable
5 Maternity Cover – Not Applicable
Room Rent Capping - If the Insured Person incurs Room Rent that is higher than the eligible Room Rent as per the limits specified under this Benefit then We
will be liable to pay only a rateable proportion of the Associated Medical Expenses incurred in the proportion of the difference between the eligible Room Rent
6
and the Room Rent actually incurred, provided that Reasonable and Customary costs incurred on medicines/pharmacy, medical consumables, medical
implants and diagnostic costs will be re
7 Alternative Treatment (AYUSH) - Covered Upto Sum Insured

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 PERMANENT EXCLUSIONS

1.Intentional self-injury (whether arising from an attempt to commit suicide or otherwise).

2.Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof (Excl12)
3.Expenses related to sterility and infertility.(Excl17)
4.Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.
(Excl10)
5.Any treatment taken outside India
6.Any consequential or indirect loss arising out of or related to Hospitalization
7.Any Injury or Illness directly or indirectly caused by or arising from or attributable to war or war like perils
8.Any Illness or Injury directly or indirectly caused by or contributed to by nuclear weapons/materials
For complete details please refer to the Policy wordings available with the Group Master Policyholder. Alternatively, the same can be downloaded
from our website www.zurichkotak.com

TERMS AND CONDITIONS

In case of any claim made under the Policy, no content shall be refunded on cancellation of Insurance.
The insurance coverage shall commence from the date of receipt of content by Zurich Kotak General Insurance Company (India) Limited
I agree that the policy can become voidable at the point of Insurer,in event of any untrue or incorrect statement ,misrepresentation,non-description or non -
disclosure in any material particular in this Application form ,declaration and connected documents ,or any material information has been withheld by me or
anyone acting on my / our behalf to obtain benefit under the Insurance.
I confirm that the content is paid out of my legitimate sources of funds and the company has the right to call for documents to establish sources of funds.
The Company has the right to cancel the policy in case I am/have been found guilty by any competent authority or court of law.

PAYMENT DETAILS
Payment Mode: RTGS/NEFT

Payment Reference No: VP-80962246

Payment Amount: 13,402.00

Payment/Transaction Date: 05/10/2024

Bank Details:

Online/ Credit card premium payment should be made by the master policy holder (group administration)/ beneficiary as the case may be.Third party payments are not
allowed

DECLARATION

Group Health Care UIN: ZUKHLGP21221V032021

I 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 am authorized to propose on behalf of these other persons.

I 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 insurer and that the
policy will come into force only after full payment of the content chargeable.

I further declare that I 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 declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be insured/proposer
or from any past or present employer concerning anything which affects the physical or mental health of the person to be insured/proposer and seeking information from
any insurer to whom an application for insurance on the person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim
settlement.

I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the sole purpose of underwriting the
proposal and/or claims settlement and with any Governmental and/or Regulatory authority.”

*Place: Mumbai *Date: 09/10/2024

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 STATUTORY WARNING PROHIBITION OF REBATES (Under Section 41 of Insurance Act 1938)

1)No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of 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 content 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 published prospectuses or tables of the
Insurer.

2) Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to Ten Lakhs Rupees.

Group Health Care UIN: ZUKHLGP21221V032021

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com
 TAX INVOICE

Details of Receiver (Billed To) Details of Supplier (billed by)

Zurich Kotak General Insurance Company
GSTIN/UIN Name :
(India) Limited
Customer ID 1013501176 GSTIN : 27AAFCK7016C1ZT
Customer Name BIPIN KUMAR SINGH.. Pan Number : AAFCK7016C
Email ID [email protected] CIN: U66000MH2014PLC260291
Neptune Element, 2Nd Floor, Plot No.
Contact No 8604713545 Address: F3,S3/1Road Number 22Wagle Industrial
EstateThane Maharashtra 400604.
128, MINI MARKET, Shikhargarh,
Address Date of Invoice 08/10/2024
JODHPUR, 342001, RAJASTHAN, India
IMD Code 1579291461 Invoice No 5036267300
Receipt No 1202501094147 Proposal No 202410080089289
Partner Application No RGI20245453024
State Code 08 State Code: 27
Place Of Supply Name RAJASTHAN - 08 State Name MAHARASHTRA
IRN

HSN/SAC Description HSN / SAC Code Total Value of Supply (Rs.) Taxable value of Supply (Rs.) IGST Rate IGST Amt (Rs.)
997133 11357.28 11357.28 18% 2,044.31
Accident and Health Insurance Services
Total 11357.28 11357.28 2044.31
Total Invoice Value (In Figure) 13,402.00
Total Invoice Value (In Words) Thirteen Thousand Four Hundred Two
Whether Tax Payable on a Reverse Basis or Not No

For : Zurich Kotak General Insurance Company (India) Limited

Authorized Signatory

Group Health Care UIN: ZUKHLGP21221V032021

"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."

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:[email protected] Website: www.zurichkotak.com