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Policy Issuing Office : Reliance General Insurance Co. Ltd.

, Policy Servicing Branch Office : Reliance General Insurance Co. Ltd,


570, Naigaum Cross Road, Reliance General Insurance Co Ltd 202-21
Next to Royal Industrial Estate, 2nd Floor MERCANTILE HOUSE
Wadala (W), Mumbai – 400031 KASTURBA GANDHI MARG New Delhi
New Delhi 110001
Reliance Individual Mediclaim Policy Schedule
Name and Address of the Proposer : KOUSHIK DUTTA
F-93, GROUND FLOOR, SECTOR - 54
GURGAON, HARYANA
122001
India
Mobile No: 7838080811
Policy Number 1301812821000291
Details of previous policy (in case of renewal)
Previous policy No. : NA
Date of expiry : NA
Sum Insured : As Indicated Below
Period of Insurance : From 00:01 on 25/05/2016 to mid-night on 24/05/2017

Name of Insured Person Gender Date of Relationship with Occupation Pre-Existing Sum Domiciliary Amount Loading Premium
Birth the Proposer Illness Insured (Rs) Hospitalisation of CB (%) (Rs)
Limit (Rs) (Rs)
KOUSHIK DUTTA Male 28/12/1980 Self Others 50000.00 500000.00 555000.00 0 18110.00
APARNA GAWAS Female 21/10/1986 Spouse Others
* Where an Insured Person is added to this Policy, either by way of endorsement or at the time of renewal, the pre-existing disease clause,first year exclusion and 30 days
waiting period is applicable considering such policy period as the first policy with us.
* Policy would be considered as a fresh policy if there would be break of fifteen or more days between the prevoius policy expiry date and current policy start date.
* Any enhanced Sum insured during subsequent policy renewals will not be available for an illness, diseases, injury already contracted under the preceding policy periods.All
Waiting periods as defined in the policy shall apply for this enhanced limit from the effective date of enhancement of such Sum Insured.
* This Insurance is subject to the terms and conditions of policy attached .The policy wordings with detailed terms , conditions and exclusions is available on our
website www.reliancegeneral.co.in

Special Conditions, if any :

Premium Details Amount (Rs.)


Gross Premium 18,110.00
Service Tax (12% of Net Premium) 2173.20
Education Cess (2% of Service Tax) 43.46
Secondary and Higher Education Cess (1% of Service Tax) 21.73
Total Premium 20,348.00

(Service Tax Registration No: AABCR6747BST001)


Consolidated Stamp duty Paid vide Receipt No.20984 dated 25/05/2016 **
** Not applicable for the State of Jammu and Kashmir
Note: In the event of dishonor of cheque, this policy document automatically stands cancelled from inception, irrespective of whether a separate communication is sent or
not.
In witness whereof this policy has been signed at Mumbai on 25/05/2016
For any assistance with claims, please contact us on 1 800 3002 8282 (toll free) and 3989 8282 (local charges apply) or email us at services.rgicl@relianceada.com

TPA/Service Provider Details


TPA/Service Provider Name Paramount Health Services Pvt. Ltd.
Address Please Log on to www.paramounttpa.com for locating the nearest office for submission of claim documents
24X7 Customer Helpline Number 022-66620880/ (022) 6662 0880(TollFree)
Fax Number (022) 2825 9543 /9743
Email id contact.phs@paramounttpa.com ( For Insured
Grievances & for any other queries)

Premium Certificate
Premium Certificate for the purpose of deduction under Section 80-(D) of Income Tax (Amendment) Act 1986.
This is to certify that KOUSHIK DUTTA has paid Rs.20348 (TWENTY THOUSAND THREE HUNDRED FOURTY EIGHT) towards premium for Health Insurance for the
Period From 00:01 on 25/05/2016 to Midnight of 24/05/2017 on May 25 2016
Policy Number : 1301812821000291
Date : 25/05/2016 Place : Mumbai
Note: This certificate must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation of policy or any alteration in the insurance
affecting the premium.

Registered Office: Reliance Centre, 19, Walchand Hirachand Marg,Ballard Estate ,Mumbai - 400 001