7/13/2018 7:36:05 PM

KOTAK GROUP SECURE ONE - Certificate Of Insurance

(Product UIN: 107N051V03)
SCHEDULE
Certificate No: GO000002_PMGW00000564534_itzic20000 Member ID: PMGW00000564534 Member
Name of Master Policyholder: Demo Client

Policy No: GO000002

Name of the Member: Mr Saumitra Ghogale

Address: S/O,Atmaram Laxman Ghogale,A/5 Chandrgiri,Laxman Sum Assured:: 200000

Mhatre Road,Mandapeshwar,Borivali West Mumbai,Maharashtra
Maharashtra 400103
Premium Amount (Exclusive of Goods and Services Tax and Cess) Rs: 496.82
Premium Amount (Inclusive of Goods and Services Tax and Cess) Rs: 586.25
Premium Payment Term: Annually Renewable

Cover Term: 1 year (Annually Renewable)

Member Renewal Date: 04/07/2019

Date of Commencement of Risk/Cover: 04/07/2018

Cover Termination Date: 03/07/2019
Age of the Member as on Date of Commencement of Risk/Cover: 31
Name of Nominee: Manoj Ghogale

Premium payment Mode: Single Premium

Benefit Type: Easy Secure
Branch: Tirupur Region: Coimbatore

CRM Branch : Maharashtra

Goods and Services Tax and Cess are at the current applicable rates and may vary from time to time.
Our Valued Member,

Kotak Mahindra Life Insurance Company Ltd. (Formerly known as Kotak Mahindra Old Mutual Life Insurance Ltd.) (hereinafter referred to as "the Insurer") takes great pride in
extending life insurance cover to you under KOTAK GROUP
SECURE ONE. KOTAK GROUP SECURE ONE (Policy No. GO000002) is a group insurance cover designed for the Members of Demo Client (hereinafter referred to as “the
Policyholder”). KOTAK GROUP SECURE ONE (hereinafter referred to as “the Policy/ the Policy Contract”). This Certificate of Insurance constitutes of this Schedule and the
benefits sections, along with the standard terms and conditions mentioned in Annexure 1, enclosed hereunder (“COI”). The COI is issued on the basis of the facts, information and
declaration provided in the Member Data/Membership Form and such other documents duly provided/signed and executed by you.

The Benefits payable will be calculated on the basis of the type of benefit (as mentioned in the table above) as chosen by the Policyholder.
Following are the benefits under the Policy:

1. Benefit Terms & Conditions: Benefits under the Policy shall be payable to the Beneficiary as follows, depending upon the Benefit Type chosen:

A. Benefits available under Easy Secure:

i. Death Benefit: Upon death of the Member during the Cover Term while the Policy is in force, Sum Assured shall be payable to the Nominee.
ii. Maturity Benefit: No benefits under the Policy are available on maturity of the Policy.

2. Surrender Value: In the event of voluntary surrender/ cancellation of insurance cover by the Member following surrender value shall be payable:

Within Freelook Period

Free look cancellation Amount = Premium (net of service tax) × (Outstanding days to next Premium Payment /365) - Stamp duty and Medical expenses, if any

In case of premium being borne by the Policyholder, post exercising of Freelook by the Policyholder, all the benefits payable under the policy shall be null and void.

Post Freelook Period

No surrender value is payable.

Where the Member pays the Premium, and the Policyholder surrenders the Policy, the Members will be given the option to continue life cover till the end of their respective
tenure with same terms and conditions.

3. Suicide Exclusion:
In case of death of insured Member due to suicide, within first 12 months from the date of commencement of cover i.e. the date when the Member was first covered as a
member of the Group under the Group Secure One plan of the Insurer, no benefits under the Policy shall be payable and the Nominee of the Member shall be paid 80% of the
total Premiums paid (excluding service tax and cess) by the Member under the Policy.

4. Beneficiary: shall be the nominee/legal heir or such person as may be directed by a competent court in India, The Policyholder shall be responsible to identify the eligible legal
heirs of the Member in case of death of Nominee.

5. Lapse: The cover for Member will cease if the Premiums are not received by the Insurer/Policyholder within the Grace Period. The Member cover can be revived as per the
clause on `Revival' mentioned below. In case the Member cover is not revived as per the Revival provisions, the same shall stand terminated.

6. Revival:
The Policyholder / Member may revive the policy anytime within 6 months, from the due date of the first unpaid premium and payment of outstanding premiums together with
interest (currently calculated at 9% p.a. on the due premium). The interest rate may be revised from time to time upon prior approval from IRDAI. The option to revive the Policy is
available only for Premium payment modes other than annual mode.

The Member cover can be revived subject to prevailing option revival conditions and board approved underwriting policy of the Insurer.

This COI is issued for the purpose of information only and mere possession of this COI shall not entitle any person to the cover unless he/she satisfies all the relevant terms
and conditions (including but not limited to the eligibility criteria for Membership and payment of premiums) as specified in the Policy Contract. This COI is the summary of
the key terms of the Policy Contract. In the event of any difference, discrepancy or conflict between the terms of this COI and the Policy arises; the terms of the Policy
Contract shall prevail. In all events, the Policy Contract shall be the final and superseding document governing your cover benefit under the Policy Contract.

The standard terms and conditions as mentioned in Annexure 1 are also available on the following URL: (www.insurance.kotak.com)ĺ'RZQORDG&HQWUHĺ3ROLF\'RFXPHQW
6SHFLPHQĺ*URXS3ODQVĺ.27$.*52836(&85(21(

Sincerely,
For Kotak Mahindra Life Insurance Company Ltd. (Formerly known as Kotak Mahindra Old Mutual Life Insurance Ltd.)

Authorised Signatory
 Annexure 1

Terms used

• Member is a person who is entitled to be a member as defined in the Policy Contract and has been added to the list of `Members' in accordance with the terms of the Policy
Contract.
• “Grace Period”: Means the time granted by the Insurer i.e. 30 days from the due date for the payment of Premium for annual, half-yearly and quarterly mode and 15 days for
monthly mode without levy of any interest or penalty during which time the Policy is considered to be in-force with the risk cover without any interruption as per the terms of
the Policy. Grace Period is not applicable to Single Premium policy
• “Terminal Illness”: Terminal Illness is a non-correctable/non-curable medical condition or a non-response to specific disease therapy (which is very likely to culminate in
death within a year - to be certified by the treating specialist). Terminal Illness should be established and confirmed in writing and with reasonable certainty; in the opinion of
both the life insured's attending physician/ Medical Practitioner* (based on consultation with relevant medical specialists) as well as Insurer's Chief Medical Officer.
• *Medical Practitioner is a person who holds a valid registration from the medical council of any state of India and is thereby entitled to practice medicine within its
jurisdiction and is acting within the scope and jurisdiction of his license
• Cover Schedule - is a schedule decided between the Insurer and the Policyholder, giving the details of the cover.

1. Difference in Age: The Insurer may vary or decline benefit(s) if it comes to the notice of the Insurer that the actual age of the member differs from the age declared to the
Insurer at the time of commencement of cover. In such cases, , without prejudice to the Insurer's other rights and remedies including those under the Insurance Act, 1938, and
any other laws then prevailing, the Insurer will have the right to recover balance premium without interest for the concerned Member/Life Insured before settling his/her claim.
In case of excess Premium, the Insurer shall refund the same without interest, after deducting expenses (if any).
2. Loans: No loans are available under this Policy.
3. Discontinuation of Policy: This policy may be discontinued for new entrants at the option of the Insurer or the Policyholder by giving the other party at least one month's prior
notice in writing. The cover for the existing members will continue only for the period for which the premiums have been paid. Thereafter, the cover will continue subject to
the payment of future premiums as per the premium rate table.
4. Cessation of Cover: A member cover ceases on the earliest of the date on which any one of the type of benefits are paid; the date on which the Member discontinues payment
of regular premiums; the date on which the premium for that Member ceases; the Member attaining the Maximum Age at maturity as mentioned in the synopsis provided by
the Insurer .
5. Fraud/Misrepresentation: In case of fraud or misrepresentation by the Member, the provisions of section 45 of the Insurance Act, 1938 as amended from time to time shall be
applicable.
6. Free Look Period: In case Member is not agreeable to any of the provisions stated in the COI, then he/she has the option of returning the COI,stating the reasons thereof
within 15 days from the date of the receipt of the COI. On receipt of letter along with the original COI Insurer shall refund the Premium paid after deducting the proportionate
risk premium (excluding service tax and cess), medical charges (if any) and stamp duty. A COI once returned shall not be revived, reinstated or restored at any point of time
and a new proposal will have to be made.
7. Claims: All claims must be notified to the Insurer by the Policyholder/Nominee in writing preferably within 3 months of the date of the death along with the death certificate
and the documents as specified in the Policy Document. The Insurer may condone the delay on merit for delayed claims, where the delay is genuine and proved to be for reasons
beyond the control of the life insured/claimant.

The Insurer is liable for any claim if the premiums in respect of the concerned member is received by the Insurer/Policyholder, subject to underwriting, if any.

The benefits/claim payment will be payable to the Member or Beneficiary, as applicable.

All amounts due under this policy are payable in Indian Currency at the office of the Insurer situated at Mumbai, but the Insurer at its absolute discretion may fix an alternative
place of payment for the claim at any time before or after the claim arises.

The primary documents normally required for processing a death claim are:
1) Death Claim Intimation Form 2) Proof of age of life insured. 3) Original death certificate and related documents based on death, 4) Last attending doctors certificate and
hospital papers (where cause of death is suspicious) 5) Original Certificate of Insurance or other proof of membership. 6) Original Declaration of Good Health. 7) Proof of
identity of beneficiaries if claim is payable to beneficiaries, 8) Particulars of Beneficiary(ies), if any, in writing in the Insurer's format signed by the authorised representative of
the Policyholder, 9)If death is due to accident or any other unnatural cause - Certified copy of the FIR filed with the police authorities, A certified copy of the post mortem/
autopsy report, A certified copy of the driving license if death occurred while driving

Additional requirements may be called for by the Insurer depending on the circumstances of the death of the Member on a case-to-case evaluation. The claimant can lodge claim
at following address of the Policyholder

Demo Client
Bay road Santacruz Mumbai Maharashtra

or at the following address of the Insurer and comply with further documentation requirements as mentioned in the Policy Contract.

The Claims Manager - Group Claims, Kotak Mahindra Life Insurance Company Ltd. (Formerly known as Kotak Mahindra Old Mutual Life Insurance Ltd.), (IRDAI Regn. No:
107) 7th Floor, Building No.21, Infinity Park, Off Western Express
Highway, General A.K. Vaidya Marg, Malad (E), Mumbai - 400097

8. Query/ Complaint Resolution:

For any clarifications on policy terms, conditions & exclusions or claims, the member may contact either the Policyholder at the address mentioned above or the
Insurer at the address mentioned below. The Complaints, if any, should be addressed to the Insurer at the address mentioned below.
“Group Operations, Kotak Mahindra Life Insurance Company Ltd. (Formerly known as Kotak Mahindra Old Mutual Life Insurance Ltd.), (IRDAI Regn. No: 107)7th Floor
Zone IV, Building No.21, Infinity Park, Off Western Express Highway,
General A.K. Vaidya Marg, Malad (E), Mumbai - 400097”. Telephone:022-64511556 (Monday-Friday (excluding public holidays) between 10.00 a.m. to 6.00 p.m). Email:
kli.groupoperations@kotak.com.

Disclaimer: “This is a system generated document. The validity and enforceability of the terms and conditions including the benefits mentioned in the COI, is subject to
fulfillment of underwriting or any other requirements as specified by the Insurer.”

Note: The Policy is subject to prevailing Indian Laws.

In the event of any difference or discrepancy between this COI and the details provided in the “list of proposed lives to be insured” by the Policyholder to the Insurer, the
details provided in the “list of proposed lives to be insured” by the policyholder shall prevail for payment of benefits under this COI, subject to the terms and conditions of the
policy contract.

Please note that this arrangement can be modified, suspended or withdrawn at any time by Kotak Mahindra Life Insurance Company Ltd. (Formerly known as Kotak Mahindra
Old Mutual Life Insurance Ltd.) and /or the Policyholder without prior intimation.

The COI is the simplified version of important terms and conditions applicable to the Policy contract, which are compiled for the information and benefit of the member.
Member shall be liable for the compliance of additional terms and conditions in the master policy contract, if any.

For details on all terms and conditions of the said policy contract the Member should contact the Policyholder for reference to the Policy contract. The Policy is subject to the
tax laws and other legislation prevailing in India, including the amendments thereto from time to time.

Registered Office: Kotak Mahindra Life Insurance Company Ltd. (Formerly known as Kotak Mahindra Old Mutual Life Insurance Ltd.), CIN: U66030MH2000PLC128503,
Regd. Office: 2nd Floor, Plot # C- 12, G- Block, BKC, Bandra (E),
Mumbai- 400 051, Website: http://insurance.kotak.com, Email: clientservicedesk@kotak.com, Toll Free No.: 18002098800, Fax No.: +91 22 67425649 / 50, Email:
clientservicedesk@kotak.com, Website: http://insurance.kotak.com