Digitally signed by Suraj Mishra

Date: 2017.06.25 15:50:13 +05:30

Mr Suresh Kumar R
Flat no 306 This Policy Kit contains:
Skytech marion residency phase1 1. The Policy Schedule along with income tax (80 D)
Crossingrepublick certificate (wherever applicable)
Ghaziabad - 201016 2. Customer Information Sheet and Policy wording
Ghaziabad 3. Member cashless card/s
Uttar Pradesh 4. Network Hospital List, and
India 5. Copy of proposal form*
Contact No.: 9999983251
Policy No: 110104/11121/AA00624794

Your Optima Restore Insurance Policy

Dear Mr Suresh Kumar R,

Welcome to Apollo Munich Health Insurance Co. Ltd. We are pleased to issue you an Optima Restore Insurance Policy. We advise you to
retain your Policy Kit during the entire term of the Policy (including renewals).

Please note that the Policy has been issued to you based on the declarations, details and documents received from/on behalf of you
in/along with the Proposal Form submitted to us. We request you to kindly review the Copy of the Proposal Form along with all the
documents/material contained in the enclosed Policy Kit carefully. In case you notice any inconsistency or any discrepancy in any of the
document/s in the Policy Kit including the Proposal Form; please write back to us or call us at the email id or toll free number within 15
days of receipt of the Policy Kit.

You have the option of cancelling the Policy within 15 days of receipt of the Policy Kit [Free Look Period] subject to terms and conditions
in the policy. Kindly note that Free Look Cancellation option is not available at the time of renewal of the Policy.

Please visit our website www.apollomunichinsurance.com to access information about our Company, the customer service touch points
including the Grievance handling process and various forms including Free Look cancellation that you can use for service support. You
will also get latest updates on products, Policy Wordings which you can download for your reference and record. You may also register
yourself at our website using your unique member ID and policy number as mentioned in the Policy Schedule.

For Free Look Cancellation Procedure or any assistance you may write to us at customerservice@apollomunichinsurance.com or call us
at our 24 hours toll free number 1800-102-0333. We shall be happy to assist you.

Warm Regards,

Location: Gurgaon
Authorized Signatory Date: 25-Jun-2017

Note:-
- Please update us with your latest contact details (in case of any change) so that same can be updated in our records.
You can either write back to us or call us on our toll free no. 1800-102-0333.
*The copy of the Proposal Form has been sent earlier if the Policy has been issued through our Website.

Intermediary Code Intermediary Name Intermediary Contact No

80133720 JITENDER KUMAR 9891907890
 OPTIMA RESTORE POLICY SCHEDULE - Optima Restore Floater

Issuing/Servicing Office: Janakpuri Branch Office,612A, Mahatta Tower, 54,B Block

Community Centre, Janak Puri,New Delhi,Delhi-110058,PH :
01145595353
Policy Holder's Name: Mr Suresh Kumar R
Policy Holder's Address: Flat no 306
Skytech marion residency phase1
Crossingrepublick
Ghaziabad - 201016
Ghaziabad
Uttar Pradesh
India
Intermediary Code: 80133720
Intermediary Name: JITENDER KUMAR
Intermediary Contact No: 9891907890
Policy Number: 110104/11121/AA00624794
First policy inception date: 25-Jun-2017
Policy Period: From 15:46 hrs on 25-Jun-2017 To 24:00 hrs on 24-Jun-2018
Insured Persons Details:
Member ID Insured Person's Name Age Relationship Basic Sum Critical Multiplier Critical Gross
to Insured Advantage Benefit Advantage Premium
Policyholder (Rs.) Sum Insured (Rs) Rider Premium (Rs)
(USD$) (Rs)

10012110575 Mr Suresh Kumar R 40 Policy Holder 500000 0 0 0 18737.18

10012110576 Mrs Anukrishnan 34 Wife 0 0
10012110577 Miss Yamuna s nair 6 Daughter 0 0
10012110578 Master Harendra s nair 4 Son 0 0

Nominee Name: Mrs Anukrishnan Relationship: Wife

The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee.

Premium Calculation:
Net Premium (Rs) 16293.20
Discounts (Rs) 0.00
Loadings (Rs) 0.00
Service Tax/J&K GST as applicable (Rs) 2281.05
SBC & KKC (Rs) 162.93
Gross Premium (Rs) 18737.18
Gross premium amount (in words) Rupees Eighteen Thousand Seven Hundred Thirty-Seven and Paisa
Eighteen Only
The stamp duty of Rs. 1.00/- (Rupees One Only) paid vide No.F.10(783)/COS(HQ)/Con.duty/08. (Not applicable for the state of
Jammu & Kashmir).
Service Tax Registration No.: AAGCA1654HST002
GST TIN: 01871052106
For and on behalf of Apollo Munich Health Insurance Company Limited
Claim Administrator: Apollo Munich
(For critical advantage rider:)
Location: Gurgaon
Date: 25-Jun-2017
Authorized Signatory
 Certificate for the purpose of deduction under Section 80 D of Income Tax Act, 1961*

This is to certify that MR Suresh Kumar R has paid Rs 18737.18 (Rupees Eighteen Thousand Seven Hundred Thirty-Seven and
Paisa Eighteen Only ) towards premium for Optima Restore Floater Policy No 110104/11121/AA00624794 issued to Mr Suresh
Kumar R for period 25-Jun-2017 to 24-Jun-2018.

For and on behalf of Apollo Munich Health Insurance Company Limited

Location: Gurgaon
Date: 25-Jun-2017 Authorized Signatory

*Note

1. This is subject to the provisions of Section 80D of Income Tax Act, 1961 as amended from time to time.
2. This certificate must be surrendered to the company in case of cancellation of this policy. In event of incorrect representation of
this declaration the liability shall be upon the policy holder.
3. Please note that this certificate will not be issued if the premium payment has been made in cash.
4. In case of dishonour of the premium instrument, the policy will be deemed cancelled ab initio.
5. 80D benefit is applicable for only Self, Spouse, Dependent Children and Dependent parents