HN09092011000274 C

HDFC ERGO General Insurance Company Limited

CERTIFICATE OF INSURANCE
Master Policy Number

GMC0000475000100 SOURABH BHATTACHARYA AM II/I NR BAPAT HOSPITAL BAPAT SQUARE SUKHLIYA H NO 1 INDORE - 452010 MADHYA PRADESH

Certificate Number

50887383

Name of Proposer Address

Policy Effective Date

From To Midnight of

10/09/2011 09/09/2012

This is to certify that as per the proposal form and declaration submitted to the company and subject to the terms , conditions, exclusions and definitions of the Master Policy Number mentioned above issued to HDFC Bank Limited, the following is/are covered under the Group Mediclaim Policy.
BENEFIT DETAILS Sno. List of Insured Persons/Dependents Relationship Date of Birth Age (yrs) Pre-Existing Diseases Nominee Name Relationship with Insured

SADHVI BHATTACHARYA
Rs. 100,000

Self

02/08/1986

25

SAURABH BHATTACHARYA

Spouse

Sum Insured:

TYPE OF POLICY - FAMILY FLOATER

Family Floater means the sum shown in the Certificate which represents the Companys maximum liability for any and all claims made by the Insured Person during the Policy Period.
TERMS AND CONDITIONS APPLICABLE Sno. Particulars

1 2 3 4 5 6 7

Pre & Post Hospitalization Expenses shall be 60days and 90days respectively Day Care Procedures are as per Annexure Pre-Existing Diseases shall be covered after 4 continuous claim free renewals of this policy Health Checkup benefit is available after 4 continuous claim free renewals of this policy Maximum Claim Limit For Ayurvedic/Homeopathic Treatments - 20% of Sum Insured; Maximum Rs. 20,000 Maximum Claim Limit For Emergency Ambulance Limit per hospitalisation - Rs. 2,000 Maximum Limit for Health Checkup benefit is Upto 1% of Sum Insured
PREMIUM DETAILS

Gross Premium (Rs) Tax,duties and cess as applicable (Rs)

Net Premium (Rs)

1,281 132
1,413

Service Tax Reg. No. : AABCH0738EST004

(1) Third Party Administrator details : Family Health Plan Limited (2) The limits of Indemnity/Benefit provided by this certificate shall be restrictive and need to be referred in concurrence with the policy wordings.

Agent Code: 201587086428 Agent Name: HDFC BANK CC HEALTH Phone No: 022-28561818
Notes: Signed for and on behalf of the HDFC ERGO General Insurance Company Limited Location Date Mumbai 10/09/2011 Authorized Signatory

Insurance is the subject matter of the solicitation. 6th Floor, Leela Business Park , Andheri Kurla Road , Andheri (East), Mumbai 400 059, Toll-Free No. 1800-2-700-700 Fax : 91 22 6638 3699 care@hdfcergo.com www.hdfcergo.com Registered Office : Ramon House , H.T. Parekh Marg, 169 , Backbay Reclamation , Mumbai 400 020.

HN09092011000274 C

HDFC ERGO General Insurance Company Limited

CERTIFICATE FOR THE PURPOSE OF DEDUCTION UNDER SECTION 80 D OF INCOME TAX (AMENDMENT) ACT, 1986*

This is to certify that the certificateholder has paid Rs. 1,413 ( One Thousand Four Hundred Thirteen Only ) towards premium for Group Mediclaim Certificate No 50887383 issued to SOURABH BHATTACHARYA for the period 10/09/2011 to 09/09/2012

For and on behalf of HDFC ERGO General Insurance Co. Ltd. Location Date Mumbai 10/09/2011 Authorized Signatory * Note 1. 2. This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended from time to time. 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.

Insurance is the subject matter of the solicitation. 6th Floor, Leela Business Park , Andheri Kurla Road , Andheri (East), Mumbai 400 059, Toll-Free No. 1800-2-700-700 Fax : 91 22 6638 3699 care@hdfcergo.com www.hdfcergo.com Registered Office : Ramon House , H.T. Parekh Marg, 169 , Backbay Reclamation , Mumbai 400 020.