HDFC ERGO General Insurance Company Limited
2805203586542601002
Mr Sumit Kumar Koshal
RZD-69,
1ST FLOOR, FRONT SIDE,
STREET NO 4, NEAR SULABH,
MAHAVIR ENCLAVE,
DELHI
NEW DELHI - 110045
Contact No.: 8744009880
Email:
[email protected]Policy No : 2805 2035 8654 2601 002
Intermediary Code Intermediary Name Intermediary Contact Number
- - -
Your Optima Restore Floater Policy
Dear Mr Sumit Kumar Koshal ,
Welcome to HDFC ERGO General Insurance Company Limited. We are pleased to issue you Your Optima Restore Floater 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.
Please visit our website www.hdfcergo.com for more information about our Company, Grievance handling and any other support. To know the updated list of our
network hospitals please visit https://www.hdfcergo.com/locators/cashless-hospitals-network
We value your relationship with us and assure you our best services at all times and we look forward to serve you.
Warm Regards,
Location: Mumbai
Date: 23/07/2022
Authorized Signatory
Note:
1. Please update us with your latest contact details (in case of any change) so that same can be updated in our records.
2. You can either email us on [email protected] or call on our Customer care no. 022 6234 6234 / 0120 6234 6234.
3. *The Copy of the proposal form has been sent on your registered email id if policy is purchased through website.
Certificate for the purpose of deduction under Section 80 D of Income Tax Act, 1961*
This is to certify that the SUMIT KUMAR KOSHAL has paid Rs. 23804 (Rupees Twenty Three Thousand Eight Hundred Four And Zero Paise Only) towards premium
for Optima Restore Floater Policy No. 2805203586542601002 issued to SUMIT KUMAR KOSHAL for period of 27/07/2022 to 26/07/2023.
For and on behalf of HDFC ERGO General Insurance Company Limited
Location: Mumbai
Date: 23/07/2022
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 Policyholder.
3. Please note that this certificate will not be issued if the premium payment has been made in cash.
4. In case of dishonor 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.
HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDHHLIP21322V062021. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
Endorsement Cum Policy Schedule - Optima Restore Floater
Policy Number 2805 2035 8654 2601 002
Policy Holder’s Name Mr Sumit Kumar Koshal
RZD – 69, 1ST FLOOR,FRONT SIDE, STREET NO 4, NEAR SULABH, MAHAVIR ENCLAVE, N E W D E L H I - 110045
Policy Holder’s Address
Policy Holder State Name & Code New Delhi(36) Place of Supply Delhi
GSTIN/ UIN (if any) of Policy Holder
First policy inception date 27/07/2013 Policy Issuance Date 23/07/2022
Policy Period From 00:01 hrs on 27/07/2021 To 24:00 hrs on 26/07/2022
Unit No 502, 5th Floor, Mahatta Tower, 54, B-1 Block, Community Center, Janakpuri, New Delhi – 110058, Contact No :
Issuing/Servicing Office 011-25612361
GSTIN 36AABCL5045N1Z9
EIA Number Not provided
Intermediary Name - Intermediary Contact No -
Intermediary Code - Description/ Harmonized System Of Accident and Health insurance
Nomenclature Code Services/9971
Insured Person Details
Member 1 Member 2 Member 3 Member 4 Member 5 Member 6
Sumit Mrs Baby Aarohi Baby Aarvi Koshal
Particulars / Member ID Kumar Abhilasha Koshal / /
Koshal/ Choudhary/ 202009172862399 202009172862400
20200917 202009172
2862397 862398
Date of Birth (Age) 26/06/1982(39) 01/07/1986 (35) 29/01/2014 (7) 08/03/2019 (2) - -
Relationship to Policy Holder Self Wife Daughter Daughter - -
Base Sum Insured (`) 500000
Multiplier Benefit SI (`) 500000
Protector Rider
-
Sum Insured (`)
Total Sum Insured (`) 1000000
Other Riders and Benefits ( `)
Protector Rider -
Hospital Daily Cash Rider SI
-
(Max. 30 days)
Critical Advantage Rider SI
- - - - - -
($)
IPA Rider SI - - - - - -
Nominee Details
Nominee Name : Mrs Ramya Jonnalagadda Relationship to Policyholder: 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 20174 CGST@9% 1815.0
Discounts 0 SGST/UTGST@9% 1815.0
Loadings 0 IGST@18% 0
Taxable Premium 20174 Any other Cess or Taxes 0
Gross Premium 23804
Gross Premium (in words) Rupees Twenty Three Thousand Eight Hundred Four And Zero Paise Only
The stamp duty of Rs. 1/- ( Rupees One And Zero Paise Only ) paid vide e-stamp Certificate No. CSD/105/2021/2914 dated 03/08/2021.
Original for Recipient/ Duplicate for Supplier
Whether tax is payable on reverse charge basis: No
List of Endorsements
Endt No Description Effective Date
002 Reinstatement of policy period 27/07/2022
Exclusion(s) / Special Condition(s) (Refer the leaflet attached in the policy document w.r.t. exclusions) :
Member ID No. Name Exclusion Type Applicable Health Condition Exclusion Portability/ Renewal Benefit
on SI Duration
(Years)
202009172862397 SUMIT KUMAR KOSHAL For Rs 300000(Rupees Three Lakhs)
Sec 5 A (i) and Sec 5 A (ii) Sec 5 A
(iii) of the policy wording is waived.
For Rs 200000(Rupees Two Lakhs)
Sec 5 A (i) of the policy wording is
waived and Sec 5 A (ii) is reduced to
1 year and Sec 5 A (iii) is reduced to
2 years.
202009172862398 Mrs ABHILASHA For Rs 300000(Rupees Three Lakhs)
CHOUDHARY Sec 5 A (i) and Sec 5 A (ii) Sec 5 A
(iii) of the policy wording is waived.
HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDHHLIP21322V062021. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
Endorsement Cum Policy Schedule - Optima Restore Floater
Endorsement Cum Policy Schedule - Optima Restore Floater
Exclusion(s) / Special Condition(s) (Refer the leaflet attached in the policy document w.r.t. exclusions) :
Member ID No. Name Exclusion Type Applicable Health Condition Exclusion Portability/ Renewal Benefit
on SI Duration
(Years)
For Rs 200000(Rupees Two Lakhs)
Sec 5 A (i) of the policy wording is
waived and Sec 5 A (ii) is reduced to
1 year and Sec 5 A (iii) is reduced to
2 years.
202009172862399 Baby Aarohi Koshal For Rs 300000(Rupees Three Lakhs)
Sec 5 A (i) and Sec 5 A (ii) Sec 5 A
(iii) of the policy wording is waived.
For Rs 200000(Rupees Two Lakhs)
Sec 5 A (i) of the policy wording is
waived and Sec 5 A (ii) is reduced to
1 year and Sec 5 A (iii) is reduced to
2 years.
202009172862400 Baby Aarvi For Rs 300000(Rupees Three Lakhs)
Koshal Sec 5 A (i) and Sec 5 A (ii) Sec 5 A
(iii) of the policy wording is waived.
For Rs 200000(Rupees Two Lakhs)
Sec 5 A (i) of the policy wording is
waived and Sec 5 A (ii) is reduced to
1 year and Sec 5 A (iii) is reduced to
2 years.
Claim Administrator : HDFC ERGO General Insurance Company Ltd For and on behalf of HDFC ERGO General Insurance Company Limited
Location: Mumbai Authorized Signatory
Date: 23/07/2022
"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings"
HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDHHLIP21322V062021. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
Endorsement Cum Policy Schedule - Optima Restore Floater
Terms and Conditions
(1) This card would be valid till your relationship with HDFC ERGO General Insurance
Policy No.: 2805203586542601002 Company Limited / This card is invalid if the policy is cancelled (2) In case of renewal please
refer original policy number (3) This card is issued for the purpose of identification only and does not
entail automatic cashless facility at the network hospital. (4) A photo ID issued by any government
authority is to be produced to avail cashless facility. (5) Please apply for cashless facility 48 hours prior
to admission in case of planned admissions and within 24 hours of admission in case of emergency.(6) All
terms and conditions of the policy would be applicable while processing your cashless request. (7) In case
your cashless facility is denied due to any reason, please submit the claim for reimbursement. Denial of
cashless facility does not indicate rejection of the claim. (8) Please read policy documents carefully for
detailed terms and conditions. For claim status visit help section on our web site www.hdfcergo.com.
Alternatively you may write to us at
[email protected].
F
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg,
Churchgate, Mumbai – 400 020. Health Claim Services Address : HDFC ERGO General Insurance Company
Limited Stellar IT Park, Tower-1 , 5th Floor, C - 25, Noida, Sector 62, 201301, Uttar Pradesh.
Service No. 022-62346234/ 0120-62346234Email:
[email protected] Logo displayed above
belongs to HDFC Ltd and ERGO International AG and used by the Company under license.
HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDHHLIP21322V062021. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
