HDFC ERGO General Insurance Company Limited
2805205550662901000
Mrs Nirmal Devi
W / O AJIT SINGH HOUSE NO
- 600 CHAUHAN MOHALLA
MADANPUR K SARITAVIHAR SOUTH
DELHI DELHI-110076
DELHI
DELHI - 110076
Contact No.: 87XXXXXXX6
Email:
[email protected]Policy No : 2805 2055 5066 2901 000
Intermediary Code Intermediary Name Intermediary Contact Number
BROKER : BAJAJ CAPITAL
21038790 -
INSURANCE BROKING LTD
Renewal of Your Optima Restore Floater Insurance Policy
Dear Mrs Nirmal Devi ,
Welcome to HDFC ERGO General Insurance Company Limited. We are pleased to issue you Renewal of Your Optima Restore Floater 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. Along with this policy you are also eligible for Wellness Benefits under our Add-on "HDFC ERGO Wellness Corner" -UIN:
HDFHLIA24051V012324. For details of the benefits, please click on the following link https://hdfcergo.onelink.me/ARLJ/v6t9r5kz
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.
Proposer details have been updated basis the information present in the KYC documents. If you find any detail which needs to be corrected, request you
to create/ modify the eKYC ID and place a request for endorsement.
Soft copy of the policy is valid for all purposes including claims.
Warm Regards,
Location: Mumbai
Date: 02/07/2024
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 MRS. NIRMAL DEVI has paid Rs. 24348 (Rupees Twenty-Four Thousand Three Hundred Forty-Eight And Zero Paise Only) towards
premium for Optima Restore Floater Policy No. 2805205550662901000 issued to MRS. NIRMAL DEVI for period of 12/07/2024 to 11/07/2025.
For and on behalf of HDFC ERGO General Insurance Company Limited
Location: Mumbai
Date: 02/07/2024
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: HDFHLIP22193V072122. Policy Issuing/ Customer Happiness Center: D 301, 3rd Floor,Eastern
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Business District,LBS Marg, Bhandup (West),
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Mumbai- 400 078.Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
Policy Schedule - Optima Restore Floater
Policy Number 2805 2055 5066 2901 000
Policy Holder’s Name Mrs Nirmal Devi
W / O AJIT SINGH HOUSE NO - 600 CHAUHAN MOHALLA MADANPUR K SARITAVIHAR SOUTH DELHI
Policy Holder’s Address
DELHI-110076 DELHI DELHI - 110076
Policy Holder State Name & Code Delhi(07) Place of Supply DELHI
GSTIN/ UIN (if any) of Policy Holder
First policy inception date 12/07/2023 Policy Issuance Date 02/07/2024
Policy Period From 00:01 hrs on 12/07/2024 To 24:00 hrs on 11/07/2025
Issuing/Servicing Office GROUND FLOOR EROS CORPORATE TOWER NEHRU PLACE SOUTH DELHI Tel : +91-11-30294200
GSTIN 07AABCL5045N1ZA
EIA Number Not provided
BROKER : BAJAJ CAPITAL INSURANCE
Intermediary Name Intermediary Contact No -
BROKING LTD
Intermediary Code 21038790 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
NIRMAL DEVI / Mr. Manish Chauhan
Particulars / Member ID
2023310029853296 /
2023310029853297
Date of Birth (Age) 01/01/1978 (46) 11/01/2004 (20) - - - -
Relationship to Policy Holder Self Son - - - -
Base Sum Insured (`) 500000
Multiplier Benefit SI (`) -
ABHA ID - - - - - -
Protector Rider Sum
-
Insured(`)
Co-payment % -
Deductible -
Total Sum Insured(`) 500000
Note : In case any insured person's wish to generate his/her ABHA ID kindly visit link given below :
https://https://healthid.ndhm.gov.in/register
Protector Rider - HDHHLIP21335V022021 | Individual Personal Accident Rider - APOPAIP19004V011920 | Hospital Daily Cash Rider - HDHHLIP21344V022021
| Critical Advantage Rider HDHHLIP21342V022021 | my:health Critical Illness - HDFHLIA22141V032122 | Optima Wellbeing (Add-on) - HDFHLIA24099V012324
Other Riders and Benefits ( `)
Protector Rider -
Hospital Daily Cash Rider SI
-
(Max. 30 days)
Critical Advantage Rider SI
- - - - - -
($)
IPA Rider SI - - - - - -
my: health Critical Illness
Sum Insured (Rs.)
my: health Critical Illness
Plan
Unlimited Restore Benefit Yes
Optima Wellbeing Rider No
Nominee Details
Nominee Name : Mr. Manish Chauhan Relationship to Policyholder: Son
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 20634 CGST@9% 1857
Discounts 0 SGST/UTGST@9% 1857
Loadings 0 IGST@18% 0
Taxable Premium 20634 Any other Cess or Taxes 0
Gross Premium 24348
Gross Premium (in words) Rupees Twenty-Four Thousand Three Hundred Forty-Eight And Zero Paise Only
The stamp duty of Rs. 1/- paid vide Order No:(LOA/ENF-1/CSD/64/2024-25/ Validity Period Dt. 15/10/2024 to Dt. 31/12/2028, OW No. 4742 Dt 04/10/2024 GRN
NO. MH007778466202425M, Dt. 10/09/2024, SBI Bank & DEFACE No. 0005045616202425, Dt. 03/10/2024) as prescribed by Government of Maharashtra
Notification No. Mudrank 2017/C.R.97/M-1, Dt.09/01/2018
Original for Recipient/ Duplicate for Supplier
Whether tax is payable on reverse charge basis: No
HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLIP22193V072122. Policy Issuing/ Customer Happiness Center: D 301, 3rd Floor,Eastern
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Business District,LBS Marg, Bhandup (West),
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Mumbai- 400 078.Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
Policy Schedule - Optima Restore Floater
For declared and accepted pre-exiting medical conditions, waiting period (s) shall apply per policy terms and conditions from 1st policy inception date
of the policy, fresh waiting period (s) shall apply on enhanced sum insured.
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)
2023310029853296 NIRMAL DEVI For Rs 500000(Rupees Five Lakhs)
Sec C1 (i) of the policy wording is
waived and Sec C1 (ii) is reduced to 1
year and Sec C1 (iii) is reduced to 2
years..
2023310029853297 Mr. Manish Chauhan For Rs 500000(Rupees Five Lakhs)
Sec C1 (i) of the policy wording is
waived and Sec C1 (ii) is reduced to 1
year and Sec C1 (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: 02/07/2024
"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings "
SCHEDULE OF BENEFITS
In-patient Treatment Upto 500000
Pre-Hospitalization Upto 500000 for 60 days
Post-Hospitalization Upto 500000 for 180 days
Day Care Procedures Upto 500000
Domiciliary Treatment Upto 500000
Organ Donor Upto 500000
Daily Cash for choosing Shared Accommodation Rs.800 per day, Maximum Rs.4,800
Ambulance (per hospitalization limit) Upto Rs.2,000 per Hospitalization
E-Opinion in respect of a Critical Illness One per policy year
Restore Benefit 100% of Basic SI (for any illness or any insured person)
Unlimited Restore Benefit (Optional Benefit) Unlimited restorations in a policy year
Bonus of 50% of Basic Sum Insured post completion of each Policy Year irrespective of claims, maximum upto 100% of Basic
Multiplier Benefit
Sum Insured
Preventive Health Check-up (Floater) Up to a maximum of Rs.2,500 per policy, only once at the end of a block of every continuous two policy years.
HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLIP22193V072122. Policy Issuing/ Customer Happiness Center: D 301, 3rd Floor,Eastern
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Business District,LBS Marg, Bhandup (West),
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Mumbai- 400 078.Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
Terms and Conditions
(1) This card would be valid till your relationship with HDFC ERGO General Insurance
Policy No.: 2805205550662901000 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 b y any government
authority i s 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
Insured Name Member ID Date of Birth Gender terms and conditions of the policy would be applicable while processing your cashless request. (7) In case
Nirmal Devi 2023310029853296 01/01/1978 F your cashless facility i s denied due to any reason, please submit the claim for reimbursement. Denial of
Mr. Manish Chauhan 2023310029853297 11/01/2004 M 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].
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: HDFHLIP22193V072122. Policy Issuing/ Customer Happiness Center: D 301, 3rd Floor,Eastern
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Business District,LBS Marg, Bhandup (West),
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Mumbai- 400 078.Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
