HDFC ERGO General Insurance Company Limited
2805101016051602001
Mr Rizwan Achhanali Siddiqui
-
-
NA
B704 ANJANI PARADISE KANOONGO
THANE
MAHARASHTRA - 401105
Contact No.: 99XXXXXXX2
Email:
[email protected]Policy No : 2805 1010 1605 1602 001
Intermediary Code Intermediary Name Intermediary Contact Number
HE DIRECT : HE DIRECT_DBG
200278133519 91-22-66383600
DIRECT_10137
Your Optima Restore Floater Policy
Dear Mr Rizwan Achhanali Siddiqui ,
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.
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: 27/03/2023
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 MR. RIZWAN ACHHANALI SIDDIQUI has paid Rs. 22635 (Rupees Twenty-Two Thousand Six Hundred Thirty-Five And Zero Paise
Only) towards premium for Optima Restore Floater Policy No. 2805101016051602001 issued to MR. RIZWAN ACHHANALI SIDDIQUI for period of 23/03/2023
to 22/03/2024.
For and on behalf of HDFC ERGO General Insurance Company Limited
Location: Mumbai
Date: 27/03/2023
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: UIN No: HDFHLIP22193V072122. Critical Advantage Rider - HDHHLIP21342V022021 | Customer
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Service Address: D 301, 3rd Floor,Eastern Business District (Magnet Mall),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
Endorsement Cum Policy Schedule - Optima Restore Floater
Policy Number 2805 1010 1605 1602 001
Policy Holder’s Name Mr Rizwan Achhanali Siddiqui
Policy Holder’s Address - - NA B704 ANJANI PARADISE KANOONGO THANE MAHARASHTRA - 401105
Policy Holder State Name & Code Maharashtra Place of Supply MAHARASHTRA
GSTIN/ UIN (if any) of Policy Holder
First policy inception date 15/03/2021 Policy Issuance Date 27/03/2023
Policy Period From 19:11 hrs on 23/03/2023 To 24:00 hrs on 22/03/2024
Issuing/Servicing Office SEWA CORPORATE SUITES, M.G.ROAD, NEAR IFFCO CHOWK GURGAON Tel : +91-22-66383600
GSTIN 06AABCL5045N1ZC
EIA Number Not provided
Intermediary Name HE DIRECT : HE DIRECT_DBG DIRECT_10137 Intermediary Contact No 91-22-66383600
Intermediary Code 200278133519 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
RIZWAN FAUJIYA RIZWAN
Particulars / Member ID ACHHANALI SIDDIQUI /
SIDDIQUI / 2021031528192306
2021031528192305
Date of Birth (Age) 28/02/1991 (32) 03/04/1994 (28) - - - -
Relationship to Policy Holder Self Wife - - - -
Base Sum Insured (`) 1000000
Multiplier Benefit SI (`) 500000
Protector Rider
-
Sum Insured (`)
Total Sum Insured (`) 1500000
Other Riders and Benefits ( `)
Protector Rider /
-
HDHHLIP21335V022021
Hospital Daily Cash Rider SI
(Max. 30 days) / Rs. 3000 per day
HDHHLIP21344V022021
Critical Advantage Rider SI
($) / - - - - - -
HDHHLIP21342V022021
IPA Rider SII /
- - - - - -
APOPAIP19004V011920
my: health Critical Illness
Sum Insured (Rs.)
my: health Critical Illness
Plan
Unlimited Restore Benefit No
Nominee Details
Nominee Name : Faujiya Rizwan Siddiqui 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 20070.92 CGST@9%
Discounts 888.92 SGST/UTGST@9%
Loadings 0 IGST@18%
Taxable Premium 19182 Any other Cess or Taxes
Gross Premium 22635
Gross Premium (in words) Rupees Twenty-Two Thousand Six Hundred Thirty-Five And Zero Paise Only
The stamp duty of Rs. 1/- ( Rupees One And Zero Paise Only ) paid vide e-stamp Certificate No. NO.LOA/ENF-1/CSD/34/2023/6045 dated 27/12/2023.
I/ We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under
sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule
Original for Recipient/ Duplicate for Supplier
Whether tax is payable on reverse charge basis: No
List of Endorsements
Endt No Description Effective Date
001 General Endorsement 23/03/2023
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.
HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: UIN No: HDFHLIP22193V072122. Critical Advantage Rider - HDHHLIP21342V022021 | Customer
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Service Address: D 301, 3rd Floor,Eastern Business District (Magnet Mall),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
Endorsement Cum Policy Schedule - Optima Restore Floater
Claim Administrator : HDFC ERGO General Insurance Company Ltd For and on behalf of HDFC ERGO General Insurance Company Limited
Location: Mumbai Authorized Signatory
Date: 27/03/2023
"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings"
SCHEDULE OF BENEFITS
In-patient Treatment Upto 1000000
Pre-Hospitalization Upto 1000000 for 60 days
Post-Hospitalization Upto 1000000 for 180 days
Day Care Procedures Upto 1000000
Domiciliary Treatment Upto 1000000
Organ Donor Upto 1000000
Daily Cash for choosing Shared Accommodation Rs.800 per day, Maximum Rs.4,800
Ambulance (per hospitalization limit) Upto Rs.2,000 per Hospitalization
Emergency Air Ambulance Cover Covered upto rs. 2.5 Lacs per hospitalization and maximum upto sum insured in an year
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)
Bonus of 50% of the Basic SI for every claim free policy year, maximum upto 100%. In case of claim, accumulated bonus will be
Multiplier Benefit
reduced by 50%
Preventive Health Check-up (Floater) Upto a maximum of Rs.5,000 per policy, at the end of each year at renewal.
HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: UIN No: HDFHLIP22193V072122. Critical Advantage Rider - HDHHLIP21342V022021 | Customer
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Service Address: D 301, 3rd Floor,Eastern Business District (Magnet Mall),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.: 2805101016051602001 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
Rizwan Achhanali Siddiqui 2021031528192305 28/02/1991 M your cashless facility i s denied due to any reason, please submit the claim for reimbursement. Denial of
Faujiya Rizwan Siddiqui 2021031528192306 03/04/1994 F 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: UIN No: HDFHLIP22193V072122. Critical Advantage Rider - HDHHLIP21342V022021 | Customer
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Service Address: D 301, 3rd Floor,Eastern Business District (Magnet Mall),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
