HDFC ERGO General Insurance Company Limited

2805203520507701000

MR JAYESH RASIKLAL MORAKHIYA

91 UMA APTMNT 1 NR RATNA RAJ
ADAJAN PATIA
adajan Surat
SURAT
GUJARAT - 395009
Contact No.: 9825088700

Policy No : 2805 2035 2050 7701 000

Intermediary Code Intermediary Name Intermediary Contact Number

200544120638 MINAXIBEN NILANGKUMAR MEHTA 91-9879511296

Renewal of Your Optima Restore Floater Two Year Insurance Policy

Dear Mr Jayesh Rasiklal Morakhiya ,

Welcome to HDFC ERGO General Insurance Company Limited. We are pleased to issue you Renewal of Your Optima Restore Floater Two Year 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.

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: 16/03/2021

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 care@hdfcergo.com 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 JAYESH RASIKLAL MORAKHIYA has paid Rs. 23648 (Rupees Twenty-Three Thousand Six Hundred Forty-Eight And Zero Paise
Only) towards premium for Optima Restore Floater Two Year Policy No. 2805203520507701000 issued to JAYESH RASIKLAL MORAKHIYA for period of
27/03/2021 to 26/03/2023.

For and on behalf of HDFC ERGO General Insurance Company Limited

Location: Mumbai
Date: 16/03/2021

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 CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165/166 Backbay Reclamation, H.T.Parekh Marg,
Churchgate, Mumbai - 400 020. UIN: HDHHLIP21322V062021. Customer Service Address: D 301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400078. Customer Service
No : +91 22-62346234 /+91-120 6234 6234 www.hdfcergo.com
 HDFC ERGO General Insurance Company Limited

Policy Schedule - Optima Restore Floater Two Year

Policy Number 2805 2035 2050 7701 000

Policy Holder’s Name Mr Jayesh Rasiklal Morakhiya
Policy Holder’s Address 91 UMA APTMNT 1 NR RATNA RAJ ADAJAN PATIA adajan Surat SURAT GUJARAT - 395009
Policy Holder State Name & Code Gujarat(24) Place of Supply GUJARAT
GSTIN/ UIN (if any) of Policy Holder
First policy inception date 27/03/2019 Policy Issuance Date 16/03/2021
Policy Period From 00:01 hrs on 27/03/2021 To 24:00 hrs on 26/03/2023
HDFC ERGO HEALTH INSURANCE LIMITED OFFICE NO.-1004, UPPER GROUND FLOOR, 21ST CENTURY
Issuing/Servicing Office
CENTER, RUSTAMPURA, RING ROAD, SURAT-395002, GUJARAT SURAT Tel : +91-22-66383600
GSTIN 24AABCL5045N1ZE
Intermediary Name MINAXIBEN NILANGKUMAR MEHTA Intermediary Contact No 91-9879511296
Intermediary Code 200544120638 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
JAYESH RASIKLAL Mrs Dimple / Mr Chit /
Particulars / Member ID
MORAKHIYA / 202008282835747 202008282835748
202008282835746
Date of Birth (Age) 01/09/1977 (43) 08/06/1978 (42) 27/08/2005 (15) - - -
Relationship to Policy
Self Wife Son - - -
Holder
Base Sum Insured (`) 300000
Multiplier Benefit SI (`) -
Protector Rider
-
Sum Insured (`)
Total Sum Insured (`) 300000
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 Dimple 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 20041 CGST@9% 1803.5
Discounts 0 SGST/UTGST@9% 1803.5
Loadings 0 IGST@18% 0
Taxable Premium 20041 Any other Cess or Taxes 0
Gross Premium 23648
Gross Premium (in words) Rupees Twenty-Three Thousand Six Hundred Forty-Eight And Zero Paise Only
The stamp duty of Rs. 1/- ( Rupees One And Zero Paise Only ) paid vide e-stamp Certificate No. CSD/362/2020/1302 dated 20/03/2020. (Not applicable for the
state of Jammu ).
Original for Recipient/ Duplicate for Supplier
Whether tax is payable on reverse charge basis: No
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)
202008282835746 JAYESH RASIKLAL For Rs 100000(Rupees One Lakhs)
MORAKHIYA 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) and Sec 5 A (ii) of the
policy wording is waived and Sec 5 A
(iii) is reduced to 1 year.
202008282835747 Mrs Dimple For Rs 200000(Rupees Two Lakhs)
Sec 5 A (i) and Sec 5 A (ii) of the
policy wording is waived and Sec 5 A
(iii) is reduced to 1 year.

For Rs 100000(Rupees One Lakhs)

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 CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165/166 Backbay Reclamation, H.T.Parekh Marg,
Churchgate, Mumbai - 400 020. UIN: HDHHLIP21322V062021. Customer Service Address: D 301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400078. Customer Service
No : +91 22-62346234 /+91-120 6234 6234 www.hdfcergo.com
 HDFC ERGO General Insurance Company Limited

Policy Schedule - Optima Restore Floater Two Year

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)
202008282835748 Mr Chit For Rs 200000(Rupees Two Lakhs)
Sec 5 A (i) and Sec 5 A (ii) of the
policy wording is waived and Sec 5 A
(iii) is reduced to 1 year.

For Rs 100000(Rupees One Lakhs)

Sec 5 A (i) and Sec 5 A (ii) Sec 5 A
(iii) of the policy wording is waived.

Claim Administrator : HDFC ERGO Health Insurance Company Ltd For and on behalf of HDFC ERGO General Insurance Company Limited

Location: Mumbai Authorized Signatory

Date: 16/03/2021

"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 CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165/166 Backbay Reclamation, H.T.Parekh Marg,
Churchgate, Mumbai - 400 020. UIN: HDHHLIP21322V062021. Customer Service Address: D 301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400078. 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.: 2805203520507701000 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 Gender terms and conditions of the policy would be applicable while processing your cashless request. (7) In case
Jayesh Rasiklal Morakhiya M your cashless facility i s denied due to any reason, please submit the claim for reimbursement. Denial of
Mrs Dimple 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.
Mr Chit M Alternatively you may write to us at Healthclaims@hdfcergo.com.

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: healthclaims@hdfcergo.com.Trade 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 CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165/166 Backbay Reclamation, H.T.Parekh Marg,
Churchgate, Mumbai - 400 020. UIN: HDHHLIP21322V062021. Customer Service Address: D 301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400078. Customer Service
No : +91 22-62346234 /+91-120 6234 6234 www.hdfcergo.com