HDFC ERGO General Insurance Company Limited 2917100597928000000

Policy Schedule
N
Policy No. 2917100597928000000
Home Insurance Policy
GSTIN:

Insured Name Mr sourabh das Gender MALE PAN No.

Correspondence C-309 , C-2 BLOCK,DHPL SAHOO RESIDENCY Risk Location 0 6
C-309 , C-2 BLOCK,DHPL SAHOO RESIDENCY RANGAMATIA
Address RANGAMATIA NEAR MANCHESWAR STATION Address NEAR MANCHESWAR STATION BHUBANESHWAR, 751017
BHUBANESHWAR, 751017 ODISHA
ODISHA
Mobile 8057909309 Phone E Mail SOURABH.DAS.1989@GMAIL.COM
Occupancy Residential Place of Supply ODISHA
Period of Insurance From Date & Time 19/03/2019 00:01 hrs To Date & Time 18/03/2022 Midnight Policy Issuance Date 18/03/2019
Coverage Details & Sum Insured (`)
Section Description Sum Insured Premium
I. Fire & Special Perils B. Contents 500,000.00 318.75
Add
a) Additional Premium for Terrorism risk inclusion. (Subject to Endorsement A1) 500,000.00 120.00
b) Premium for Earthquake, Volcanic Eruption and Other Convulsions of nature 500,000.00 150.00
c) Premium for Riots, Strikes and Malicious Damage Risk 500,000.00 127.50
d) Premium for of Storm / Tempest / Flood / Inundation risk 500,000.00 191.25

Premium Details (`)

Basic Premium 908.00

Integrated Tax 18% 163.00
Total Premium 1071.00

Payment Details
Cheque No./DD/Fund Transfer Date Bank Name
Fund Transfer No. 1721903023256 18/03/2019 BizDirect

Special Conditions

List of Endorsements
Endt No Description Effective Date

022-6234 100597928000000
Customer HSN
For Queries/Claim Services 6234/0120-6234 E-mail care@hdfcergo.com Invoice No. 9971
Service No. Code
6234
Address 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri(E), Mumbai 400 059.
If the premium is not realised the policy shall be void from inception. Where proposal forms are not received, information obtained from an insured whether
orally or otherwise is captured in the cover note, if issued, and / or in the policy document. Discrepancies, if any, in the information contained in the policy
document may be pointed out by an insured within 30 days from policy issue date after which information contained in the policy shall be deemed to have
been accepted as correct.
Consolidated stamp duty for this Insurance Policy is paid by Demand Draft,vide Receipt/Challan no. CSD/324/2019/559/19
dated 14/02/2019 as prescribed in Government Notification Revenue and Forest Department No. Mudrank 2017/CR.97/M-1,dated 09/01/2018.Goods and Service
Tax for this invoice is not payable under reverse charge basis.

Policy Issuing Office : LEELA BUSINESS PARK, 6TH FLR, ANDHERI - KURLA RD, MUMBAI, 400059. Phone No. : +91-22-66383600

For HDFC ERGO General Insurance Company Ltd.

Duly Constituted Attorney

The Policy wording attached herewith includes all the standard coverage offered by the Company to its customers. Your entitlement for coverage/benefits shall be restricted to the coverage/benefits as
mentioned in this policy schedule. For any clarification please call our toll free number.

HDFC ERGO General Insurance Company Limited (Formerly HDFC General Insurance Limited) UIN : IRDAN125P0017V01201415 || IRDAI Reg No.146 || CIN: U66030MH2007PLC177117
Registered & Corporate Office: Customer Service Address: Customer Service no : 022 - 6234 6234 / 0120 - 6234 6234
1st Floor, HDFC House, 165/166 Backbay Reclamation, D 301, 3rd Floor, Eastern Business District (Magnet Mall), Telephone: 022 6638 3600 Fax : 022 6638 3699
H.T.Parekh Marg, Mumbai - 400 020 LBS Marg, Bhandup (West), Mumbai - 400 078 Email : care@hdfcergo.com
HDFC ERGO General Insurance Company Limited 2917100597928000000

Policy No. 2917100597928000000

Home Insurance - Proposal Form For Home Insurance
Policy
Insured Name Mr sourabh das Gender MALE
Correspondence C-309 , C-2 BLOCK,DHPL SAHOO RESIDENCY Risk Location C-309 , C-2 BLOCK,DHPL SAHOO RESIDENCY RANGAMATIA
Address RANGAMATIA NEAR MANCHESWAR STATION Address NEAR MANCHESWAR STATION 0 6
BHUBANESHWAR, 751017 BHUBANESHWAR, 751017
ODISHA ODISHA

Mobile 8057909309 Phone E Mail SOURABH.DAS.1989@GMAIL.COM

Period of Insurance From Date & Time 19/03/2019 00:01 hrs To Date & Time 18/03/2022 Midnight Occupancy Residential

Coverage Details & Sum Insured (`)

Section Description Sum Insured Premium
I. Fire & Special Perils B. Contents 500,000.00 318.75
Add
a) Additional Premium for Terrorism risk inclusion. (Subject to Endorsement A1) 500,000.00 120.00
b) Premium for Earthquake, Volcanic Eruption and Other Convulsions of nature 500,000.00 150.00
c) Premium for Riots, Strikes and Malicious Damage Risk 500,000.00 127.50
d) Premium for of Storm / Tempest / Flood / Inundation risk 500,000.00 191.25

Premium Details (`)

Basic Premium 908.00

Integrated Tax 18% 163.00
Total Premium 1071.00
Payment Details
Cheque No./DD/Fund Transfer Date Bank Name
Fund Transfer No. 1721903023256 18/03/2019 BizDirect

For Queries/Claim Services Toll-free 022-6234 6234/0120-6234 6234 E-mail care@hdfcergo.com

Address 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri(E), Mumbai 400 059.

Proposer declaration

I / We hereby declare that the statements made by me / us in this Proposal Form are true to the best of my /our knowledge and belief and I / We hereby agree that this declaration shall form the basis of
the contract between me / us and the Insurer – M/S HDFC ERGO General Insurance Company Ltd. If any additions or alterations are carried out in the risk proposed after the submission of this proposal
form then the same should be conveyed to the insurers immediately.

Anti rebate clause

Prohibition of Rebates (Section 41 of Insurance Act, 1938 as amended) : 1. No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew
o r continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy,
nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer: provided
that acceptance b y an insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be acceptance of a rebate of premium within
the meaning of this sub-section if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed by the insurer.

2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees..

HDFC ERGO General Insurance Company Limited (Formerly HDFC General Insurance Limited) UIN : IRDAN125P0017V01201415 || IRDAI Reg No.146 || CIN: U66030MH2007PLC177117
Registered & Corporate Office: Customer Service Address: Customer Service no : 022 - 6234 6234 / 0120 - 6234 6234
1st Floor, HDFC House, 165/166 Backbay Reclamation, D 301, 3rd Floor, Eastern Business District (Magnet Mall), Telephone: 022 6638 3600 Fax : 022 6638 3699
H.T.Parekh Marg, Mumbai - 400 020 LBS Marg, Bhandup (West), Mumbai - 400 078 Email : care@hdfcergo.com
HDFC ERGO General Insurance Company Limited

Bharat Griha Raksha

2111101191004200000

MR. SOURABH DAS

C-309,DHPL SAHOO RESIDENCY Rangamatia ,
Bhubaneshwar Near Mancheswar Railway Station
KHORDA,KHORDA,
ODISHA,751017
Contact No.: 8057909309

Dear Customer,
Sub: Bharat Griha Raksha Policy No. 2111101191004200000

We thank you for having preferred us for your Insurance requirements. We at HDFC ERGO General Insurance
believe “Insurance” as not only to be an assurance to indemnify in the event of unfortunate circumstances,
but one that signifies protection and support, which you can count on when you need it most.

The Insurance Policy enclosed herewith is a written agreement providing confirmation of our responsibility
towards you that puts insurance coverage into effect against stipulated perils.

Please note that the policy has been issued based on the information contained in the proposal form and / or
documents received from you or your representative / broker. Where the proposal form is not received,
information obtained from you or your representative /broker, whether orally or otherwise, is captured in the
policy document.

If you wish to contact us in reference to your existing policy and /or other general insurance solutions offered
by us, you may write to our correspondence address as mentioned below. Alternatively, you may visit our
website www.hdfcergo.com . To enable us to serve you better, you are requested to quote your Policy Number
in all correspondences.

Thanking you once again for choosing HDFC ERGO General Insurance Company Limited and looking forward
to many more years of association.

Yours sincerely,

Authorised Signatory

HDFC ERGO General Insurance Company Limited. UIN NO.: IRDAN125RP0003V01202021. 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. Policy Issuing/ Customer Happiness Center: D-301, 3rd Floor, Eastern Business
District LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on www.hdfcergo.com for
policy copy/tax certificate/make changes/register & track claim. Trade Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company under license.
HDFC ERGO - Bharat Griha RakshaI HE/CL/Fire/20-21/227.
HDFC ERGO General Insurance Company Limited
Policy Schedule
21
Bharat Griha Raksha

2111101191004200000
Policy No. :2111 1011 9100 4200 000
Period of Insurance :From 04/04/2022 00:01 hrs To 03/04/2027 Midnight
Customer ID :Customer Id:101422625418
Policy Issuance Date :03/04/2022
MR. SOURABH DAS Customer GSTN :
C-309,DHPL SAHOO RESIDENCY Rangamatia , Bhubaneshwar Place of Supply :ODISHA
Near Mancheswar Railway Station Age of Building :NA
KHORDA,KHORDA, Cost of construction (in :5000000
ODISHA,751017 INR per sq mt.)
Contact No.: 8057909309
Carpet Area (in sq mts) :0
Email ID :SOURABH.DAS.1989@GMAIL.COM
Payment Details : 1722204003880, Bank Name:Bizdirect
RM Code Case ID/Loan Account No. Client ID
Financier Name
Co-insurance Details
Details of Property Insured & Location of Risk Covered
Risk Location Occupancy Detail of the Property Insured Sum Insured (`)
C309DHPLSAHOORESIDENCY,
RANGAMATIABHUBANESHWAR,NearMancheswarRailwayStation,
BHUBANESHWAR, KHORDA, ODISHA, PIN-751017.
Dwellings Others excluding valuables & Jewellery 500,000.00
Invoice No. :2040300176821 , Premium:814 , Integrated Tax 18%
(`147 ) , Place of Supply : ODISHA
Total Sum Insured 500,000.00
Details of In built / Add On Cover
S.No Description of In built / Add On Cover Sum Insured / Limit of Liability
1 Escalation 10% per Year for Building Only
2 Terrorism 500000
3 Loss of Rent 0
4 Rent for alternative accommodation 0
5 Personal Accident Cover 0
6 Valuables (As per annexure) -
7 Hardship Allowance - IRDAN125RP0003V01202021/A0027V01202122 0
Accidental Hospitalization of Domestic Staff - IRDAN125RP0003V01202021/A0028V01202122
8 0
No.of Domestic Staff Covered :
Premium Details
Basic Premium 614.00
Terrorism Premium 200.00
Integrated Tax 18% 147.00
Total Premium 961.00
Excess/Deductibles
Fire Excess:Nil
Terrorism Excess: 1% of the claim amount for each and every claim subject to minimum of Rs. 10,000/- and maximum limit of Rs. 5,00,000/-
Special Condition /Clauses / Warranties
DESIGNATION OF PROPERTY CLAUSE
REINSTATEMENT VALUE CLAUSE
Local Authorities Clause
TERRORISM DAMAGE COVER ENDORSEMENT (MATERIAL DAMAGE ONLY)
EARTHQUAKE (FIRE & SHOCK) INCLUSION
REMOVAL OF DEBRIS CLAUSE (Upto 1% of the claim amount)
ARCHITECTS, SURVEYORS AND CONSULTING ENGINEERS FEES CLAUSE (Upto 3% of the Claim Amount)
SUM INSURED UNDER THE POLICY SHALL BE DEEMED TO HAVE INCREASED BY 10% OF THE ORIGINAL SUM INSURED AT THE END OF EVERY 12 MONTHS PERIOD
Warranted Interest Covered is not located in Basement.
Warranted there is no Kutcha Construction at insured premises
Communicable Disease Exclusion [Endorsement][Clause]

1.Notwithstanding any provision, clause or term of this [Insurance Contract] to the contrary, this [Insurance Contract] excludes any loss, cost, damage, liability, claim, fines, penalty or
expense or any other amount of whatsoever nature, whether directly or indirectly and/or in whole or in part, related to, caused by, contributed to by, resulting from, as a result of, as a
consequence of, attributable to, arising out of, arising under, in connection with, or in any way involving (this includes all other terms commonly used and/or understood to reflect or
describe nexus and/or connection from one thing to another whether direct or indirect):
1.1 a Communicable Disease and/or the fear or threat (whether actual or perceived) of a Communicable Disease and/or the actual or alleged transmission of a Communicable
Disease regardless of any other cause or event contributing and/ or occurring concurrently or in any sequence thereto, and
1.2 a pandemic or epidemic, as declared by the World Health Organisation or any governmental authority.
2. As used herein, Communicable Disease means: any infectious, contagious or communicable substance or agent and/or any infectious, contagious or communicable disease which
can be caused and/or transmitted by means of substance or agent where:
2.1 the disease includes, but is not limited an illness, sickness, condition or an interruption or disorder of body functions, systems or organs, and
2.2 the substance or agent includes, but is not limited to, a virus, bacterium, parasite, other organism or other micro-organism (whether asymptomatic or not); including any variation or
mutation thereof, whether deemed living or not, and
2.3 the method of transmission, whether direct or indirect, includes but not limited to, airborne transmission, bodily fluid transmission, transmission through contact with human fluids,

HDFC ERGO General Insurance Company Limited. UIN NO.: IRDAN125RP0003V01202021. 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. Policy Issuing/ Customer Happiness Center: D-301, 3rd Floor, Eastern Business
District LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on www.hdfcergo.com for
policy copy/tax certificate/make changes/register & track claim. Trade Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company under license.
HDFC ERGO - Bharat Griha RakshaI HE/CL/Fire/20-21/227.
HDFC ERGO General Insurance Company Limited
0 21
Bharat Griha Raksha

waste or the like, transmission from or to any surface or object, solid, liquid or gas or between organisms including between humans, animals, or from any animal to any human or from
any human to any animal, and
2.4 the disease, substance or agent is such
2.4.1 that causes or threatens damage or can cause or threaten damage to human health or human welfare, or
2.4.2 that causes or threatens damage to or can cause or threaten damage to, deterioration to, contamination of, loss of value of, loss of marketability of or loss of use or usefulness of,
tangible or intangible property.
For avoidance of doubt, Communicable Disease includes but is not limited to Coronavirus Disease 2019 (Covid -19) and any variation or mutation thereof.
3. For further avoidance of doubt, any contingent or other business interruption loss, cost, damage, loss of income, loss of use, increased cost of working and/or extra expense arising
out of or attributable to:
3.1 any partial or complete closure of and/or slowdown in, including but not limited to any closure by or under the advisories of public, military, government or civil authorities, or any
denial of access to insured premises, or customer and or supplier premises (including service / utility providers), or
3.2 change in consumer behaviour, or
3.3 an absence of infected employees or employees suspected of being infected shall not be covered by this [Insurance Contract]
4. For still further avoidance of doubt, loss, cost, damage, liability, claim, fines, penalty or expense or any other amountexcluded hereby, includes but is not limited to any cost to
identify, clean-up, detoxify, disinfect, decontaminate, mitigate, remove, evacuate, repair, replace, monitor, sanitize or test: (1) for a Communicable Disease or (2) any tangible or
intangible property covered by this [Insurance Contract] that is affected by such Communicable Disease.
5. It is clarified that (1) no other prior, concurrent or subsequent provision, clause, term or exception of this [Insurance Contract] (including (but not limited to) any prior, concurrent or
subsequent endorsement and/or any provision, clause, term, buy back or exception that operates, or is intended to operate, to extend the coverage of, or protections provided by, this
[Insurance Contract] by whatever name called like any coverage extension, additional coverage, global extension, exception to any exclusion); (2) no change in the law, clause or
similar provision; (3) no follow the fortunes clause or similar provision; and/or (4) no change in the law or any regulation (to the extent permitted by applicable law), shall operate to
provide any insurance, coverage or protection under this [Insurance Contract] that would otherwise be excluded through the exclusion set forth in this [Endorsement][Clause].
6. If the [Insurer] alleges that by reason of this [Endorsement][Clause] any amount is not covered by this [Insurance Contract] the burden of proving the contrary shall rest in the
[Insured].
Sanction and Embargo Clause
No (re)insurer shall be deemed to provide cover and no (re)insurer shall be liable to pay any claim or provide any benefit hereunder to the extent that the provision of such cover,
payment of such claim or provision of such benefit would expose that (re)insurer to any sanction, prohibition or restriction under United Nations resolutions or the trade or economic
sanctions, laws or regulations of the European Union, United Kingdom or United States of America.
Details for PA Cover
Insured Name Insured DOB
Spouse Name Spouse DOB
Nominee Name Nominee Relation
Intermediary Name
Intermediary Code 200278133519
For Claim/Policy related queries call us at +91- 22 6234 6234/+91- 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim.
Address 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri(E), Mumbai 400 059.
If the premium is not realised the policy shall be void from inception. Please note that any misrepresentation, non-disclosure or withholding of material facts will lead to cancellation of policy ab initio with forfeiture of
premium and non-consideration of claim, if any.
" The stamp duty of ` 0.50 paid by Demand Draft, vide Receipt/Challan no. LOA/CSD/303/2022/1381 dated 28/03/2022 as prescribed in Government of Maharashtra Order No. Mudrank-2017/CR.97/M-1, dated
the 09th January 2018".
GST Registration No: 27AABCL5045N1Z8 . GST for this invoice is not payable under reverse charge basis.
Branch :leela business park, 6th flr, andheri - kurla rd, mumbai
For HDFC ERGO General Insurance Company Ltd.

Authorized Signatory
"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings

HDFC ERGO General Insurance Company Limited. UIN NO.: IRDAN125RP0003V01202021. 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. Policy Issuing/ Customer Happiness Center: D-301, 3rd Floor, Eastern Business
District LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on www.hdfcergo.com for
policy copy/tax certificate/make changes/register & track claim. Trade Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company under license.
HDFC ERGO - Bharat Griha RakshaI HE/CL/Fire/20-21/227.
HDFC ERGO General Insurance Company Limited
0 21
Bharat Griha Raksha

Details of Insurerd Details of Insurer

Insured Name : SOURABH DAS Insurer Name : HDFC ERGO General Insurance Company Limited
Correspondance : Rangamatia , BhubaneshwarNear Mancheswar Railway Branch Address : LEELA BUSINESS PARK, 6TH FLR, ANDHERI - KURLA
Address StationC-309,DHPL SAHOO RESIDENCYKHORDA, ODISHA RD, MUMBAI, 400059.
-751017 GSTIN : 27AABCL5045N1Z8
Billing Address : C309DHPLSAHOORESIDENCY,
RANGAMATIABHUBANESHWAR,
NearMancheswarRailwayStation, BHUBANESHWAR,
KHORDA, ODISHA, PIN- 751017.
Place of Supply : ODISHA Policy No. : 2111101191004200
State Code : 21 Certificate No. : 2111101191004200000
PAN : Invoice No. : 2040300176821
Policy issue date / : 03/04/2022
GSTIN :
Invoice date

Premium Details (`)

CGST SGST IGST Premium Value with
S.No. Description of Services HSN Code Premium Amount Total Tax
Tax % Amount Tax % Amount Tax % Amount Tax
1 Bharat Griha Raksha 997133 814 9% 0 9% 0 18% 147 147 961
Total Invoice Value 961
Total Invoice Value (In Words) RUPEES NINE HUNDRED SIXTY-ONE AND ZERO PAISE ONLY

Whether Tax is payable on Reverse charge basis : No

For HDFC ERGO General Insurance Company Ltd

Authorised
Policy No. 2111101191004200000

HDFC ERGO General Insurance Company Limited. UIN NO.: IRDAN125RP0003V01202021. 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. Policy Issuing/ Customer Happiness Center: D-301, 3rd Floor, Eastern Business
District LBS Marg, Bhandup (West), Mumbai - 400 078. For Claim/Policy related queries call us at +91 22 6234 6234/+91 120 6234 6234 or Visit Help Section on www.hdfcergo.com for
policy copy/tax certificate/make changes/register & track claim. Trade Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company under license.
HDFC ERGO - Bharat Griha RakshaI HE/CL/Fire/20-21/227.