BlueDart / / M-3680

Policy No. : 7000033583 00

Name : SABITA MAHAPATRA
Address : C/O PRAVAKAR MAHAPATRA
AT BARUNEI SAHI PO KHORDA
KHORDA
KHORDHA - KHORDHA
ORISSA - 752055
9833580873

Dear Customer,

We are glad that you thought ahead and did the right thing by continuing your trust with Tata AIG MediCare,
7000033583. We value your relationship with us and appreciate your confidence in our services. We will not compromise
on your health insurance and neither should you. We will strive to serve you the best.

Please find the following documents along with letter in the parcel.

• Policy schedule
• Premium payment receipt
• 80d certificate
• Customer Information Certificate

For further queries you can visit our website www.tataaig.com or contact us on our Toll Free No.: 1800 266 7780/ For
Senior Citizens: 1800 22 9966.

For Tata AIG General Insurance Company Limited

Authorized Signatory

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before
concluding a sale.

TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower
Parel, Mumbai 400013. IRDA Registration No.108, CIN No : U85110MH2000PLC128425, PAN : , UIN No : TATHLIP21224V022021
Website: www.tataaig.com 24X7 Tollfree Helpline 18002667780 Email:customersupport@tataaig.com
Policy No. 7000033583 / M-3680 Page No. 1
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Policy
Schedule } Intermediary name
Intermediary code
: PROBUS INSURANCE
BROKERPRIVATELIMITED
: 150
Intermediary contact no. : 1126521101(mobile or landline)

Issuing Office : MUMBAI

Client Id : 6099677256
Proposal no : IDV000055148
Policy holder’s name : SABITA MAHAPATRA

Policy holder’s address : C/O PRAVAKAR MAHAPATRA

AT BARUNEI SAHI PO KHORDA
KHORDA
KHORDHA,752055
KHORDHA ORISSA
9833580873

Insured GST No :
Place of Supply : ORISSA
Supply Code : 21

Policy Number : 7000033583 00

Product name : Tata AIG MediCare
Plan type : Individual Basis
Policy period : From 21/12/2022 00:00 hrs to 20/12/2024 on 11:59 PM
Business Type : RENEWAL BUSINESS
Policy Tenure : 2 Years
Insured Persons Details :
Member Insured Insured Date Age Relation- Restore Sum Cumu- Accidental
ID person’s with TATA of Birth ship to Benefits Insured lative Death
name AIG General proposer % (Rs.) Bonus (Rs.)
Insurance (Rs.)
Co. Since
IDV0000551480 SABITA
21/12/2021 10/09/1971 51 Self 100 1,000,000.00 500 000.00 0.00
1050 MAHAPATRA
*For Family Floater policy, Sum Insured and cumulative bonus floats among the insured members of the family as mentioned above. This shall not be
applicable for newly added members in this policy.

# Sum Insured mentioned is excluding cumulative bonus. Earned cumulative bonus is separately mentioned
Nominee Details for Proposer:
Insured Name Nominee Name Relationship to Proposer
SABITA MAHAPATRA SHAKTIPADA MAHAPATRA Sister
The nominee must be an immediate relative of the policyholder. For all other insured persons the policyholder shall be the nominee.

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before
concluding a sale.

TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower
Parel, Mumbai 400013. IRDA Registration No.108, CIN No : U85110MH2000PLC128425, PAN : , UIN No : TATHLIP21224V022021
Website: www.tataaig.com 24X7 Tollfree Helpline 18002667780 Email:customersupport@tataaig.com
Policy No. 7000033583 / M-3680 Page No. 2
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Benefits table
Net Premium: (Rs) 41097.00
Cover Coverage
Discounts: (Rs) 1957.00
Loading: (Rs) 3914.00
In-Patient Treatment Upto Sum Insured
UGST/SGST (9%): (Rs)
Pre-Hospitalization expenses Upto 60 days CGST(9%): (Rs)
IGST(18%): (Rs) 7397.46
Post-Hospitalization expenses Upto 90 days Gross Premium: (Rs) 48494.00
Gross Premium amount(in words) : Rupees Forty Eight
Day Care Procedures Upto Sum Insured Thousand Four Hundred And Ninety Four and Paise 00 Only

Organ Donor Upto Sum Insured

Domiciliary Treatment Upto Sum Insured

Claim Servicing Details:
Global cover Upto Sum Insured n Name : TAGIC Health Claims
n Website: www.tataaig.com
Bariatric Surgery Cover Upto Sum Insured
n Email: healthclaimsupport@tataaig.com
In-Patient Treatment - Dental Upto Sum Insured n Toll Free: 1800 266 7780 or 1800 229 966 (For
Senior Citizens)
Restore benefit Upto Sum Insured n Claims TATA AIG General Insurance Company
Administrator Limited,
Address: 5th and 6th Floor, Imperial Towers,
AYUSH Benefit Upto Sum Insured H.No 7-1-6-617/A, GHMC No - 615,616,
Ameerpet, Hyderabad – 500016, Telangana.
Upto Rs. 3000 per
Ambulance Cover
Hospitalization
Upto 1% previous year Stamp Duty Registration Details
Health Checkup Sum Insured; max.
Rs.10,000 per policy The stamp duty of Rs.100.00/- paid in cash or demand draft or
by pay order,vide Receipt/Challan no:LOA-
Upto Rs.5000 per NO.CSD/434/2022/3588 dated the 18/08/2022
Vaccination cover
policy
50% of actuals;
Hearing Aid maximum Rs.10,000
per policy
Daily Cash for choosing 0.25% of base Sum For Tata AIG General Insurance Co. Ltd.
Shared Accommodation Insured; maximum
(If applicable) Rs. 2000 per day
0.25% of base Sum Authorized Signatory
Daily Cash for Accompanying
Insured; maximum In the event of non-realization of premium, the
an Insured Child Company shall not be liable under the policy and the
Rs. 2000 per day
policy shall stand cancelled ab initio (from inception).
Upto Rs.20,000 per
Compassionate travel policy year
Policy Servicing Address :
Consumables Benefit Upto Sum Insured A-6, 6th Floor, Trade World,Kamala Mills Compound,
Senapati Bapat Marg, Lower Parel, Mumbai-400013 Tel
Second Opinion Covered No: 022-66382333 Fax No: 022-66382390

Room Category No restriction

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before
concluding a sale.

TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower
Parel, Mumbai 400013. IRDA Registration No.108, CIN No : U85110MH2000PLC128425, PAN : , UIN No : TATHLIP21224V022021
Website: www.tataaig.com 24X7 Tollfree Helpline 18002667780 Email:customersupport@tataaig.com
Policy No. 7000033583 / M-3680 Page No. 3
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Specific Exclusion / loading if applicable

Member ID Insured Person’s Name Pre-Existing Disease Permanent Exclusion Loading Reason Effective date for
Exclusion/loading
IDV00005514801050 SABITA MAHAPATRA Hypertension Hypertension 21/12/2021

Portability Details (If Applicable)

This Policy is in continuation with , for below mentioned members.

Name of previous Previous Insurer Sum

Member name Claim Details if any
insurer policy inception Insured

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before
concluding a sale.

TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower
Parel, Mumbai 400013. IRDA Registration No.108, CIN No : U85110MH2000PLC128425, PAN : , UIN No : TATHLIP21224V022021
Website: www.tataaig.com 24X7 Tollfree Helpline 18002667780 Email:customersupport@tataaig.com
Policy No. 7000033583 / M-3680 Page No. 4
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Certificate of Premium payment for the purpose of declaration under Section 80 D of Income Tax
(Amendment) Act, 1961*
Date: 28/11/2022
Policy Number:7000033583
Customer Name:SABITA MAHAPATRA
GSTIN no.:

Dear Sir/Madam,

Sub: Tax Benefit Letter forTata AIG MediCare policy no. 7000033583

This is to certify that premium amount of Rupees Forty Eight Thousand Four Hundred And Ninety Four Only for health
insurance Policy No 7000033583 issued to SABITA MAHAPATRA for the period 21/12/2022 to 20/12/2024 has been paid.

Receipt Illustration

Receipt ID. Name of Payer Mode of payment Amount paid

102001039316728 SABITA MAHAPATRA Online 48 494.00
Total Amount Paid 48 494.00

Premium illustration (Member wise)

Total member premium paid
Member ID Name of Member Relationship with Policyholder (Including Taxes & Loading)
IDV00005514801050 SABITA MAHAPATRA Self 48 494.46
Total Premium Paid (Inclusive of Loading & Taxes collected) 48 494.00

Financial Year wise premium bifurcation (for policy tenure more than 1 year)

Financial Year Year wise premium

2022-2023 24 247.00
2023-2024 24 247.00
Please feel free to get in touch with us for any further help or queries at our 24x7 Helpline 18002667780
(Toll-free) or email us at customersupport@tataaig.com

We assure you of our best services at all times.

Regards,
For Tata AIG General Insurance Company Limited

Authorized Signatory

Date of Issue: 28/11/2022

Place of Issue:MUMBAI

*Note
1. Tax deductions can be claimed subject to the provisions prescribed in the relevant sections of the Income-tax Act, 1961 as
amended from time to time.
2. Premium paid in advance will be applied to the policy on premium due date.
3. This premium paid certificate is conditional upon credit in company's account post clearance of the instrument/facility
including electronic mode.
4. For any confirmation / impact analysis, customer is advised to refer the matter to his/her Tax consultant.
5. This certificate must be surrendered to the company in case of cancellation of this policy. In the event of incorrect
representation of this declaration the liability shall be upon the policyholder/payer.

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before
concluding a sale.

TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower
Parel, Mumbai 400013. IRDA Registration No.108, CIN No : U85110MH2000PLC128425, PAN : , UIN No : TATHLIP21224V022021
Website: www.tataaig.com 24X7 Tollfree Helpline 18002667780 Email:customersupport@tataaig.com
Policy No. 7000033583 / M-3680 Page No. 5
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Receipt } Receipt No. : 102001039316728

Receipt Date : 22/11/2022
Policy No : 7000033583 00

Received with thanks from SABITA MAHAPATRA a sum of Rs. 48494.00 Rupees Forty Eight Thousand Four Hundred Ninety
Four And Paise Zero Only Online

Gross Premium (`) Utilized from the receipt for policy (`) Balance (`)

48494.00 48494.00 0.00

Tax Benefit
Letter } Certificate for the purpose of deduction under Section 80 D
of Income Tax (Amendment) Act, 1986*

This is to certify that the Proposer has paid Rs 48494.00 (Fourty Eight Thousand Four Hundred Ninty Four Rupees only.) towards
premium for health Policy No 7000033583 issued to SABITA MAHAPATRA for the period 21/12/2022 to 20/12/2024

For Tata AIG General Insurance Co. Ltd.

Authorized Signatory
Date of Issue : 21/12/2022
Place of Issue : MUMBAI
* Note
1. This is subject to the provisions of section 80D of the 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 the event of incorrect representation of this declaration the liability shall
be upon the policyholder.
3. This certificate will not be issued if the premium payment has been made in cash/ demand draft.

*Tax benefit is available to the Premium payer. Tax benefits are not applicable on premium made in cash. The qualifying amounts under section 80D for self, spouse and
dependent children is Rs. 25,000. In case the proposer is aged 60 years or more during any time of the financial year, the qualifying amount shall be Rs. 50,000.
Additional deduction is available if premium is paid on behalf of the parents of the proposer. However, the aggregate deduction for the premium paid for self, family and
parents will be restricted to Rs. 50,000. The premium paid would be allowed as a deduction from the total income of the Proposer/ Assessee. The Porposer/ Assessee is
requested to consult his/ her tax consultant prior to taking deduction.

Note:
1. This is a computer generated receipt and does not require a signature.
2. Upon issuance of this Receipt, all previously issued temporary receipts, if any, related to this Policy shall be
considered null and void.
3. Amounts received by cheque shall be subject to realisation.
4. Any amount received in excess of the Premium is being/shall be refunded by the Company.
Revenue (consolidated) Stamp Duty duly paid vide challan No.LOA-NO.CSD/507/4491 date for applicable cases.

MAHARASHTRA. Service Accounting Code : 997133

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before
concluding a sale.

TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower
Parel, Mumbai 400013. IRDA Registration No.108, CIN No : U85110MH2000PLC128425, PAN : , UIN No : TATHLIP21224V022021
Website: www.tataaig.com 24X7 Tollfree Helpline 18002667780 Email:customersupport@tataaig.com
Policy No. 7000033583 / M-3680 Page No. 6
SABITA MAHAPATRA, 51years, Female

M-3680 ( 1 to 0 )
Policy No. : 7000033583

Valid From : 21/12/2022

Member ID : IDV00005514801050
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Annexure to customer information sheet(CIS)- Benefit illustration in respect of policies offered on individual and family floater basis.

Age of the Coverage opted on individual Coverage opted on individual basis covering Coverage opted on family floater basis with
members basis covering each member of multiple members of the family under a single overall Sum Insured(only one sum insured
insured the family separately(at a single policy(Sum insured available for each member of available for entire family)
point of time) the family)

Premium (`) Sum Insured (`) Premium (`) Discount if Premium Sum Premium or Floater Premium Sum
any after Insured Consolidated discount after Insured (`)
Discount (`) premium for if any discount
(`) all members (`)
of the family
(`)

51 39140.00 1000000.00

Total Premium for all members of the Total Premium for all members of the family is Total Premium when policy is opted on floater
family is Rs 41097.00when each Rs_________ when they are covered under a single basis is Rs__________
member is covered separately policy

Sum Insured available for each Sum Insured available for each family member is Sum Insured of Rs____________ is available for
individual is Rs 1000000.00 Rs_________________. the entire family

Note: Premium rates specified in the above illustration shall be standard premium rates without considering any loading. Also, the
premium rates shall be exclusive of taxes applicable.

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before
concluding a sale.

TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower
Parel, Mumbai 400013. IRDA Registration No.108, CIN No : U85110MH2000PLC128425, PAN : , UIN No : TATHLIP21224V022021
Website: www.tataaig.com 24X7 Tollfree Helpline 18002667780 Email:customersupport@tataaig.com
Policy No. 7000033583 / M-3680 Page No. 8