2809206078552500000

HDFC ERGO General Insurance Company Limited

2809206078552500000
To,

Ashish Tiwari
S/O GURU PRASAD TIWARI AIRDEEH KALOO JALALPUR, KK BAJAR
RAEBARELI UTTAR PRADESH-, 229124
Contact No : 78XXXXXXX2

Date :02/02/2024

Dear ASHISH TIWARI

Thank you for choosing HDFC ERGO as your preferred insurance partner. We welcome you to be a part of our family !

Your Health insurance Certificate of Insurance reference no 2809206078552500000 is confirmed on the basis of the information and declaration given by
you.
The details of coverage are mentioned in the enclosed Certifcate of Insurance .

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.

Regards,

Arun Sharma
Senior Vice President Operations and Services Group

HDFC ERGO General Insurance Company Limited

Dear Ashish Tiwari,

Subject : Certificate for the purpose of deduction under section 80 D of Income Tax Act, 1961

This is to certify that we have received an amount of ` 13,869.00 (Rupees Thirteen Thousand Eight Hundred Sixty-Nine And Zero Paise Only) towards premium
for HDFC ERGO Group Health Insurance Certificate of Insurance no. 2809206078552500000 issued to Ashish Tiwari for the period 01/02/2024 to 31/01/2025.
Note:

1. This is subject to the provisions of Section 80D of income tax (Amendment) 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 policy holder.

Date : 01/02/2024 For HDFC ERGO General Insurance Company Ltd.

Policy Issuing Office: Mumbai

Duly Constituted Attorney

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLGP24095V022324,HDFHLGA24091V012324. Customer Service Address: D 301, 3rd
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Floor,
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
 2809206078552500000
HDFC ERGO General Insurance Company Limited
Certificate of Insurance
Certificate No. 2809 2060 7855 2500 000
HDFC ERGO Group Health Insurance

2809206078552500000

Certificate No. : 2809 2060 7855 2500 000 Issuance Date : 01/02/2024
Period of Insurance : From 01/02/2024 11:38 hrs To 31/01/2025 Midnight
Invoice No. : 206078552500000 Premium Frequency : Single
Proposer Name : Mr Ashish Tiwari Policy Type : Family Floater
HSN Code : 997133 Territory Limit : India
MR ASHISH TIWARI Customer Id:102050467395 PAN No.
S/O GURU PRASAD TIWARI AIRDEEH KALOO JALALPUR, KK
Master Policy Holder Name: HDFC BANK LIMITED GST No.
BAJAR RAEBARELIUTTAR PRADESH-, 229124
Contact No : 78XXXXXXX2 Master Policy No. 2999205754858000000 Customer UIN : 191391670
Residential Status Loan Amount : NA
Loan Tenure in Month : NA
Payment Details : 91124020100179, Date : 01/02/2024, Bank Name :Hdfc bank ltd
Email ID : arxxxxxx92@gxxxx.com

Insured Person's Details

Aggregate Base Sum Cumulative Personal Critical Co 1st Policy
Insured's Name Gender Date of Birth Age. Relation Member Id
Deductible Insured (Rs.) Amount Accident- SI Illness-SI Payment% Inception Date
Ashish Tiwari M 09/01/1992 32 Self NA NA 0 GC00298949
Rekha Tiwari F 11/12/1998 25 Wife NA NA 0 GC00298950
0 1021000 0
Dependent
Arnika tiwari F 09/04/2023 0 NA NA 0 GC00298951
Daughter
Nominee Details
Insured's Name Pre-existing disease Nominee Name Nominee Relationship Appointee Name Appointee Relation
Ashish Tiwari No Rekha Tiwari Spouse
Rekha Tiwari No Ashish Tiwari Spouse
Arnika tiwari No Ashish Tiwari Child
The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee

Coverage Details & Sum Insured (`)

Benefit Details
Specific Illness Waiting Period 24 months
30 days Waiting Period Applicable
Alternative Treatment 100 % of Sum Insured Covered
Restore Benefit Applicable
Cumulative Bonus 10 % Subject to Max 100 %
Air Ambulance India only At Actuals
Home Healthcare Covered upto Base Sum Insured
Convalescence Benefit 10000
Home Nursing Cover 1000 per day upto15 days
Unlimited Restore Benefit Applicable
Doctor Consultation In Person Covered upto Investigation Covers Pathology and Radiology SI
Investigation Covers Pathology and Radiology 10000
General waiting Period 30 Days
Pharmacy Covered upto Investigation Covers Pathology and Radiology SI
Medical Expenses 1000000
Pre-Hospitalization Medical Expenses Cover 90 days
Post-Hospitalization Medical Expenses Cover 180 days
Domiciliary Hospitalization Covered Upto Sum Insured
Organ Donor Expenses Covered Upto Sum Insured
Day Care Treatment Covered Upto Sum Insured
Road Ambulance Cover Rs.5000
Preexisting disease waiting period 24 months
Please read the Policy Wording in conjunction with the Certificate of Insurance. For any clarification, please call our Customer service number.
HDFC ERGO Group OPD Care (Add-on) claim process
Please Go To Self Help Page, Select Claims Tab, Authenticate yourself ,Select the policy with above cover and proceed with the service
Premium Details (`)
Particulars Arnika tiwari Ashish Tiwari Rekha Tiwari
Base Premium (A) 3291 4231 4231
Loading (B) 0 0 0
Total Premium (C=A+B) 3291 4231 4231
Goods & Service Tax (GST) 2116
Grand Total - Premium excluding GST 11753
Grand Total - Premium including GST 13869
Special Condition :

1. Alternative Treatment : Alternate Medical expenses incurred for in-patient treatment taken under Ayurvedic Unani ,Sidha,Homeopathy Provided that
the treatment has been undergone in a Ayush Hospital and is prescribed by Medical Practitioner

General Exclusion

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLGP24095V022324,HDFHLGA24091V012324. Customer Service Address: D 301, 3rd
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Floor,
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
 2809206078552500000
HDFC ERGO General Insurance Company Limited
Certificate of Insurance
HDFC ERGO Group Health Insurance

1. Congenital external diseases, defects or anomalies

2. Expenses related to any admission primarily for diagnostic and evaluation
3. OPD treatment War or any act of war, invasion, act of foreign enemy, Nuclear, Chemical or Biological attack or weapons, radiation of any kind.
4. Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of Medically
Necessary Treatment.
5. Any Insured Person committing or attempting to commit intentional self-injury or attempted suicide or suicide
6. Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof
Adress 6th Floor, Leela Business Park, Andheri-Kurla Road, Andheri(E), Mumbai 400 059.
For any other query call 022 - 6234 6234 / 0120 - 6234 6234 or write to us at healthclaims@hdfcergo.com to register & track claim.
If the premium is not realised the policy shall be void from inception.
Consolidated stamp duty for this Insurance Policy is paid by Demand Draft, vide Receipt/Challan noNO.LOA/ENF-1/CSD/34/2023/6045 dated 27/12/2023 as prescribed in
Government of Maharashtra Order No. Mudrank-2017/CR.97/M-1, dated the 09th January 2018". . Goods & Services Tax Registration No: 27AABCL5045N1Z8
GST for this invoice i s not payable under reverse charge basis. 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
Branch :leela business park, 6th flr, andheri - kurla rd, mumbai

For HDFC ERGO General Insurance Company Ltd

Agent Name : HDFC BANK LTD

Agent Code : 201587086428 Tel No. : 91-22-61606161
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 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 UIN: HDFHLGP24095V022324,HDFHLGA24091V012324. Customer Service Address: D 301, 3rd
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Floor,
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
 2809206078552500000
HDFC ERGO General Insurance Company Limited
Certificate of Insurance
HDFC ERGO Group Health Insurance

HDFC ERGO General Insurance Company Limited 0

Policy No.:2809206078552500000 This card is for identification purpose only.
Valid From: 01/02/2024 Renewal Date: 31 January
Card has to be presented to the Network Service Provider at the time of admission/ availing
cashless hospitalization o r any other services. Insurance claim will be processed in accordance
Insured Name Date Of Birth Gender
with the policy term & conditions. Card does not guarantee cashless hospitalization or any other
service. For more details and updated list of Network Service Provider please refer our website or
Ashish Tiwari 09/01/1992 M call our call centre. This card is valid till the time policy is active.

Rekha Tiwari 11/12/1998 F

Customer Service No : 022 - 6234 6234 / 0120 - 6234 6234
Arnika tiwari 09/04/2023 F
Email : healthclaims@hdfcergo.com
Processing Centre : 6th Floor, Leela Business Park, Andheri-Kurla Road,
Andheri(E), Mumbai 400 059.
Website : www.hdfcergo.com

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLGP24095V022324,HDFHLGA24091V012324. Customer Service Address: D 301, 3rd
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Floor,
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
 2809206078552500000
HDFC ERGO General Insurance Company Limited

e-Enrollment Form for HDFC ERGO Group Health Insurance

Certificate No. : 2809 2060 7855 2500 000 Issuance Date : 01/02/2024
Period of Insurance : From 01/02/2024 11:38 hrs To 31/01/2025 Midnight
Invoice No. : 206078552500000 Premium Frequency : Single
Proposer Name : Mr Ashish Tiwari Policy Type : Family Floater
HSN Code : 997133 Territory Limit : India
MR ASHISH TIWARI Customer Id:102050467395 PAN No.
S/O GURU PRASAD TIWARI AIRDEEH KALOO JALALPUR, KK
Master Policy Holder Name: HDFC BANK LIMITED GST No.
BAJAR RAEBARELIUTTAR PRADESH-, 229124
Contact No : 78XXXXXXX2 Master Policy No. 2999205754858000000 Customer UIN : 191391670
Residential Status Loan Amount : NA
Loan Tenure in Month : NA
Payment Details : 91124020100179, Date : 01/02/2024, Bank Name :Hdfc bank ltd
Email ID : arxxxxxx92@gxxxx.com

Insured Person's Details

Date of Aggregate Base Sum Cumulative Personal Critical Co 1st Policy
Insured's Name Gender Age. Relation Member Id
Birth Deductible Insured (Rs.) Amout Accident- SI Illness SI Payment% Inception Date
Ashish Tiwari M 09/01/1992 32 Self NA NA 0 GC00298949
Rekha Tiwari F 11/12/1998 25 Wife NA NA 0 GC00298950
0 1021000 0
Dependent
Arnika tiwari F 09/04/2023 0 NA NA 0 GC00298951
Daughter
Nominee Details
Insured's Name Pre-existing disease Nominee Name Nominee Relationship Appointee Name Appointee Relation
Ashish Tiwari No Rekha Tiwari Spouse
Rekha Tiwari No Ashish Tiwari Spouse
Arnika tiwari No Ashish Tiwari Child
The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee

Coverage Details & Sum Insured (`)

Benefit Details
Specific Illness Waiting Period 24 months
30 days Waiting Period Applicable
Alternative Treatment 100 % of Sum Insured Covered
Restore Benefit Applicable
Cumulative Bonus 10 % Subject to Max 100 %
Air Ambulance India only At Actuals
Home Healthcare Covered upto Base Sum Insured
Convalescence Benefit 10000
Home Nursing Cover 1000 per day upto15 days
Unlimited Restore Benefit Applicable
Doctor Consultation In Person Covered upto Investigation Covers Pathology and Radiology SI
Investigation Covers Pathology and Radiology 10000
General waiting Period 30 Days
Pharmacy Covered upto Investigation Covers Pathology and Radiology SI
Medical Expenses 1000000
Pre-Hospitalization Medical Expenses Cover 90 days
Post-Hospitalization Medical Expenses Cover 180 days
Domiciliary Hospitalization Covered Upto Sum Insured
Organ Donor Expenses Covered Upto Sum Insured
Day Care Treatment Covered Upto Sum Insured
Road Ambulance Cover Rs.5000
Preexisting disease waiting period 24 months
Please read the Policy Wording in conjunction with the Certificate of Insurance. For any clarification, please call our Customer service number.
HDFC ERGO Group OPD Care (Add-on) claim process
Please Go To Self Help Page, Select Claims Tab, Authenticate yourself ,Select the policy with above cover and proceed with the service
Premium Details (`)
Particulars Arnika tiwari Ashish Tiwari Rekha Tiwari
Base Premium (A) 3291 4231 4231
Loading (B) 0 0 0
Total Premium (C=A+B) 3291 4231 4231
Goods & Service Tax (GST) 2116
Grand Total - Premium excluding GST 11753
Grand Total - Premium including GST 13869

Declaration & Warranty on behalf of all Persons Proposed to be insured

“I/We hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are true and complete in all respects to the best of my
knowledge and that I/We am/are authorized to propose on behalf of these other persons.
I/We understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurance company and that the policy will come into force
only after full receipt of the premium chargeable.
I/We further declare that I/we will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been submitted but before communication of the
risk acceptance by the company.

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLGP24095V022324,HDFHLGA24091V012324. Customer Service Address: D 301, 3rd
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Floor,
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
 2809206078552500000
HDFC ERGO General Insurance Company Limited

e-Enrollment Form for HDFC ERGO Group Health Insurance

I/We declare and consent to the company seeking medical information from any doctor or from a hospital who at anytime has attended on the life to be insured/proposer or from any past or present employer
concerning anything which affects the physical or mental health of the life to be assured/proposer and seeking information from any insurance company to which an application for insurance on the life to be
assured/proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Governmental
and/or Regulatory authority.”
Declaration & Warranty on behalf of Insurance Company
Note: The liability of the company does not commence until the acceptance of the proposal has been formally intimated to the insured and full premium has been realized by the company.
We are under no obligation to accept any proposal for insurance. The Proposer agrees that the receipt of the Proposal Form by HDFC ERGO General Insurance Company Limited along with the premium
payment does not tantamount to the acceptance of the Proposal for insurance by HDFC ERGO General Insurance Company Limited and does not result in a concluded contract of insurance. The acceptance of
the Proposal for insurance shall be at the Company's sole and absolute discretion and upon full realization of the premium payment .In the event of acceptance of the Proposal for insurance by HDFC ERGO
General Insurance Company Limited, such acceptance shall be specifically intimated to the Proposer by HDFC ERGO General Insurance Company Limited along with the date from which the insurance Cover
shall become effective. HDFC ERGO General Insurance Company Limited shall not be liable for any claim in respect of an event giving rise to a claim covered under the Policy of Insurance that has occurred
prior to policy issuance is not covered under this policy(Your proposal form will be considered after HDFCERGO General Insurance Company Limited receives premium payment.).

Fraud Warning: This policy shall be voidable at the option of the Company in the event of mis-representation, mis-description or non-disclosure of any material particulars by the Proposer. Any person who,
knowingly and with intent to fraud the insurance company or any other person, files a proposal for insurance containing any false information, or conceals or the purpose of misleading, Information concerning any
fact material thereto, commits a fraudulent insurance act, which will render the policy voidable at the sole discretion of the insurance company and result in a denial of insurance benefits

Anti-Rebating Warning: As per Section 41 of the Insurance Act 1938,as amended, the practice of rebating is prohibited, as follows: No person shall allow or offer to allow, either directly or indirectly, as an
inducement to any person to take out or renew or continue an insurance policy in respect to 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 o r renewing o r continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published
prospectus or tables of the insurer. Violation of Section41 of the Insurance Act 1938, as amended, shall be punishable with a fine which may extend to`10Lakhs.

Disclaimer : Proposal Form and Policy Schedule have been generated basis details authenticated b y proposer / insured on Online Platform of HDFC ERGO General Insurance Co Ltd. For Changes if any, kindly
visit URL https://www.hdfcergo.com/customer-care/customer-support.html and register.

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLGP24095V022324,HDFHLGA24091V012324. Customer Service Address: D 301, 3rd
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Floor,
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com