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Date : 19 September 2018

Mr V Kingsley Hopper

Ars Enclave F3 Apartment No 12 Meenakshi Street

Suthanthira Colony Tambaram Sanatorium

Nr Tambaram Sanatorium Bridge

Chennai 600047

Tamil Nadu

Policy No. : 13026389

Mobile No. : 9840660941

Dear Mr V Kingsley Hopper,

Welcome to a world where what matters, above all, is your Health....Hamesha!

Welcome to a philosophy that adheres to the tested and somewhat traditional adage that caring yields the best cure; from a company that is driven
by its commitment to provide you with the very best healthcare, as much as its determination to delight and surprise you, at every given
opportunity.

We welcome you to Religare Health Insurance.

We at Religare Health Insurance are unerringly focused on providing you access to the highest quality of healthcare and putting you back on the road
to a worry-free recuperation, without a care about medical bills and other related expenses.

To help you understand our services better, please go through the 'Know your policy better' kit that accompanies this letter and constitutes the
following details:

Policy Certificate
Premium Acknowledgement
Key Policy Information
Policy Terms and Conditions
Claim Process

Also enclosed for your convenience is your Religare Health Card(s). This card should be presented at the time of an emergency or a planned
hospitalization, to access cashless treatment at our network of over 4,500+ hospitals pan-India.

To further simplify procedures, we're online as well. Visit our portal www.religarehealthinsurance.com; and view network hospitals across the
country, cashless procedures and do much more. In case of a query at any juncture, feel free to mail us at [email protected]
or call us at 1800-200-4488.

Once again, we thank you for this opportunity to serve you, and wish you and your loved ones good health always!

Team Religare Health Insurance

Religare Health Insurance Company Limited

Correspondence address : Vipul Tech Square, Tower C, 3rd Floor, Sector – 43,Golf Course Road, Gurgaon - 122009
www.religarehealthinsurance.com
 Policy Certificate

Mr V Kingsley Hopper Policy No. 13026389

Ars Enclave F3 Apartment No 12 Meenakshi Street Plan Name CARE
Cover type Floater
Suthanthira Colony Tambaram Sanatorium Policy Period - Start Date 00:00 hrs 20-Sep-2018
Nr Tambaram Sanatorium Bridge Policy Period - End Date Midnight 19-Sep-2019
Nominee Name Arumaiselvi Vincent Hopper
Chennai 600047 Premium Paid Rs. 35692
(Premium Rs 30247.56 + CGST Rs 0 + IGST Rs 5444.56 + SGST
Tamil Nadu 33 Rs 0 + UGST Rs 0)
Premium Payment Mode Single Premium
1
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Policyholder Date Of Birth Client ID

V Kingsley Hopper 24-Dec-1988 62343593

Details of Insured
Date of Birth Insured with the
Name Client ID Relationship (DD-MM-YYYY) Pre-existing diseases (since) Company (since)
Vincent Hopper Sn 62343594 Father 10-May-1959 None 20-Sep-2018
Arumaiselvi Vincent Hopper 62343595 Mother 04-Jun-1965 None 20-Sep-2018
2
Details of Cover
S No. Particulars Details
1 Sum Insured Rs. 5,00,000

Contact details for Claims & Policy Servicing

Correspondence address Religare Health Insurance Company Limited Vipul Tech Square, Tower C, 3rd Floor, Sector – 43,Golf Course Road, Gurgaon - 122009.

Contact no. 1800-200-4488

Fax no. 1800-200-6677

E-mail ID for Claims [email protected]

E-mail ID for Policy servicing [email protected]

Website www.religarehealthinsurance.com

v Intermediary Details
Name Code Contact Number

Religare Health Insurance

Direct 1860-500-4488
Co. Ltd.

for Claims & Assistance: Call 1800-200-4488

11
Schedule of Benefits
S No. Particulars Basis of Offering
1 Hospitalization Expenses (In-patient Care and Day Care Treatment) Room Category = Single Private Room

Pre-hospitalization up to 30 days before & Post-hospitalization up to

2 Pre-hospitalization & Post-hospitalization medical Expenses 60 days after hospitalization

3 Ambulance Cover Up to Rs. 2,000 per Hospitalization

4 Organ Donor Cover Up to Rs. 1,00,000 per Policy Year

Up to 10% of the Sum Insured per Policy Year, with a deductible of

5 Domiciliary Hospitalization first 3 days

6 Automatic Recharge One re-instatement of up to Sum Insured per Policy Year

7 Second Opinion Once per Policy Year per Insured Person for each major illness/injury

8 Alternative Treatments Up to Rs. 20,000 per Policy Year

10% of Sum Insured for each Claim free year, maximum upto 50% of
9 No Claims Bonus Sum Insured; reduced by 10% of Sum Insured in case of claim

10 Annual Health Check-up One Health Check-up per Insured Person per Policy Year

50% of Sum Insured for each Claim free year, maximum upto 100% of
11 No Claim Bonus - SUPER (Add-on Cover) Sum Insured; Reduced by 50% of Sum Insured in case of Claim

Optional Cover
S No. Particulars Details
1 No Claim Bonus - SUPER Applicable

1 Special Conditions
S No. Particulars
1 Co-payment (Applicable where age of member at entry is 61 years or above)

For Religare Health Insurance Company Limited

Authorized Signatory Date of Issue : 19-Sep-2018 Place of Issue : Gurgaon, Haryana

Service Branch : RHICL, Gurgaon Ho Vipul, Gurgaon , Haryana - 122009 Branch Contact No. : 1800-200-4488
Correspondence Address:
Religare Health Insurance Company Limited
Vipul Tech Square, Tower C, 3rd Floor, Sector – 43,Golf Course Road, Gurgaon - 122009 Contact No : 1800-200-4488 Fax:1800-200-6677
Website : www.religarehealthinsurance.com Email : [email protected]
Consolidated Stamp Duty paid vide E-Challan GRN no. 0037428096 dated 27 Jul 2018, RCM Applicability- N/A
SAC: 997133 and Description of Service: Accident and Health Insurance Services State GSTIN No.: 06AADCR6281N1ZW IRDA Registration Number - 148 UIN :
IRDAI/HLT/RHI/P-H/V.II/253/16-17
Registered office address : 5th Floor, 19 Chawla House, Nehru Place, New Delhi - 110019
CIN : U66000DL2007PLC161503
Note:
Attached with this Policy Certificate are the Policy terms and conditions, Optional Covers (if opted) and Annexures. Please ensure that these documents have been received, ead and understood. If any of these
documents have not been received, please email at [email protected] or contact the Company at 1800-200-4488 / 1860-500-4488.
For waiting periods and exclusions under this Policy, please refer to Clause 4 of the Policy terms and conditions.
This Policy Certificate in original must be surrendered to the Company in case of cancellation of the Policy.
13026389

62343594 10-May-1959 VINCENT HOPPER SN

62343595 04-Jun-1965 ARUMAISELVI VINCENT HOPPER
NB
1

Premium Acknowledgement

Policy No. 13026389

Client ID 62343593
Policyholder Mr V Kingsley Hopper
Address Ars Enclave F3 Apartment No 12 Meenakshi Street
Suthanthira Colony Tambaram Sanatorium
Nr Tambaram Sanatorium Bridge
Chennai 600047, Tamil Nadu
Policy Period 20-Sep-2018 to 19-Sep-2019

Premium Details
Particulars Amount (in Rs.)

Gross Premium
Care 25,206.30

-NCB-Super 5,041.26

Goods & Services Tax (GST) 5,444.56

Total 35,692.00

The Premium is rounded off to the nearest rupee.

Eligibility of Premium for Deduction u/s 80D of the Income Tax Act, 1961

This is to certify that Religare Health Insurance Co.Ltd. has received an amount of Rs. 35,692.00/- from Mr V Kingsley Hopper
towards Payment of Health insurance premium as per the details mentioned above. The premium paid for this policy is eligible for
applicable tax benefits u/s 80D of the Income Tax Act, 1961 and amendments thereof.

For Religare Health Insurance Company Limited

Authorized Signatory Date of Issue: 19-Sep-2018 Place of Issue: Gurgaon, Haryana

IRDA Registration Number - 148

Registered office address : 5th Floor, 19 Chawla House, Nehru Place, New Delhi - 110019
CIN : U66000DL2007PLC161503

Note
1) In case of any discrepancy, the Policyholder is requested to contact the Company immediately.
2) Any amount paid in cash towards the premium would not qualify for tax benefits as mentioned above.
3) This document must be surrendered to the Company in case of Cancellation of the Policy or for the issuance of a fresh certificate in the case of any alteration in the Policy.
 2

Proposal Form-'CARE'

Dear Mr V Kingsley Hopper

In reference to your online proposal (1120006351179) for 'Care'- Comprehensive Health Insurance policy, please find below the details as provided
by you:

Proposer Details

Name : MR V KINGSLEY HOPPER

Address : Ars Enclave F3 Apartment No 12 Meenakshi Street

Suthanthira Colony Tambaram Sanatorium
Nr Tambaram Sanatorium Bridge
Chennai-600047
Tamil Nadu

Date of Birth : 24/12/88

Landline :

Mobile : 9840660941

E-mail : [email protected]

Details of the Persons be Insured

Name Date of Birth Relation Pre-existing Diseases

Vincent Hopper SN 10/05/59 FATHER NONE
ArumaiSelvi Vincent Hopper 04/06/65 MOTHER NONE

Additional Details
A. Does any person(s) to be insured has any pre-existing diseases?

Insured 1 Insured 2
No No
B. Have any of the person(s) to be insured ever filed a claim with their current/previous insurer?

Insured 1 Insured 2
No No

C. Has any proposal for Health insurance been declined, cancelled or charged a higher premium?

Insured 1 Insured 2
No No

D. Is any of the person(s) to be insured, already covered under any other health insurance policy of Religare Health Insurance?

Insured 1 Insured 2
No No
 You agreed to following terms & conditions of the purchase of policy
a. I have read and understood the brochure/prospectus/sales literature/Terms and Conditions of the Policy and confirm to abide by the same.
b. Receipt of proposal form by the Company shall not be construed as acceptance of proposal. Commencement of risk under the Policy shall be subject to realization of full
premium and individual underwriting by the Company. The Company at its sole discretion reserves the right to accept or reject or load any proposal. Policy would start
from the date as specified in the Policy Certificate.

c. I understand that the Policy Period Start Date as specified in the Policy Certificate shall be from the 00:00 hours of the next day of the Proposal receipt at branch,
proposed policy period start date as opted by me or cheque date, whichever is later.

d. I understand that the Policy shall become void at the Company's option, in the event of any untrue or incorrect statement, misrepresentation, non-description or
non-disclosure of any material fact, in the proposal form/personal statement, declaration and connected documents or any material information having been withheld by
me or anyone acting on my behalf.

e. I hereby declare that the lives proposed to be insured would submit to medical examinations before the nominated doctors of the Company or undergo diagnostic or
other medical tests, as suggested by the Company for its underwriting.
f. I consent to and authorize the Company and/or any of its authorized representative agents to seek medical information from any hospital/medical practitioner or any other
related entity that I have attended or may attend in future concerning any illness or injury.
g. I consent to provide a valid age proof and identity proof at the time of claims or any other time when required by the Company. h.I authorize the Company to exchange,
share or part with the information relating to myself/person(s) to be insured with any external entity other than regulatory and statutory bodies, as may be required and I
will not hold the Company or its agents liable for use/sharing of this information.

h. I authorize the Company to exchange, share or part with the information relating to myself/person(s) to be insured with any external entity other than regulatory and
statutory bodies, as may be required and I will not hold the Company or its agents liable for use/sharing of this information.
i. I/We agree and undertake to convey to the Company any change/alterations carried out in the risk proposed for insurance after submission of this proposal form.
j. I/We consent to receive information from the Company the through physical, electronic or telecommunication means from time to time.

the undersigned hereby declare on my behalf and on behalf of each of the persons proposed to be insured that the above statements and particulars are true, accurate and
complete and correct in all respects and that there is all information which is relevant to this proposal that has been disclosed and not withheld from the Company. I declare
that the money used to make the premium payment has not been derived from any illegal activity or unaccounted funds. I further declare and agree that this declaration and
the answers given above shall be held to be promissory and shall be the basis of the contract between me/us and the Company.

You also agreed to receive service SMS and E-mail alerts.

Signature Not
Verified
Digitally signed by
MANISH DODEJA
Date: 2018.09.19
16:33:14 IST
Reason: I'm the author
Location: India

Religare Health Insurance Company Limited

Correspondence address : Vipul Tech Square, Tower C, 3rd Floor, Sector – 43,Golf Course Road, Gurgaon - 122009
Website : www.religarehealthinsurance.com E-mail : [email protected] UIN: IRDAI/HLT/RHI/P-H/V.II/253/16-17 Call Us : 1800-200-4488