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Date : 22 January 2021

Ms Samla Bal Markam

Forest Range Office Bajag

Village Midli Bajag

Dindori

Dindori 481882

Madhya Pradesh

Policy No. : 19743223

Mobile No. : 8224096299

Dear Ms Samla Bal Markam,

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 Care Health Insurance.

We at Care 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 Care 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.careinsurance.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
1800-102-4488.

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

Team Care Health Insurance

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Policy Certificate
Ms Samla Bal Markam Policy No. 19743223
Plan Name POS CARE
Forest Range Office Bajag
Cover type Individual
Village Midli Bajag Policy Period - Start Date 00:00 hrs 23-Jan-2021
Policy Period - End Date Midnight 22-Jan-2022
Dindori Nominee Name Saroj Markam
Nominee Relationship (Daughter)
Dindori 481882 Premium Paid Rs. 13049
(Premium Rs 11058.3 + CGST Rs 995.24 + IGST Rs 0 + SGST Rs
Madhya Pradesh 23 995.24 + UGST Rs 0 + Kerala Flood Cess Rs 10729.25)
Premium Payment Mode Single Premium

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Policyholder Gender Date Of Birth Client ID

Samla Bal Markam Female 01-Jan-1973 83525979

Details of Insured
Date of Birth Insured with the Sum Insured
Name Client ID Relationship (DD-MM-YYYY) Pre-existing diseases (since) Company (since)
Samla Bal Markam 83525979 Member 01-Jan-1973 None 23-Jan-2021 5,00,000.00

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Contact details for Claims & Policy Servicing
Correspondence address Care Health Insurance Limited
(Formerly known as Religare Health Insurance Company Limited)
Unit no 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector 39, Gurgaon -122001.(HARYANA)

Contact no. 1800-102-4488

Fax no. 1800-200-6677

E-mail ID for Claims [email protected]

E-mail ID for Policy servicing [email protected]

Website www.careinsurance.com

Intermediary Details
Name Code Contact Number

Shreyansh Pol 20332637 7777880211

POS Details
Name PAN No. Contact Number

RMPORTAL 481882

for Claims & Assistance: Call 1800-102-4488

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

00 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
Additional 20% Co-payment applicable for all claims made in Non
2 Smart Select Smart Select Network Hospitals.
Special Conditions
S No. Particulars
1 Co-payment (Applicable where age of member at entry is 61 years or above)
For Care Health Insurance Limited
(Formerly known as Religare Health Insurance Company Limited)

Authorized Signatory Date of Issue : 22-Jan-2021 Place of Issue : Gurgaon, Haryana

Service Branch : CHIL, 1193, Weight Town Behind Icici Bank, Chanchal Bai College Road Bhawani Prasad Tiwari Ward, Wright Town, Golbazar, Jabalpur, Madhya Pradesh - 482001 Branch Contact
No. : 1800-102-4488
Correspondence Address:
Care Health Insurance Limited
(Formerly known as Religare Health Insurance Company Limited)
Unit no 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector 39, Gurgaon -122001.(HARYANA) Contact No : 1800-102-4488
Website : www.careinsurance.com Email : [email protected]
Consolidated Stamp Duty paid vide E-Challan GRN no. 69910718 dated 02 Dec 2020, RCM Applicability- N/A
SAC: 997133 and Description of Service: Accident and Health Insurance Services State GSTIN No.: 23AADCR6281N1Z0 IRDA Registration Number - 148 UIN : RHIHLIP21017V052021
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 1800-102-4488 / 1800-102-6655.
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.
19743223

83525979 01-Jan-1973 SAMLA BAL MARKAM

NB
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Premium Acknowledgement

Policy No. 19743223

Client ID 83525979
Policyholder Ms Samla Bal Markam
Address Forest Range Office Bajag
Village Midli Bajag
Dindori
Dindori 481882, Madhya Pradesh
Policy Period 23-Jan-2021 to 22-Jan-2022

Premium Details
Particulars Amount (in Rs.) S.no. Receipt Number Amount Mode of Payment
1 32954561 13049 INTERNET PAYMENT GATEWAY (IPG)
Gross Premium
POS Care 9,215.25

-NCB-Super 1,843.05

Goods & Services Tax (GST) 1,990.48

Total 13,049.00

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 Care Health Insurance Ltd. (Formerly known as Religare Health Insurance Company Limited) has received an
amount of Rs. 13,049.00/- from Ms Samla Bal Markam 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 Care Health Insurance Limited

(Formerly known as Religare Health Insurance Company Limited)

Authorized Signatory Date of Issue: 22-Jan-2021 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.
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Proposal Form-'POS CARE'

Dear Ms Samla Bal Markam

In reference to your online proposal (1120017485950) for 'Care'- Comprehensive Health Insurance policy, please find below the details as provided
by you:

Proposer Details

Name : MS SAMLA BAL MARKAM

Address : Forest Range Office Bajag

Village Midli Bajag
Dindori
Dindori-481882
Madhya Pradesh

Date of Birth : 01/01/73

Landline :

Mobile : 8224096299

E-mail : [email protected]

Details of the Persons be Insured

Name Date of Birth Relation Pre-existing Diseases

SAMLA BAL MARKAM 01/01/73 MEMBER NONE

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

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

Insured 1
No

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

Insured 1
No

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

Insured 1
No
E. Does your job require you to be involved with any hazardous activity, significant manual labor, operating heavy machinery, handling hazardous
material, working at heights / underground / construction sites, oil rigging, high voltage, high temperature, working in aircrafts or sea-going vessels or
adventure sports or armed forces?
Insured 1
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: 2021.02.13
07:13:42 IST
Reason: I'm the author
Location: India