HDFC ERGO General Insurance Company Limited

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HDFC ERGO General Insurance Company Limited 2825203005751802001

2825203005751802001

2825

Dear MR SILIGAM RAMAKANTH


4-69/63/6 ROAD NO.1, VIDYARANYAPURI
KARIMNAGAR
KARIM NAGAR, TELANGANA, 505001
Contact No. 9121868969

Date :25/09/2021

Thank you for choosing HDFC ERGO as your preferred insurance partner. We welcome you to be a part of our family !
Your Health insurance policy reference no 2825203005751802001 i s confirmed on the basis of the information and declaration given by you.The details of coverage are
mentioned in the enclosed policy schedule of insurance.

As a measure of our customer convenience we have implemented a Lifetime Validity Health Card. For you, this simply means that your Health Card is valid for all subsequent
renewals and as long as your policy is active with us. Hence, you need not replace your health card every year.

We value your relationship with us and assure you our best services at all times and we look forward to serve you.
Now you can view your policy details and health card at your fingertips. Download our Mobile App now and experience convenience today!!"

For HDFC ERGO General Insurance Company Ltd.

Arun Sharma
Head - Customer Experience Management

HDFC ERGO General Insurance Company Limited


TAX CERTIFICATE

Dear Siligam Ramakanth,

Subject : Certificate for the purpose of deduction under section 80 D of Income Tax (Amendment) Act, 1986

This is to certify that we have received an amount of ` 16,633.00 towards premium for Policy No. 2825203005751802000 issued to SILIGAM RAMAKANTH for the
period 25/09/2021 to 24/09/2022.
Note : This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended from time to time.
Deduction under Section 80D can be claimed only on payment of the premium. In case where all the installment are not paid, the deduction to be claimed under section 80D will be
restricted to the proportion of the premium actually paid.In case of free look cancellation or otherwise, the benefit under this section would be nullified or prorated, as applicable.
For HDFC ERGO General Insurance Company Ltd.

Date : 22/09/2021
Policy Issuing Office: Mumbai
Duly Constituted Attorney

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFHLIP23031V062223. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited 2825203005751802001
Policy Schedule - Endorsed Copy
my:health Suraksha Policy
( Silver Smart )

2825203005751802001

Policy No. : 2825 2030 0575 1802 001 Issuance Date : 22/09/2021
Period of Insurance : From 25/09/2021 00:01 hrs To 24/09/2022 Midnight
Invoice No. : 203005751802001 Premium Frequency : Single
Proposer Name : Mr Siligam Ramakanth Policy Type : Family
MR SILIGAM RAMAKANTH HSN Code : 997133 PAN No.
4-69/63/6 ROAD NO.1, VIDYARANYAPURI KARIMNAGAR Customer Id : 101024378280
KARIM NAGAR, TELANGANA- 505001
Contact No : 9121868969

EIA No. : Not provided

Email ID : sunsiris@gmail.com
my:health Suraksha - Insured Person’s Details & Sum Insured
Insured's Relation with Gender DOB Nominee Name Nominee 1st Policy Basic Sum Tier CB Amount Unlimited Pre Existing
Name policy holder Relationship Inception Insured (`) (`) Restore Add Disease
on (Y/N)
Siligam Self Male 03/08/1980 Shireesha Wife 25/09/2019 500000 2 Tier 100000 No
No
Ramakanth
S Shireesha Wife Female 20/09/1982 S Ramakanth Husband 25/09/2019 No No
S Saanvi Dependent Female 08/03/2005 S Ramakanth Father 25/09/2019 No
No
Daughter
Unlimited Restore UIN No: HDFHLIA22188V012122
Schedule of Coverage
Section Covers Details/ Applicability of Sum Insured Limit
Base Covers
A Hospitalization Cover up to Basic Sum Insured including cumulative Bonus Basic Sum Insured and CB
Medical Expenses Basic Sum Insured and CB
1B Mental Healthcare Basic Sum Insured and CB
2 Home Healthcare Basic Sum Insured and CB
3 Domiciliary Hospitalization Basic Sum Insured and CB
4 Pre-Hospitalization 60 Days
5 Post-Hospitalization 180 Days
6 Day Care Procedures Basic Sum Insured and CB
7 Road Ambulance cover Sub limited within the Basic Sum Insured including SI 1 to 5 L -2,000
Cumulative Bonus SI 6 to 50 L -3,500
SI Above 50 L -15,000
8 Organ Donor Expenses upto Basic Sum Insured including cumulative Bonus Basic Sum Insured and CB
9 Alternative Treatment upto Basic Sum Insured including cumulative Bonus Basic Sum Insured and CB
C1 Preventive Health Check Up -Booster over and above the Basic Sum Insured Covered Up to 1% of Basic Sum Insured max
upto Rs 5,000, on every renewal
C5 Recovery Benefit over and above the Basic Sum Insured 5000
C6 Sum Insured Rebound over and above the Basic Sum Insured Upto 100% of Basic Sum Insured
C11 Waiting Period Modification Option Reduction in the standard waiting period as opted for 3 Years
Renewal Benefits
1 Cumulative Bonus Applicable
2 my:health Active Applicable
Waiting Periods
Sec E 1 i - General waiting period - 30 days from Policy inception date
Section A Hospitalization Cover Sec E 1 ii - Listed illness & procedures - 24 Months
Sec E 1 iii - Preexisting conditions - 36 Months
Premium Details (`)
Basic Premium 14095.86
Medical U/W Loading + 0
Total Premium (Insured) excluding Tax 14096.00
Tax as Applicable 2537.00
Total Premium (Including Taxes) 16633.00

Endt No List of Endorsements Description Effective Date


001 General Endorsement 25/09/2021
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.
The policy is valid subject to payment received by us. 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 noLOA NO. CSD/418/2022/3270 dated 27/07/2022 as prescribed in Government of Maharashtra Order No. Mudrank-2017/CR.97/M-1, dated the 09th January 2018;. GST
Registration No: 36AABCL5045N1Z9 .GST for this invoice is 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 :ground fl. yaikunta complex , h.no:3-1-836, cvrn rd karimnagar karim nagar

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFHLIP23031V062223. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited 2825203005751802001

Policy Schedule - Endorsed Copy

Agent Name : RAMAKANTH SILIGAM For HDFC ERGO General Insurance Company Ltd.
Agent Code : 200200063013 Tel No. : 91-9121868969

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

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFHLIP23031V062223. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited 2825203005751802001

HDFC ERGO General Insurance Company Limited 3


Policy No.:2825203005751802001 This card is for identification purpose only.
Valid From: 25/09/2021 Renewal Date: 24 September

Insured Name Date Of Birth Gender Card has to be presented to the Network Service Provider at the time of admission/ availing
SILIGAM RAMAKANTH 03/08/1980 Male cashless hospitalization o r any other services. Insurance claim will be processed in accordance
with the policy term & conditions. Card does not guarantee cashless hospitalization or any other
S Shireesha 20/09/1982 Female
service. For more details and updated list of Network Service Provider please refer our website or
S Saanvi 08/03/2005 Female
call our call centre. This card is valid till the time policy is active.

Customer Service No : 022 - 6234 6234 / 0120 - 6234 6234


: 1860 2000 600
Email : healthclaims@hdfcergo.com
Processing Centre : HDFC ERGO General Insurance Company Ltd. 5th floor,
Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
Website : www.hdfcergo.com

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN:HDFHLIP23031V062223. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com

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