This Document is Digitally Signed

Signer: ATUL JERATH

Date: Mon, Jun 29, 2020 07:58:07 IST
Location: NOIDA
Reason: Signing Policy for OICL

HAPPY FAMILY FLOATER-2015 POLICY SCHEDULE

UIN: IRDAI/HLT/OIC/P-H/V.II/450/15-16

Policy No. : 171600/48/2021/4190 Prev. Policy No. : 171600/48/2020/5545

Cover Note No. : - Cover Note Date : -
Insured's Code : 80536620 Issue Office Code : 171600
Insured Name : KHIMJI K. VEKARIYA (GSTIN: 0) Issue Office Name : DO 1 SURAT (GSTIN:
24AAACT0627R2Z4)
Address : 33, V.T. NAGAR, NR. NAVJIVAN Address : 3RD FLOOR, BOYCE BUILDING
HOTEL, OPP. T & TV HIGH SCHOOL,
SARTHANA JAKATNAKA, TIMALIYAWAD, NANPURA
SURAT
SURAT SURAT GUJARAT 395003
SURAT 395010
Tel./Fax/Email : 0 / / 0 / NA Tel./Fax/Email : 0261-2472321/2472271/2471277 /
0261-2471277 /
[email protected]
Agent/Broker Details
Dev.Off.Code : NZ0000000508 AGENCY MANAGER D.O. SURAT
Agent/Broker : BA0000150417 CHAUDHARI DHAVAL SURESHBHAI
Address : 1638, VARIYAV TADWADI, CHAUDHARIVAS, CHHAPARABHATHA ROAD, AMROLI, SURAT -
394107,SURAT,GUJARAT,394107
Tel/Fax/Email : 9925960873//[email protected]

Period of Insurance : FROM 00:00 ON 25/07/2020 TO MIDNIGHT OF 24/07/2021

Collection No. & Dt. : CHQ 3226004353 - 26/06/2020 GST INVOICE NO :2419161199 UIN :0
Gross Premium : 22,870 GST 4116 Stamp Duty : .5 Total : 26,986

Co-insurance Details : Nil

TPA Details :
TPA ID YA0000000371
TPA Name Health Insurance TPA of India Limited
Address : Majestic Omnia Building, 2nd floor A-110, Sector -4 NOIDA
NOIDA 201301 Toll Free No. : 1800 102 3600
Telephone No : 1800 102 3600 FAX No. : 011 49043399

Number of persons covered 2 Plan Type SILVER Plan Sum Insured 300000
Particulars of the Persons covered :
Sr. Name of The Relationship Pre-Existing
Gender Date of Age Co-Pay PA Capital
No. Persons With Diseases
Birth (%) Sum Insured (INR
Proposer

1 KHIMJI K. M 01/01/1959 61 Self 10

VEKARIYA
2 INDU VEKARIYA F 01/04/1959 61 Spouse 10
Unemployed

Place : SURAT For and on behalf of

Date : 26/06/2020 The Oriental Insurance Company Limited

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupee Page 1 of 3
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 This Document is Digitally Signed

Signer: ATUL JERATH

Date: Mon, Jun 29, 2020 07:58:07 IST
Location: NOIDA
Reason: Signing Policy for OICL

Attached to and forming part of policy number 171600/48/2021/4190

Nk
Nominee Details
Name Of the Nominee Relationship With the Insured Age Of the Nomine M/F/TG*
INDU KHIMJI Spouse Unemployed F
VEKARIYA
Optional Cover
Value
LIFE HARDSHIP BENEFIT NO
RESTORATION OF SI NO

Total Premium in words : Indian Rupees Twenty-Six Thousand Nine Hundred Eighty-Six Only

The insurance under this policy is extended to cover risks of Domiciliary Hospitalisation up to 10 % of sum insured subject to maximum Rs
50000 only ( Fifty Thousand Only).
The insurance under this policy is extended to cover risks of :
Personal Accident Cover, Domiciliary Hospitalisation Limit.
Deductible : Nil
The insurance under this policy is subject to conditions, clauses, warranties,endorsements as per forms attached.
The policy shall pay for hospitalisation expenses for medical/surgical treatment taken as an in-patient at any Nursing
Home/Hospital in INDIA as defined in the policy.

In the event of a claim under the policy exceeding Rs. 1 lac or a claim for refund of premium exceeding Rs. 1 lac,the
insured will comply with the provisions of the AML policy of the Company.The AML policy is available in all our operaing
offices as well as Company's website.

Warranted that in case the person covered under the policy has lodged any claim under the previous policy and the sum
insured is enhanced under the current policy, for a further claim for the same disease during the current policy, the earlier
limit of Sum Insured shall be applicable and not the enhanced sum insured.

Warranted that in case of dishonour of premium cheque(s) the Company shall not be liable under the policy and the policy
shall be void abinitio (from inception).

"We at Oriental continuously strive to ensure that you get the best possible treatment from our network hospitals.
Please contact your TPA or any of the Oriental offices for our preferred hospitals in your area before going for a
treatment. This will help us serve you in the best possible manner"

In witness whereof the undersigned being authorised by and on behalf of the Company has/have herein to set his/their hands
at DO 1 SURAT (GSTIN: 24AAACT0627R2Z4) on 26-JUN-20.

1.Claim to be reported within 48 hrs of admission but before discharge.

2.Claim documents to be submitted within 15 days of discharge.

For complete details please refer to policy condition.

Place : SURAT For and on behalf of

Date : 26/06/2020 The Oriental Insurance Company Limited

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupee Page 2 of 3
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 This Document is Digitally Signed

Signer: ATUL JERATH

Date: Mon, Jun 29, 2020 07:58:07 IST
Location: NOIDA
Reason: Signing Policy for OICL

Attached to and forming part of policy number 171600/48/2021/4190

Policy History Data

Policy No. Period From Period To Insurer Name Sum Insured

171600/48/2018/8804 25-JUL-17 24-JUL-18 The Oriental Insurance Company Ltd. 200000

171600/48/2019/5856 25-JUL-18 24-JUL-19 The Oriental Insurance Company Ltd. 300000

171600/48/2020/5545 25-JUL-19 24-JUL-20 The Oriental Insurance Company Ltd. 300000

Claim History Data

Policy no. Claimant Nam Claim No. Claim OS Claim Paid

"In case of grievance related to any issue related to this policy the same may be addressed to the office In-Charge or the Grievance Officer
at above policy address. If the grievance remains pending, it may be escalated to Grievance Officer of the concerned Regional Office
MEZZANINE FLOOR, A.G. CHAMBERS,,UNIVERSITY ROAD, FATEHGUNJ, VADODARA,,. The next escalation in case grievance remains
unresolved is CSD, Head Office, situated at Oriental House, A-25/27, Asaf Ali Road, New Delhi-110002.
If the insured is not satisfied with the resolution/reply provided by the company, he/she may approach the Office of Insurance Ombudsman,
within his/her jurisdiction. The list of offices of Ombudsman is available on Company's portal."

Entered By : SUMAN BHARTI

For and on behalf of
Examined By : MR. A K CHOUDHARY The Oriental Insurance Company Limited

Policy Printed By : OICL IP :

Policy Printed On : 29-JUN-20 07:56:13 MAC :

Authorised Signatory

Place : SURAT For and on behalf of

Date : 26/06/2020 The Oriental Insurance Company Limited

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupee Page 3 of 3
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in