Raghu Nath Sahap - 241112 - 130221

Policy Schedule
Tata AIG MediCare

Intermediary Name: AXIS BANK LTD
Intermediary Code: 0015455000
Intermediary Contact No.: 1800 209 2001 (mobile or landline)
Issuing Office : BURDWAN
Client Id : 6075270216
Proposal no. : IDV001362982
Policy holder’s Name: RAGHU NATH SAHA
Policy holder’s Address: BASIRHAT, BASIRHAT (M), BASIRHAT COLLEGE,
NORTH 24 PARGANASJORA PUMP
WB
BASIRHAT 743411
NORTH TWENTY FOUR PARGANAS
WEST BENGAL
INDIA
Place of supply WEST BENGAL
State code 19
Insured GST No:
Place of Supply: WEST BENGAL
Supply Code: 19
Policy Number: 0238469758
Product name: Tata AIG MediCare
Plan type: Individual Plan
Business Type: Renewal Business
Policy Tenure: 1 Year
Policy Period: From : 12/04/202410:12 hrs TO: 11/04/2025 on 11:59 PM
Premium Payment Zone Zone B
Insured Persons Details:

Insured
with Tata
Insured AIG General
Person's Insurance Member Date of Relationship Sum Cumulative
Name Co. since Id birth Age(in years) to Policyholder Restore Benefit % Insured ( ) Bonus ( ) Accidental Death
RAGHU NATH SAHA 07/04/2020 0035835588401061 06/07/1958 65 Self 100% 400,000.00 200,000.00 0.00
Net Premium is inclusive of discount for no coverage for Global Cover for Planned Hospitalization
* For Family Floater policy, Sum Insured and cumulative bonus floats among the insured persons of the family as mentioned above. Earned Cumulative Bonus shall not be
applicable for newly added members in this policy.
# Sum Insured mentioned is excluding cumulative bonus. Earned cumulative bonus is separately mentioned.
Net Premium ( ) : 37,287.50

Loadings ( ) : 7,457.50
Discounts ( ) : 0.00
Tax, Duties and cess as applicable ( ) :
UGST/SGST @9 % ( ) : 3,355.88
CGST @9 % ( ) : 3,355.88
Gross Premium ( ) : 43,999.00
Gross Premium (In Words) : Rupees Forty Three Thousand Nine Hundred Ninety Nine And Paise Zero Only
Benefit Name Coverage Limit

Vaccination cover Upto 5000 per policy
InPatient Treatment Dental Upto Sum Insured
Organ Donor Upto Sum Insured
Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully before concluding a sale.
TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, Mumbai 400 013.
IRDA of India Registration No.108, CIN No : U85110MH2000PLC128425, UIN No : TATHLIP23118V032223
Website: www.tataaig.com 24X7 Tollfree Helpline 18002667780 Email: [email protected]
PostHospitalization expenses Upto 90 days
InPatient Treatment Upto Sum Insured
Ambulance Cover Upto 3000 per Hospitalization
Compassionate travel Upto 20,000 per policy year
Restore benefits Upto Sum Insured
Second Opinion Covered
Daily Cash for Accompanying an Insured Child 0.25% of base Sum Insured; maximum 2000 per day
Health Checkup Upto 1% previous year Sum Insured; max. 10,000 per policy
Consumables Benefit Upto Sum Insured
Day Care Procedures Upto Sum Insured
PreHospitalization expenses Upto 60 days
Bariatric Surgery Cover Upto Sum Insured
Hearing Aid 50% of actuals; maximum 10,000 per policy
Domiciliary Treatment Upto Sum Insured
Daily Cash for choosing Shared Accommodation 0.25% of base Sum Insured; maximum 2000 per day
AYUSH Benefit Upto Sum Insured
Global Cover Upto Sum Insured
Wellness Service 8 teleconsultations (GP) and Ambulance Booking Facility.
Nominee Details for Policyholder :
Nominee Name Relationship to Policyholder

PARBATI SAHA Wife
Specific Exclusion / loading if applicable
Pre
Insured Person's Permanent Loading Preexisting disease exclusion start Preexisting disease exclusion end
Member Id Existing
Name Exclusion Reason date date
Disease
0035835588401061 RAGHU NATH SAHA Diabetes Diabetes 07/04/2020 06/04/2023
Continuity benefit is already considered for this policy no.

Policy Comments if applicable
Claim Servicing Details:
Name of Claim
Administrator : Tata AIG Health Claim
Website : www.tataaig.com
Email : [email protected]
Toll Free : 18002667780
: 1800229966 (For Senior Citizens)

Submit claim : TAGIC Health Claims Claims processing HUB ,
TATA AIG General Insurance Company Limited

5th and 6th Floor, Imperial Towers H.No 716617/A,
GHMC no 615,616, Ameerpet Hyderabad 500016,
Stamp Duty of 40/ is paid as provided under Article 47C of Indian Stamp Act, 1899 and included in Consolidated Stamp Duty Paid to the Government of Maharashtra
Treasury vide Order of Addl. Controller Of Stamps, Mumbai at General Stamp Office, Fort, Mumbai 400001., vide this Order No. LOA/ENF1/CSD/42/2024/1004 Validity Period
Dt.05/02/2024 To Dt.24/01/2027/1004 Date:24/01/2024
Policy Servicing Address :
Policy Servicing Office
Tata AIG General Insurance Company Limited
KUNDU MANSION, 638,, GR. FLOOR, BHANGAKUTHI, G T ROAD,,BARDHAMAN,WEST BENGAL,AGRICULTURE FARM713101
Tel No:
Authorized Signatoryalf of Tata AIG General Insurance Company Limited Date:
Authorized Signatory
In the event of nonrealization of premium, the Company shall not be liable under the policy and the policy shall stand cancelled ab initio (from inception).
Certificate of Premium payment for the purpose of declaration under Section 80 D of Income Tax (Amendment) Act, 1961*
Date : 12/04/2024
Policy Number : 0238469758
Customer Name : RAGHU NATH SAHA
Address Line 1 : BASIRHAT, BASIRHAT (M), BASIRHAT COLLEGE,, NORTH 24 PARGANASJORA PUMP, WB,
Address Line 2 : NORTH TWENTY FOUR PARGANAS743411
Address Line 3 : WEST BENGAL
GSTIN no :
Dear Sir/Madam,
Sub: Tax Benefit Letter for Medicare policy no. 0238469758
This is to certify that premium amount of Rs 43999( Rupees Forty Three Thousand Nine Hundred Ninety Nine And Paise Zero Only) for health
insurance Policy No 0238469758 issued to RAGHU NATH SAHA for the period 12/04/2024 to 11/04/2025 has been paid.
Receipt Illustration
Receipt ID. Name of Payer Mode of payment Amount paid

102001071023531 RAGHU NATH SAHA DEBIT AUTHORIZATION 43,999.00
Total Amount Paid 43,999.00
Premium illustration (Member wise)
Total member premium

Member ID Name of Member Relationship with Policyholder paid(Including Taxes &
Loading)
0035835588401061 RAGHU NATH SAHA Self 43,999.00
Total Premium Paid (Inclusive of Loading & Taxes collected) 43,999.00
Please feel free to get in touch with us for any further help or queries at our 24x7 Helpline 18002667780 (Tollfree) or email us at
[email protected]
We assure you of our best services at all times.

Regards,
For Tata AIG General Insurance Company Limited
Authorized Signatory
Date of Issue : 12/04/2024
Place of Issue: BURDWAN
Note
1. Tax deductions can be claimed subject to the provisions prescribed in the relevant sections of the Incometax Act, 1961 as amended from time to time.
2. Premium paid in advance will be applied to the policy on premium due date.
3. This premium paid certificate is conditional upon credit in company's account post clearance of the instrument/facility including electronic mode.
4. For any confirmation / impact analysis, customer is advised to refer the matter to his/her Tax consultant.
5. This certificate must be surrendered to the company in case of cancellation of this policy. In the event of incorrect representation of this declaration the liability shall be upon
the policyholder/payer.
TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam Marg, Off Senapati Bapat Marg, Lower Parel, Mumbai
400 013.
RECEIPT
Receipt No. : 102001071023531 Receipt Date : 12/04/2024
Policy No : 0238469758 04 00
Received with thanks from MR RAGHU NATH SAHA a sum of 43,999.00 ( Rupees Forty Three Thousand Nine Hundred Ninety Nine And Paise Zero Only)
vide Card no. XXXXXXXXXXXX9999
Sr. Policy Utilized from the receipt for

Total Premium ( ) Balance ( )
No. Number policy ( )
1 0238469758 04 00 43,999.00 43,999.00 0.00
Note:
1. This is a computer generated receipt and does not require a signature.
2. Upon issuance of this Receipt, all previously issued temporary receipts, if any, related to this Policy shall be considered null and void.
3. Amounts received by cheque shall be subject to realisation.
4. Any amount received in excess of the Premium is being/shall be refunded by the Company.
GSTIN : 19AABCT3518Q1ZT WEST BENGAL Service Accounting Code : 997133
Revenue (consolidated) Stamp Duty duly paid vide challan No.LOA/ENF1/CSD/25/2023/5069 date 18/12/2023 for applicable cases.
Tata AIG MediCare
Name : RAGHU NATH SAHA

Age : 65
Gender : M
Policy No. : 0238469758 04 00
From : 12/04/2024 To 11/04/2025
Member ID : 0035835588401061
Please refer to our website or mobile application to know the list of cashless network
hospitals and excluded hospitals
TAGIC Health ClaimsTATA AIG General Insurance Company Limited
5th and 6th Floor, Imperial Towers, H.No 716617/A,
GHMC no 615,616, Ameerpet, Hyderabad 500016,Telangana,
Toll Free : 18002667780, Website : www.tataaig.com
Tata AIG MediCare UIN: TATHLIP23118V032223
Annexure to customer information sheet (CIS) Benefit illustration in respect of policies offered on individual and family floater basis.
Coverage opted on individual Coverage opted on individual basis covering

Coverage opted on family floater basis with
basis covering each member of multiple members of the family under a single
Age of the member Insured overall sum insured(only one sum insured
the family seperately(at a single policy(sum insured available for each member of
available for entire family
point of time) the family
Premium
or
consolidated
Floater
Discount Premium after Sum premium Premium after Sum
Premium Sum Insured Premium discount
if any Discount Insured( ) for all Discount Insured( )
if any
members
of the
family
65 29830 400000
Total premium for all members
Total premium for all members of the family is
of the family is 29830 when Total premium when the policy is opted on floater
when they are covered under a single
each member is covered basis is
policy
seperately
Sum insured available for each sum insured available for each family member is Sum insured of is available for the
individual is 400000 entire family
Note: Premium rates specified in the above illustration shall be standard premium rates without considering any loading. Also the premium
rates shall be exclusive of taxes applicable.
Online Proposal Form Tata AIG MediCare
URN No.: AH/202122/HL03
Proposal no. IDV001362982 Intermediary Code: 0015455000
This is an application for insurance and issuance of this does not amount to acceptance of proposal by us. Commencement of risk under this proposal is subject to acceptance
of the risk by us and receipt of premium.
The information declared by you in this form is the basis for issuance of the policy. Please answer all questions carefully. Any incomplete, incorrect or partially correct answers
may lead to rejection of the proposal and also might lead to cancelation of policy.
Please fillup this form in CAPITAL LETTERS
1. PROPOSER’S DETAILS
First Name Middle Name Surname
Date of Birth(dd/mm/yyyy) Gender MALE

Mobile 9732687176
Unique Govt ID No.
Annual Income in Rs(Lakhs) 450000 Upto 3 / 3 to 6 / 6 to 10 / 1015/ 1520/ 2025/ >25
EMail ID [email protected]
BASIRHAT, BASIRHAT (M), BASIRHAT COLLEGE,NORTH 24 PARGANASJORA PUMP
Address^
WB
Landmark Area
City/Town NORTH TWENTY FOUR PARGANAS Pin Code 743411
District NORTH TWENTY FOUR PARGANAS State WEST BENGAL
Nationality Indian Foreign Nationals
Is Residence Status of either the Policyholder or any of the Insured Person(s) is Non Resident Indians (NRI)/ Overseas Citizen of India (OCI)/ Foreign Nationals? Yes*
No
If you are Resident Indian National and want to opt out of Global Cover for Planned Hospitalization Yes* No
*If the answer to (i) or (ii) above is 'Yes', you are eligible for a premium discount and 'Global Cover for Planned Hospitalization' as a Benefit is not available under this policy
and no claim shall be admissible under this section
Tata Group Employee

PAN Card
Tata Group Employee ID:
2. POLICY DETAILS
Proposed Policy Commencement Date:
To
Plan Type Individual Basis

Policy Tenure 1 Year
Room(Category)All Room Categories Covered
Accidental Death Benefit Yes
Riders shall be opted by all the eligible members. There cannot be selection between the eligible members for choosing riders.
Dependent Children will not be covered under Personal Accident Benefit.
3. DETAILS OF THE PERSON(S) TO BE INSURED

Relationship with
Sl No Name of the Insured Person Gender Date of Birth Height Weight Sum Insured(Rs)#
Proposer*
1 RAGHU NATH SAHA Male Self 06/07/1958 160.02 61 400000
* Allowed relations (Self,Spouse, children and dependent parents/parents in law)
# Options available (3, 4, 5, 7.5, 10, 15, 20 Lakhs); Same Sum Insured for all members in floater option
4. NOMINEE DETAILS
In the event of the death of the Proposer any payment due under the Policy shall become payable
to the nominee in accordance with the Policy terms and conditions.
Nominee Name Date of Birth* Relationship Address of the Nominee
PARBATI SAHA 01/01/1968 Wife
*If the Nominee is minor, Name and Address of Appointee and Relationship with Minor:
5. EXISTING/PREVIOUS INSURER DETAILS

Is the proposer or any of the persons proposed, already Insured under a health plan with Tata AIG
General Insurance Company Ltd. or any other insurer or is a proposal pending for Policy issuance?
If yes, please indicate the Policy/ Application number(s):IDV001362982
Since when continuously insured:
Do you want Us to consider these details for portability*? Yes No

* Please note that continuity of benefits
shall NOT be considered if the details are not provided. You need to approach at least 45 days prior
to your expiry date to avoid any break in coverage. Please submit all previous year insurance policy copies.
6. MEDICAL AND LIFESTYLE DETAILS

A. Medical History:
Please answer the below mentioned questions individually in Yes(Y)/No(N): You must answer the questions truthfully.Not doing so would lead to termination of your policy
Insured Person
Please answer each of the following questions individually for each Insured Person by ticking the
relevant box.
1 2 3 4 5 6 7
Have you or any of the persons proposed for insurance, ever suffered from or taken treatment, or hospitalized for or have been recommended to take investigations /
medication / surgery or undergone a surgery for the following medical conditions?
Decline Disease Name NO NO NO NO NO NO NO
Have you or any of the persons proposed for insurance, ever suffered from or taken treatment, or
hospitalized for or have been recommended to take investigations / medication / surgery or NO NO NO NO NO NO NO
undergone a surgery for MediCal Conditions specified on Proposal form?
Any other illness/disease/injury/disability in the past other than for childbirth, flu or for minor
NO NO NO NO NO NO NO
injuries that have completely healed?
Are you or any persons proposed on regular medication (including any Ayurvedic treatment) or
awaiting any procedure/treatment?
Have you ever been diagnosed with any of these medical conditions with or without any followup
tests/medications? – Elevated Blood Sugar/ Type 2 Diabetes Mellitus/ Elevated Blood Pressure/ NO NO NO NO NO NO NO
Hypertension/High Cholesterol/Asthma
Is any of the insured pregnant currently? If yes, please mention expected date of delivery (EDD).
Any history of pregnancy related complications?
Has any application for life, Health or critical illness insurance ever been declined, postponed,
loaded or been made subject to any special conditions by any insurance company?
Has any health or life insurance policy ever been terminated in the past? NO NO NO NO NO NO NO
Have you ever been diagnosed with any Thyroid Disorder with or without any followup
tests/medications?
Do you have any signs, symptoms, illness or injury including knee joint ligament tear or back pain/
Swelling or Pain in any part of body / Breathlessness on mild effort / dizziness more than once in NO NO NO NO NO NO NO
last 6 months for which medical consultation / treatment / investigation has been required
Have you undergone any annual health checkup or routine medical examination in the past which
showed any significant finding/s? If yes, please provide details for findings or results.
Have you or any members ever undergone any surgery related to Thyroid? If yes, please provide
details for followup tests/ medications.
Have you or any of your immediate family members (spouse, parents, children, parents in law)
ever been diagnosed with cancer, heart attack, or stroke, prior to age 60?
B. Detailed information in case any of the questions in section 6 (A) is ticked 'Yes'.
(Please send us medical documents along with this application form.)
C. Lifestyle Information
Does any person proposed to be insured smoke or consume Gutka/Pan Masala or Alcohol? Yes
If yes please indicate the name and quantity per day.
Insured Person
Alcohol (in ml)
Smoking (No of Cigarettes or Bidis)
Pan Masala/Tobacco (in gms)
Others habit forming substances/addictive (Quantity consumed)
7. PAYMENT DETAILS
Name of the Premium Payer: RAGHU NATH SAHA

Relationship with the proposer: Self
Premium Amount (in ): 43999
Instrument type: DEBIT AUTHORIZATION
Please make a Crossed Cheque/DD/Pay Order in favour of ‘Tata AIG General Insurance Company Limited’ only.
Sources of funds: OTHERS
Anti Money Laundering (AML) declarations

1. I/we hereby confirm that all premiums paid / payable in future will be from bonafide sources and not paid out of proceeds of crime and that such premiums are not
disproportionate to my/our income. I / we understand that the Company has the right to call for documents to establish sources of funds and to cancel the insurance policy in
case I / we are found guilty by any competent court of law under any of the statutes, directly or indirectly governing the prevention of money laundering law in India.
2. I / we are not Politically Exposed Persons * nor are their close relatives. I / we shall keep the company informed if we subsequently become a Politically Exposed Person.
"Politically Exposed Persons" shall have the meaning assigned to it under sub clause (xii) of 3(b) of Chapter I of Master Direction Know Your Customer (KYC) Direction, 2016
issued by Reserve Bank of India (RBI), as amended from time to time
Type of Organization making the payment (Pls tick)
Limited company
Government organization
NonGovernmental Organization (NGO)
Society
Trust
Partnership
International Organization
Cooperatives
Section 25 Company
Signature of Proposer & Date :
8. BANK DETAILS (REQUIRED FOR REFUND/CLAIMS)

As per Regulatory requirements, we can effect payment of refund / claims only through Electronic Clearing System (ECS) / National Electronics Funds Transfer (NEFT) / Real
Time Gross Settlement (RTGS) / Interbank Mobile Payment Service (IMPS)
For this purpose, please submit the following details of the proposer’s bank account.
Name of the account holder
Name of the bank HSBC BANK
Branch Bank
Account no.
Bank IFSC code
Account Type SB Account Current Account Others(please specify)
9. DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED
I 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 am authorized to propose on behalf of these other persons.
I 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 insurer and that
the policy will come into force only after full payment of the premium chargeable.
I further declare that I 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.
I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be
insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be insured/proposer and
seeking information from any insurer to whom an application for insurance on the person to be insured /proposer has been made for the purpose of underwriting the
proposal and/or claim settlement.
I authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the sole purpose of underwriting the
proposal and/or claims settlement and with any Governmental and/or Regulatory authority.
Signature of the Proposer:
GoGreen: I would like to protect my environment and would like to help save paper by authorizing Tata AIG General Insurance Company Limited to send all my policy and
service related communication to the email id as mentioned in this application form. For detailed terms, conditions,exclusions and policy wordings please refer our
website(www.tataaig.com)
10. DECLARATION/VERNACULAR DECLARATION

The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained to me. I/we have understood these and confirm to abide by
the policy terms & conditions.
Signature of the proposer:
Name & Signature of agent/intermediary with code: AXIS BANK LTD 0015455000
Vernacular Declaration (Certification in case the proposer has signed in vernacular/thumb print)
The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained by me in vernacular to the proposer who has understood and
confirmed the same.
Signature/Thumb impression of the Proposer:
Name & Signature of agent/intermediary: AXIS BANK LTD
11. AGENT DECLARATION
I,AXIS BANK LTD in my capacity as an Insurance Advisor/ Specified Person of the Corporate Agent/Authorized employee of the Broker/Relationship Officer, do hereby declare
that I have explained all the contents of this Proposal Form, including the nature of the questions contained in this Proposal Form to the Proposer including statement(s),
information and response(s) submitted by him/her in this Proposal Form to questions contained herein or any details sought herein will form the basis of the Contract of
Insurance between the Company and the Proposer, if this Proposal is accepted by the Company for issuance of the Policy. I have further explained that if any untrue
statement(s)/ information/response(s) is/are contained in this Proposal Form/including addendum(s), affidavits, statements, submissions, furnished/to be furnished, the
Company shall have the right to vary the benefits which may be payable and further more if there has been a nondisclosure of any material fact, the policy issued to his/her
favor pursuant to this Proposal may be treated by the Company as null and void and all premiums paid under the Policy may be forfeited to the company.
License No.(Intermediary/Corporate Agent/Broker/Relationship

CA0069
Officer)
Name of the specified Person and code: AXIS BANK LTD 0015455000
Place: NORTH TWENTY FOUR PARGANAS Date: Signature of Agent: AXIS BANK LTD
12. SECTION 41 OF INSURANCE ACT 1938 (PROHIBITION OF REBATES)
1. 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 in respect of 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 premium shown on the policy, nor shall any person taking out
or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.
2. Any person making default in complying with the provisions of this section shall be liable for penalty which may extend to ten lakh rupees.
13. FOR OFFICE USE ONLY
Tata AIG Office Code : Intermediary Code and Name:AXIS BANK LTD
Branch Receipt Date: Channel Type:AGENT CORPORATE
Business Type: Urban/ Rural/ Social Customer ID
Tata AIG General Insurance Company Limited.
Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully, before concluding a sale. Tata
AIG General Insurance Company Limited. Registered Office: Peninsula Business Park, Tower A, 15th Floor, G. K. Marg, Off Senapati Bapat Road, Lower Parel, Mumbai 400013,
Maharashtra, India.
24X7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) Email:[email protected] Website: www.tataaig.com IRDA of India Registration No: 108
CIN: U85110MH2000PLC128425
14. ACKNOWLEDGEMENT (TO BE GIVEN TO CUSTOMER)
Proposal Number: IDV001362982 Date:

Name of the proposer:
We acknowledge with thanks the receipt of your proposal for Tata AIG MediCare and amount by DEBIT AUTHORIZATION of amount of 43999. Neither the submission to us of
a completed proposal for insurance nor any payment towards this application obliges us to agree to issue a policy, which decision is and always shall be in our sole and
absolute discretion. If we accept a proposal for insurance, it shall be subject to the policy terms and conditions and we shall have no liability to make any payment if proposal is
not accepted by us or you do not accept the terms of counter offer or premium is not received by us in full and in time, or nonfulfillments of PrePolicy Checkup and/or
additional information requested by us. We shall have no liability to make any payment under the Policy if proposal is underprocess & claim arises in the interim period before
the decision on the proposal is given by us. In case of counter offer you need to revert to Us with consent and additional premium (if any), within 15 days of the issuance of
such counter offer letter. In case, You neither accept the counter offer nor revert to Us within 15 days, we shall cancel application and refund the amount paid against this
proposal without interest subject to deduction of the Pre Policy Check up charges, as applicable. If we do not accept the proposal, we will inform you and refund any payment
received from you without interest within next 10 days subject to deduction of the PrePolicy Check up charges, as applicable.

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Policy Schedule

Tata AIG MediCare

Insured Persons Details:

Net Premium ( ) : 37,287.50

Benefit Name Coverage Limit

Nominee Details for Policyholder :

Nominee Name Relationship to Policyholder

Specific Exclusion / loading if applicable

Continuity benefit is already considered for this policy no.

Claim Servicing Details:

Toll Free : 18002667780

: 1800229966 (For Senior Citizens)

TATA AIG General Insurance Company Limited

Authorized Signatoryalf of Tata AIG General Insurance Company Limited Date:

Sub: Tax Benefit Letter for Medicare policy no. 0238469758

Receipt ID. Name of Payer Mode of payment Amount paid

Premium illustration (Member wise)

Total member premium

We assure you of our best services at all times.

Receipt No. : 102001071023531 Receipt Date : 12/04/2024

Sr. Policy Utilized from the receipt for

GSTIN : 19AABCT3518Q1ZT ­ WEST BENGAL Service Accounting Code : 997133

Name : RAGHU NATH SAHA

Coverage opted on individual Coverage opted on individual basis covering

URN No.: AH/2021­22/HL­03

Proposal no. ­ IDV001362982 Intermediary Code: ­0015455000

Please fill­up this form in CAPITAL LETTERS

First Name Middle Name Surname

Date of Birth(dd/mm/yyyy) ­ Gender ­ MALE

Tata Group Employee

Plan Type Individual Basis

3. DETAILS OF THE PERSON(S) TO BE INSURED

5. EXISTING/PREVIOUS INSURER DETAILS

Do you want Us to consider these details for portability*? Yes No

6. MEDICAL AND LIFESTYLE DETAILS

Decline Disease Name NO NO NO NO NO NO NO

(Please send us medical documents along with this application form.)

Alcohol (in ml)

Smoking (No of Cigarettes or Bidis)

Pan Masala/Tobacco (in gms)

Others habit forming substances/addictive (Quantity consumed)

Name of the Premium Payer: RAGHU NATH SAHA

Anti Money Laundering (AML) declarations

8. BANK DETAILS (REQUIRED FOR REFUND/CLAIMS)

9. DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED

10. DECLARATION/VERNACULAR DECLARATION

Signature of the proposer:

Signature/Thumb impression of the Proposer:

Name & Signature of agent/intermediary: AXIS BANK LTD

11. AGENT DECLARATION

License No.(Intermediary/Corporate Agent/Broker/Relationship

12. SECTION 41 OF INSURANCE ACT 1938 (PROHIBITION OF REBATES)

13. FOR OFFICE USE ONLY

Tata AIG General Insurance Company Limited.

14. ACKNOWLEDGEMENT (TO BE GIVEN TO CUSTOMER)

Proposal Number: IDV001362982 Date:

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GSTIN : 19AABCT3518Q1ZT WEST BENGAL Service Accounting Code : 997133

URN No.: AH/202122/HL03

Proposal no. IDV001362982 Intermediary Code: 0015455000

Please fillup this form in CAPITAL LETTERS

Date of Birth(dd/mm/yyyy) Gender MALE