HDFC ERGO General Insurance Company Limited
111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111
2805203650244702000
Mr Ketan Kumar Ramanlal Patel
B/408 KANSAS COUNTY B/H RADHE
CHAMBER NIRANT CROSS ROAD
VASTRALAHMEDABAD
GUJARAT-382418
Contact No.: 9925327787
Policy No : 2805203650244702000
lntenmediary Code Intermediary Name Intermediary Contact Number
Renewalof Your Optima Restore Floater Two Year Insurance Policy
Dear Mr Ketan Kumar Ramanlal Patel ,
Welcome to HDFC ERGO General Insurance Company Limited. We are pleased to issue you Renewal of Your Optima Restore Floater Two Year Insurance
Policy. We advise you to retain your Policy Kit during the entire term of the Policy (including renewals).
Please note that the Policy has been issued to you based on the declarations, details and documents received from/on behalf of you in/along with the Proposal
Form submitted to us.
Please visit our website www.hdfcergo.com for more information about our Company, Grievance handling and any other support. To know the updated list of our
network hospitals please visit http://www.hdfcergo.com/our-hospitals-network.aspx
We value your relationship with us and assure you our best services at all times and we look forward to serve you.
Wanm Regards,
Location: Mumbai
Date: 23/11/2023
Authorized Signatory
Note:
1. Please update us with your latest contact details (in case of any change) so that same can be updated in our records.
2. You can either email us on [email protected] or call on our Customer care no. 022 6234 6234 I 0120 6234 6234.
3. *The Copy of the proposal form has been sent on your registered email id if policy is purchased through website.
Certificate for the purpose of deduction under Section 80 D of Income Tax Act,
1961*
This is to certify that the Proposer KETAN KUMAR RAMANLAL PATEL has paid Rs.35936 (Rupees THIRTY-FIVE THOUSAND NINE HUNDRED
THIRTY-SIX) towards premium for Policy No. 2805203650244702000 issued to MR KETAN KUMAR RAMANLAL PATEL for period 23-Nov-2023 to
22-Nov-2025.
For and on behalf of HDFC ERGO GeneralInsurance Company Limited
Location: Mumbai
Date: 23/11/2023
Authorized Signatory
*Note
1. This is subject to the provisions of Section 80D of Income Tax Act, 1961 as amended from time to time.
2. This certificate must be surrendered to the company in case of cancellation of this policy. In event of incorrect representation of this declaration the
liability shall be upon the Policyholder.
3. Please note that this certificate will not be issued if the premium payment has been made in cash.
4. In case of dishonor of the premium instrument, the policy will be deemed cancelled ab initio.
5. 80D benefit is applicable for only Self, Spouse, Dependent Children and Dependent parents.
HDFC ERGO General Insurance Company Limited. IRDAIReg No.146 Critical Advantage Rider - HDHHLIP21342V022021 I Customer Service Address D 301, 3rd
CIN: U66030MH2007PLC177117. Registered & Corporate Office 1st Floor, HDFC Floor,Eastern Business District (Magnet Maii),LBS Marg, Bhandup (West),
House, Mumbai- 400 078.Customer Service No : +91 22-62346234/+91-120 6234 6234 1
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
Policy Schedule- Optima Restore Floater Two Year
Policy Number 2805 2036 5024 4702 000
Policy Holder's Name Mr Ketan Kumar Ramanlal Patel
B/408 KANSAS COUNTY BIH RADHE CHAMBER NIRANT CROSS ROAD VASTRALAHMEDABAD
Policy Holder's Address
GUJARAT-382418
Policy Holder State Name & Code Gujarat & 24 Place of Supply GUJARAT
GSTIN/ UIN (if any) of Policy Holder
First policy inception date 16/11/2019 IPolicy Issuance Date 23/1112023
Policy Period From 00:01hrs on 23/1112023 To 24:00 hrs on 2211112025
<b>Policy Issuing Office :</b> SEWA CORPORATE SUITES, M.G.ROAD,NEAR IFFCO CHOWK GURGAON,
Issuing/Servicing Office
122001.
GSTIN 24AABCL5045N1ZE
EIA Number
Intermediary Name Intermediary Contact No
Intermediary Code Description/ Harmonized System Of Accident and Health insurance
Nomenclature Code Services/9971
Insured Person Details
Member 1 Member 2 Member 3 Member4 Member 5 Member6
Master AARAV Mrs SHILPABAHEN KETAN KUMAR
Particulars I Member ID KETAN KUMAR KETAN KUMAR RAMANLAL PATEL
PATEL/ PATEL/ I
2020010001175656 2020010001175657 2020010001175658
Date of Birth (Age) 27/08/2013 (10) 30/08/1984 (39) 15/06/1981 (42) - - -
Relationship to Policy Holder Child Wife Self - - -
Base Sum Insured ) 300000
Multiplier Benefit Sl ( ) 300000
Protector Rider
Sum Insured )
-
TotalSum Insured ) 600000
Other Riders and Benefits( )
Protector Rider I
HDHHLIP21335V022021
-
Hospital Daily Cash Rider Sl
(Max. 30 days) I -
HDHHLIP21344V022021
CriticalAdvantage Rider Sl
(Rs.) I - - - - - -
HDHHLIP21342V022021
IPA Rider Sl/
- - - - - -
APOPAIP19004V011920
my:health Critical Illness
Sum Insured (Rs.)
my:health Critical Illness
Plan
Unlimited Restore Benefit No
Nominee Details
Nominee Name: Shilpabahen Ketan Kumar Patel !Relationship to Policyholder: Wife
The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee.
Premium Calculation( )
Net Premium 34656.05 CGST@O% 0
Discounts 4202.05 SGSTIUTGST@O% 0
Loadings 0 IGST@18% 5482
Taxable Premium 30454 Any other Cess or Taxes 0
Gross Premium 35936
Gross Premium (in words) Rupees Thirty-Five Thousand Nine Hundred Thirty-Six
The stamp duty of Rs.1/- (Rupees One Only ) paid vide e-stamp Certificate No. LOA/CSD/303/2022/1381dated 29/03/2022.
Originalfor Recipient/ Duplicate for Supplier
\11/hether tax is payable on reverse charge basis: No
HDFC ERGO Generallnsuran:;e Company Limited. IRDAI RegNo.146
Critci al Advantage R1der- HDHHLIP21342Vl22021 I Customer Ser. ice Address D301, 3rd
CIN U6ED30MH2007PLC177117. Registered &Corporate OffiCe 1st Floor, HDFC FloorE, astern Business District (Magnet Maii),LBS Marg,Bhandup (West),
House,
Mumbai- 400 078 Customer Ser. K:e No +9122-623462341+91-1LD 6294 6234 1 \JW!W hcfcergo com
1651166 Backbay Reclamation,H T ParekhMarg, Churchgate,Mumbai- 400 OLD
HDFC ERGO General Insurance Company Limited
Policy Schedule- Optima Restore Floater Two Year
Exclusion(s) I SpecialCondition(s) (Refer the leaflet attached in the policy document w.r.t. exclusions) :
Member ID No. Name Exclusion Type Applicable Health Condition Exclusion Portability/ Renewal Benefit
on Sl Duration
(Years)
2020010001175656 Master AARAV KETAN For Rs 300000(Rupees Three Lakhs)
KUMAR PATEL Sec C1 (i) and Sec C1 (ii) Sec C1 (iii)
of the policy wording is waived.
2020010001175658 KETAN KUMAR For Rs 300000(Rupees Three Lakhs)
RAMANLAL PATEL Sec C1 (i) and Sec C1 (ii) Sec C1 (iii)
of the policy wording is waived.
2020010001175657 Mrs SHILPABAHEN KETAN For Rs 300000(Rupees Three Lakhs)
KUMAR PATEL Sec C1 (i) and Sec C1 (ii) Sec C1 (iii)
of the policy wording is waived.
Claim Administrator: HDFC ERGO GENERAL INSURANCE COMPANY LTD For and on behalf of HDFC ERGO General Insurance Company Limited
Location: Mumbai
Authorized Signatory
Date: 23/11/2023
"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings "
SCHEDULE OF BENEFITS
In-patient Treatment Upto 300000
Pre-Hospitalization Upto 300000 for 60 days
Post-Hospitalization Upto 300000 for 180 days
Day Care Procedures Upto 300000
Domiciliary Treatment Upto 300000
Organ Donor Upto 300000
Daily Cash for choosing Shared Accommodation Rs.SOO per day, Maximum Rs.4,800
E-Opinion in respect of a Critical Illness One per policy year
Restore Benefit 100% of Basic Sl (for any illness or any insured person)
Bonus of 50% of the Basic Sl for every claim free policy year, maximum upto 100%. In case of claim, accumulated bonus
Multiplier Benefit
will be
reduced by 50%
HDFC ERGO General Insurance Company Limited. IRDAIReg No.146 Critical Advantage Rider - HDHHLIP21342V022021 I Customer Service Address D 301, 3rd
CIN: U66030MH2007PLC177117. Registered & Corporate Office 1st Floor, HDFC Floor,Eastern Business District (Magnet Maii),LBS Marg, Bhandup (West),
House, Mumbai- 400 078.Customer Service No : +91 22-62346234/+91-120 6234 6234 1
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
Terms and Conditions
(1) This card would be valid till your relationship with HDFC ERGO General Insurance
Policy No.: Company LimitedIThis card is invalid if the policy is cancelled(2) In case of renewal
2805203650244702000 please
refer original policy number [3) This card IS issued for the purpose of identifiCation only anddoes
not ental automatic cashless facll1ly at the network hcsp1lal. (4) A photo ID 1ssued by any
government authority is to be produced to avail cashless facility.(5) Please apply for casHess facility
Insured Name 48 hours prior to admission in case of plamed admissions and withn 24 hours of admission in case
Gender of emergency (6) All terms and conditions of the potK;y would be applicae whle processing your
cashless request. (7) Incase
Master Aarav Ketan Kumar Patel Male your cashless facility is denieddue to any reason, please subrrit the claim for reimbursement Derialof
Ketan Kumar RamanlalPaiel Male casHess facility does not mcficate re1ect1on of the clam (8) Please read poliCy documents carefLJiy
for detailedterms and conditions. For claim status VIsit help section on our web site
Mrs Shilpabahen KetanKumar Female www.hdfcergo.com Alternatively you may wnte to us at
[email protected]Patel
HDFC ERGO General Insurance Company Limited IRDAIReg No.146 GIN U68J3JMHL007PLC177117.
Registered & Corporate Office 1st Floor, HDFC House, 165.166 Backbay Reclamation,H. T.
Parekh Marg, Churchgate,Mumbai -400 CQO Health Claim Ser. ices Address HDFC ERGO General
Insurance Company Lim1ted Stellar IT Park, Tower·1, 5thFloor, C · 25,Naida, Sector 62,
201301,Uttar Pradesh Serv1ce No. 022·623462341 0120·62346234Emal
he<lthcla1ms@hdfcergocomTrade Logo displayed above belongs to HDFC Ltd and ERGO
InternationalAG and used by the Company under license.
HDFC ERGO General Insurance Company Limited. IRDAI RegNo.146 GIN U68J30MH2007PLC177117. Registered &Corporate OffiCe 1st Floor, HDFC House,
HDFC ERGO General Insurance Company Limited
1651166 Backbay Reclamation,H T ParekhMarg, Churchgate,Mumbai· 400 020
Critci al Advantage R1der· HDHHLIP21342VJ22CQ1 I Customer Ser. ice Address D301, 3rd
FloorE, astern Business District (Magnet Maii),LBS Marg,Bhandup (West),
Mumbai4· 00 078 Customer Ser. k;e No +9122 623462341+91·120 6234 62341 www hdfcergo com
