HN08022010000125 E

HDFC ERGO General Insurance Company Limited

SARV SURAKSHA ADVANTAGE POLICY SCHEDULE

Policy No: 50142916 Issued On : 20/02/2012 Location : Mumbai

PERSONAL DETAILS

Name of Proposer Address

UDAYKUMAR NAIK B-401 KAPILA VASTU BLDG. NO. 1 KOLBAD ROAD NEAR PRATAP CINEMA THANE (WEST) THANE - 400601 MAHARASHTRA Tel.(Res.) Mobile No. 25473991 9987222376 Office No.

Contact Nos

Email id Name of Nominee

udaykumarnaik@hotmail.com SMITA NAIK

POLICY AND PREMIUM DETAILS

Relationship to the Insured

Spouse

Policy Commencement
Sr.No.

13/02/2012
Relationship

Policy Expiry Date

Date of Birth Age Benefit % (Yrs)

12/02/2013
Nominee Name

List of Insured Persons/Dependents

1 2 3 Sr.No. 1 2

UDAYKUMAR NAIK SMITA NAIK SHUBHAMKAR NAIK Coverage Education Benefit Personal Accident

Self Wife Son

08/08/1967 05/01/1974 13/03/2001

44 37 10

100% 50% 25%

SMITA NAIK Sum Insured (Rs) 500,000 100,000

Description On Accidental Death of Self Only Accidental Death Only

TERMS & CONDITIONS

1. 2. 3. 4.

The maximum claim amount payable on this certificate is Rs. 100,000. The maximum claim amount payable for each member specified under this certificate shall be restricted to the Benefit % of the SI as shown in the schedule. The operative time for this Policy shall be 24 Hrs. The Territorial Limits for this policy shall be worldwide

PREMIUM DETAILS

Gross Premium (Rs.) Tax,duties and cess as applicable (Rs.)

Net Premium (Rs.)

792 82
874

Address of Issuing Office Date

6th Floor,Leela Business Park,Andheri-Kurla Road,Andheri (East) Mumbai 400059. 02/03/2012

Consolidated stamp duty for this Insurance Policy is paid by Demand Draft,vide Receipt/Challan no. 50436 dated 14/03/2011 as prescribed in Government Notification Revenue and Forest Department No Mudrank 2004/4125/CR 690/M-1, dated 31/12/2004.

Agent Code: 201587086428

Insurance is the subject matter of the solicitation. 6th Floor, Leela Business Park , Andheri Kurla Road , Andheri (East), Mumbai 400 059, Toll-Free No. 1800-2-700-700 Fax : 91 22 6638 3699 care@hdfcergo.com www.hdfcergo.com Registered Office : Ramon House , H.T. Parekh Marg, 169 , Backbay Reclamation , Mumbai 400 020.

HDFC ERGO General Insurance Company Limited

SARV SURAKSHA ADVANTAGE POLICY SCHEDULE

Agent Name: HDFC BANK LTD (PHONE BANKING) Phone No: 022-28561818
Service Tax Reg. No.: AABCH0738EST004

For HDFC ERGO General Insurance Company Limited

Duly Constituted Attorney

Insurance is the subject matter of the solicitation. 6th Floor, Leela Business Park , Andheri Kurla Road , Andheri (East), Mumbai 400 059, Toll-Free No. 1800-2-700-700 Fax : 91 22 6638 3699 care@hdfcergo.com www.hdfcergo.com Registered Office : Ramon House , H.T. Parekh Marg, 169 , Backbay Reclamation , Mumbai 400 020.