Mr Arun Kumar Assery

1/386 Housing Board

25-Jun-2014
Agency Code

Sriganaganagar- 335001
Rajasthan

80095655

Agency Name

BHAWNA GOEL

Agency Contact No

9313153084

India

Contact No.: 9891566771

Policy No: 110101/11119/6000112372-01
Renewal of Your Optima Restore Insurance Policy
Dear Mr Arun Kumar Assery,
Thank You for renewing the policy with us.
We are pleased to enclose your renewed Policy Kit for the period 23-Feb-2014 to 22-Feb-2015. The Kit contains:

1. The Policy Schedule along with income tax (80 C) certificate (wherever applicable)
2. Member cashless card/s
3. Important Information related to Claim Procedure, and
4. Let's Stay Healthy - Value adds from Apollo Munich

To know more about policy related information and value added offers, you may re-register yourself at our website using your unique member ID and policy number as
mentioned in the policy schedule.

In case of any query, please feel free to write to customerservice@apollomunichinsurance.com or call us at our 24 hours toll free number 1800-102-0333. Our customer care
team will be happy to assist you.

Warm Regards,

Authorized Signatory
Note:- Revision in Policy wordings (if any) due to regulatory compliance or any other reason can be accessed through our
website www.apollomunichinsurance.com.

Please update us with your latest contact details (in case of any change) so that same can be updated in our records.

You can either write back to us or call us on our toll free no. 18001020333.

OPTIMA RESTORE POLICY SCHEDULE - Optima Restore Individual

Issuing Office:

Pitampura Sales Office

Mr Arun Kumar Assery

Policy Holder's Name:

Policy Holder's Address:

1/386 Housing Board

Sriganaganagar- 335001
Rajasthan
India

Agency Code:
Agent Name:
Agent Contact No:
Policy Number:

80095655
BHAWNA GOEL
9313153084
110101/11119/6000112372-01
110101/11119/6000112372-01

First policy inception date:

Policy Period: From 00.00 hrs on 23-MayJul-2014

23-Feb-2013
To 24.00 hrs on 22-Jul-2015

Insured Persons Details:

Member ID
10005815857

Insured Person's Name

Mr Arun Kumar Assery

Nominee Name: Mrs Maheshwari Devi

Age
24

Relationship to Policyholder
Policy Holder

Basic Sum Insured (Rs.)

Multiplier Benefit (Rs)

500000

250000

Relationship: Mother

The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee.

(Rs)
(Rs)
(Rs)
(Rs)

Premium Calculation:
Net Premium Discounts

Loadings
Service Tax

(Rs)

(Rs)

Duties and cess as applicable

Gross Premium

Gross premium amount (in words)

25609.00
0.00
0.00
673.08
20.19
26302.27

Rupees Six Thousand Three Hundred Two and Paisa Twenty-Seven Only

The stamp duty of Rs. 0.50/- (Paisa Fifty Only) paid vide No.F.10(783)/COS(HQ)/Con.duty/08. (Not applicable for the state of Jammu & Kashmir).

Service Tax Registration No.: AAGCA1654HST002

EXCLUSION(S) / SPECIAL CONDITION(S):
Member ID No of Insured

Person Name

Details

10005815857

Mr Arun Kumar Assery

For Rs 500000 (Rupees Five Lakh) Sum Insured - Sec 4B) of the
policy wording is waived, Sec 4C) is reduced to 1 year and Sec
4D) is reduced to 2 years.

Claim Administrator: Apollo Munich

Location: Gurgaon
Date: 25-Jun-2014

For and on behalf of Apollo Munich Health Insurance Company Limited

Authorized Signatory

Certificate for the purpose of deduction under Section 80 C of Income Tax (Amendment) Act, 1986*

This is to certify that Mr Arun Kumar Assery has paid Rs 26302.27 (Rupees Six Thousand Three Hundred Two and Paisa TwentySeven Only ) towards premium for Optima Restore Individual Policy No 110101/11119/6000112372-01 issued to Mr Arun Kumar Assery
for period 23-Feb-2014 to 22-Feb-2015.

For and on behalf of Apollo Munich Health Insurance Company Limited

Location: Delhi

Date: 23-Feb-2014

Authorized Signatory

* Note
1. This is subject to the provisions of Section 80C of income tax (Amendment) Act, 1986 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 policy holder.
3. Please note that this certificate will not be issued if the premium payment has been made in cash.