Group MediPrime

Certificate of Insurance
81-TrackOn-620003139560-

2700001636 - 7
RAJESH TIWARI

170 INDIRAPURAM COLONY PARTAP Intermediary Code : 0015455000

UR ,RITHANI MEERUT ,MEERUT,, Intermediary Name: Axis Bank Limited

U00A0RITHANICOLONY,PARTAPUR ,MEERUT Intermediary Contact Number: 1800 209 2001

. Branch Code: Tata AIG, HO

MEERUT - 250103 - MEERUT Master Policy Number: 2700001636

UTTAR PRADESH Certificate Number: 7

Mobile No.: 9897149122 Application no. 918010102604796

Bank A/C No.: 918010102604796 Issuing Office: Tata AIG, HO

Master Policy Period : From 14/02/2019 00:00 AM (Commencement Date) To 13/02/2020 23:59 PM (Expiry Date)

Name of the insured member Member Id Gender Date of birth Age (years) Date of joining
2700001636/9180101026
RAJESH TIWARI M 05/07/1975 43
04796/01
2700001636/9180101026
anju tiwari F 07/04/1981 37
04796/02
*FLOATER SUM INSURED - Rs. 300000

NOMINEE NAME: anju tiwari

Coverage details:

Floater

Basic Health Cover

Coverage (Basic Cover) Sum Insured (INR)

Inpatient Treatment Upto Sum Insured limit
Pre/Post Hospitalization (30/60 Days) Upto Sum Insured limit
Day care procedures Upto Sum Insured limit
Domiciliary Treatment Upto Sum Insured limit
Emergency Ambulance Maximum INR 2000 per Hospitalisation
Organ Donor Upto Sum Insured limit
Covered, INR 100 per day up to a maximum
Nursing Allowance
of 15 days with a deductible of 2 days
Family Transportation Upto Rs.5000

Additional conditions /exclusions (if any)

Premium Calculation:
Basic Premium (Rs.): 5624
Loading(Rs ):-
Discounts (Rs) :--
Tax as applicable(Rs.): 1012
Gross Premium (Rs.):6636
Gross Premium amount (in words) :Six Thousand Six Hundred Thirty-Six
The stamp duty of Rs. 1/- (One Rupees only) paid in cash or demand draft or by pay order, vide receipt
/challan no. CSD/272/2018/5529/18, dated 19th December, 2018.
GST Number: 27AABCT3518Q1ZW

Claim Procedure:
For any claim related query, intimation of claim and submission of claim related documents, You can contact our duly
licensed TPA through:TPAdetails(IfAny):FamilyHealthPlan(TPA)Ltd.

- Website : www.fhpl.net
- Email : info@fhpl.net
seniorcitizensdesk@fhpl.net (for Senior Citizens)

- Toll Free : 1800-425-4090

040- 23552899 (for Senior Citizens)

- Fax : +91-40-23541400

- Courier : Claims Department,

Family Health Plan Insurance TPA Limited,
Srinilaya – Cyber Spazio
Suite # 101,102,109 & 110, Ground Floor,
Road No. 2, Banjara Hills,
Hyderabad-500 034

Documents for claims:

Claim documentation will include but is not limited to the following:
i) Our claim form -duly completed and signed for on behalf of the Insured Person.
ii) Original Bills (including but not limited to pharmacy purchase bills, consultation bills, diagnostic bills) and any
attachments thereto like receipts or prescriptions in support of any amount claimed which will then become Our
property.
iii) All reports, including but not limited to all medical reports, case histories, investigation reports treatment papers,
discharge summaries.
iv) A precise diagnosis of the treatment for which a claim is made.
v) A detailed list of the individual medical services and treatments provided and a unit price for each.
vi) Prescriptions that name the Insured Person and, in the case of drugs, the drugs prescribed, their price and a receipt
for payment. Prescriptions must be submitted with the corresponding Medical Practitioner’s invoice.

The Policyholder(s) shall have right to exercise an option to change the TPA within 30 days prior to the date of Renewal of
the Policy from empanelled TPA’s for serving and process claim under the Group MediPrime Policy.

This is only a summary of the product features. The actual benefits available are as described in the policy and will be
subject to the enclosed policy terms, conditions and exclusions.

This is to certify that RAJESH TIWARI has paid an amount of Rs. 6636 towards premium for the aforesaid policy for the
period 14/02/2019 to 13/02/2020 and is eligible for tax exemption (upto Rs.25,000) under Section 80D of Income Tax Act.

For and on behalf of Tata-AIG General Insurance Company Limited

Place: Mumbai Authorized Signatory

Date: 15/04/2019
Member Id : 2700001636/918010102604796/01
Name : RAJESH TIWARI
Age : 43
Gender : Male
Policy No. : 2700001636
Group : Axis Bank Limited
Valid Through: 14/02/2019 To 13/02/2020
81

Member Id : 2700001636/918010102604796/02
Name : anju tiwari
Age : 37
Gender : Female
Policy No. : 2700001636
Group : Axis Bank Limited
Valid Through: 14/02/2019 To 13/02/2020
81
 PROPOSAL DETAILS

Dear Mr. / Miss / Ms. Customer RAJESH TIWARI

Please note, you have been enrolled in the TATA AIG General Insurance Company’s Group Mediprime policy (UIN :
TATHLGP14004V011314) based on information provided by you over the telephone to our representativeThis information provided to our
representative on the telephone call was as follows. we request you to go through the details carefully and thoroughly to ensure that all the
details have been captured accurately and intimate us if there is a discrepancy.

Application number: 918010102604796 Bank A/c No: 918010102604796

Proposal Date: 13/02/2020 Policy Number: 2700001636 7
Policy Type: Floater Plan Type: 2 Adult Policy Term: 1year
Policy Commencement date: 13/02/2020 Policy Expiry Date: 13/02/2020

Name of the Proposer: RAJESH TIWARI Date of Birth:05/07/1975

Policy Holder’s Address: 170 INDIRAPURAM COLONY PARTAP, UR ,RITHANI MEERUT ,MEERUT,,,
U00A0RITHANICOLONY,PARTAPUR ,MEERUT, ., MEERUT, MEERUT, UTTAR PRADESH-250103
Contact Detail (R): (O): (M): 9897149122 Email Id: tiwarirajesh5775@gmail.com
Marital Status: Nationality: Indian PAN No:____________
Aadhaar No. _____________

Insured Persons Details:

Insured Person's Name Date of Birth Gender Relationship with Proposer Nominee Name Sum Insured

1. RAJESH TIWARI 05/07/1975 M Self anju tiwari 300000

2. anju tiwari 07/04/1981 F Spouse RAJESH TIWARI 300000

* For Family Floater policy Sum Insured floats among the insured members of the family as mentioned above
Nominee Details:
In the event of death of an Insured Person any payment due under the Policy shall become payable to the nominee in accordance with the
policy terms and conditions.. The nominee for all other Insured Persons proposed to be insured shall be the Proposer himself/herself.

Sr. No. Nominee Name Relationship

1. anju tiwari Wife

2. RAJESH TIWARI Husband

Commencement of risk cover under the policy is subject to receipt of premium by Tata AIG General Insurance
Company Limited.
Note - You are entitled to a voice copy of the call any time as per your need, during the tenure of the policy and
till satisfactory settlement of the claims whichever is later.

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 Ltd. Registered office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel,
Mumbai - 400013. Toll Free Nos. 1800 266 7780 . For more information Visit us at www.tataaig.com,Email us at customersupport@tataaig.com UIN:TATHLGP14004V011314
IRDA of India Registration No.: 108 CIN : U85110MH20000PLC128425 PAN: AABCT3518Q