Group Activ Secure - Certificate of Insurance

Unit no 1101 & 1104 11th

Unit no 1101 & 1104 11th floor,
floor, Unit no 1501& 1502,
Unit no 1501& 1502, 15th floor,
15th floor, G Corp Tech
Policy Issuing Office Policy Servicing Office G Corp Tech Park, Kasarwadavali,
Park, Kasarwadavali,
Ghodbunder Road, Thane
Ghodbunder Road, Thane
West-400615
West-400615
Master Policy Number 4-62-23-0001287-000 Certificate Number GFB-62-24-1895552-000
Master Policyholder
HDFC Bank Limited
Name
Product Name Group Activ Secure Member Id PT7913068
Plan Name Plan C
BANDI NARAYANA
C/O Bandi Obilesu 1/79
AVULAMARAMMAGUDI
STREET KOTHA
Name of Proposer and
MADHAVARAM SIDHOUT Unique Identification
Residential Address of 153116625
MANDALKADAPA516247AND Number
Proposer
HRA
PRADESH,,,Sidhout,Cuddapa
h,INDIA,ANDHRA
PRADESH,516247
Mobile Number 7013388128 Email Id info.lakshmisql@gmail.com

Inception date & Time of Master Policy 00:01 hrs 05/01/2024

Expiry Date & Time of Master Policy 23:59 on 06/10/2027
Period of Insurance 5 Years
Start Date 00:01 hrs 18/06/2024
End Date 23:59 on 17/06/2029
Insured Person Detail

Nominee
Insured Person Date of Birth Gender Nominee Sum Insured
Relationship
PUTTURU NAGA As Per Coverage
BANDI NARAYANA 07/07/1994 Male Spouse
LAKSHMI Details

Coverage Details

Group Activ Secure -

Capital Sum Insured/ Sum Insured (Rs)
Personal Accident
Section A: Basic Covers
800000
Accidental Death Cover (AD)

100000
Accidental In-patient Hospitalization
Accidental hospitalization is covered upto Rs 100,000/- on indemnity basis or actual claims
(limited to India)
whichever is lower. minimum 24 hrs hospitalization is required.
800000
Permanent Total Disablement (PTD)

Group Activ Secure -

Sum Insured (Rs)
Critical Illness
Group 11 CIs
Initial Waiting Period -90 Days
Critical Illness Benefit
100000
Pre Existing Disease-Not covered
30
Survival Period

Product UIN : ADIHLGP23155V032223

Grievance Redressal

In case of a grievance, the Insured Person/ Policyholder can contact Us with the details through our website:
www.adityabirlacapital.com,Email:care.healthinsurance@adityabirlacapital.com or Toll Free : 1800 270 7000. Address: Any of Our
Branch office or Corporate office. For senior citizens, please contact respective branch office of the Company or call at 1800 270
7000 or write an e- mail at seniorcitizen.healthinsurance@adityabirlacapital.com. The Insured Person can also walk-in and
approach the grievance cell at any of Our branches. If in case the Insured Person is not satisfied with the response, then they
can contact Our Head of Customer Service at the following email carehead.healthinsurance@adityabirlacapital.com. If the Insured
Person is still not satisfied with Our redressal, he/she may approach the nearest Insurance Ombudsman. The contact details of
the Ombudsman offices are provided on Our website and in the Policy.

Policy Exclusions
Plan C <As per Quote & Policy Wordings>

Premium Details
Particulars Amount
Net Premium 2603.26
CGST (9%) 234.29
SGST / UTGST (9%) 234.29
IGST (18%) NA
Total Premium 3071.84
Premium payment mode CD-Customer
GST Registration No.: 27AANCA4062G1ZN Category: General Insurance SAC Code: 997133

Authorized Signatory

Claim Process
Address for Unit no 1101 & 1104 11th floor, Unit no 1501& 1502, 15th floor, G Corp Tech
Please contact us
Correspondence Park, Kasarwadavali, Ghodbunder Road, Thane West-400615
through any of these
Contact Number 1800 270 7000
Modes
Email ID care.healthinsurance@adityabirlacapital.com

Product UIN : ADIHLGP23155V032223

 PREMIUM CERTIFICATE

Premium Certificate is for the purpose of deduction under Section 80-(D) of Income Tax (Amendment) Act 1986.
This is to certify that BANDI NARAYANA paid INR. 3071.84 (In words Three Thousand Seventy One and Eight Four Paisa Only)
towards Premium for Health Insurance for the Period from null to midnight null.

Instrument Number Instrument Date Amount Name of the Bank

NA 19/06/2024 3071.84 HDFC

Stamp Duty - Consolidated Stamp Duty paid vide E-challan GRN no. MH015093118202324E dated 05/02/2024

Master Policy Number: 4-62-23-0001287-000 Certificate GFB-62-24-1895552-000

Date 18-06-2024 Place: Mumbai

Authorized Signatory

Note Amount is inclusive of all taxes and cesses as applicable. This certificate must be surrendered to the Insurance
Company for issuance of fresh certificate in case of cancellation of Master Policy or any alteration in the insurance
affecting the premium. Only for Premium contributed towards Group Critical Illness and Group Hospital Cash

Product UIN : ADIHLGP23155V032223

 Group Protect - Certificate of Insurance
Unit no 1101 & 1104 11th floor, Unit no 1501& MBC InfoTech Park, 07th Floor, C
Policy Issuing Office 1502, 15th floor, G Corp Tech Park, Kasarwadavali, Policy Servicing Office Building,,Kasarvadavali, Ghodbunder Road,Thane
Ghodbunder Road, Thane West-400615 West, Mumbai (W),Thane,MAHARASHTRA,400615
Master Policyholder's
HDFC Bank Limited Policy Number 4-74-23-0000016-000
Name
HDFC Bank House, 1st Floor,C.S.No.6/242,Senapati
Master Policyholder's
Bapat Marg,Lower Parel,Mumbai - 400 013 Product & Plan Name Group Protect
Address
,NA,,Mumbai,Mumbai,INDIA,MAHARASHTRA 400013
Policy start date 18/06/2024 Policy end date 17/06/2029
Intermediary Code 2113243 Intermediary Name HDFC Bank - Personal Loan
Intermediary E-mail ID NA Intermediary Contact Details 9999999999
Certificate Number GP-74-24-0079624-000
Name of Proposer and BANDI NARAYANA
Residential Address of C/O Bandi Obilesu 1/79 AVULAMARAMMAGUDI STREET KOTHA MADHAVARAM SIDHOUT MANDALKADAPA516247ANDHRA
Proposer PRADESH,,,Sidhout,Cuddapah,INDIA,ANDHRA PRADESH,516247
Communication Address of
the Proposer (Please
NA
mention if different than
Residential Address)
Unique Identification 153116625 Coverage Type Individual
Insured Person Email ID info.lakshmisql@gmail.com Insured Person Contact Details 7013388128
Period of Insurance: From 00:00 hrs on 2024-06-18 00:00:00.0 To 23:59 hrs on 2029-06-17 00:00:00.0 (both days inclusive)

Insured Person Details

Initial Certificate
Insured Person Name/ Unique
Member ID Date of Birth Gender Nominee Name Relationship Number & Initial start
Identifier
date
PT7913286 BANDI NARAYANA 07/07/1994 Male PUTTURU NAGA LAKSHMI Spouse NA

Coverage Details

A) OPD Expenses
Cover Payout Basis Options Applicability Sum Insured / Limit
OPD Expenses Indemnity Applicable NA
Waivers
30 days Waiting Period Applicable

D) Preferred provider network

Cover Payout Basis Options Applicability Sum Insured / Limit
Preferred provider
network (Can be
opted only along Indemnity Applicable NA
with Coverage -
OPD Expenses)
30 days Waiting Period Applicable

I) Credit Protect
Cover Payout Basis Options Applicability Sum Insured / Limit
Credit Protect Fixed ADPTD Applicable 2000000

Group Protect, Product UIN: ADIHLGP22023V032122.

 Assignment
Assigned to NA

Coverages assigned NA

Pre-Existing Disease Details

Premium Details
Particulars Amount (Rs.)
Net Premium 6456.36
CGST (9%) 581.07
SGST / UTGST (9%) 581.07
IGST (18%) NA
Gross Premium 7618.5

GST Registration No.: 27AANCA4062G1ZN Category: General Insurance SAC Code: 997133

Claim Assistance
Unit no 1101 & 1104 11th floor, Unit no 1501& 1502, 15th floor, G Corp Tech Park, Kasarwadavali,
Address for Correspondence
Please contact us Ghodbunder Road, Thane West-400615
through any of these Contact Number 1800 270 7000
Modes Fax Number
Email ID care.healthinsurance@adityabirlacapital.com

Underwriter Notes and Important terms & conditions

NA

Group Protect, Product UIN: ADIHLGP22023V032122.

 Premium Receipt
We confirm the receipt of premium amount of INR 7618.5 as per below details paid by Mr./Mrs. BANDI NARAYANA for Self and/or Family and/or Parents

COI Number Type of Coverage Premium Amount (Rs.) Payment Date

GP-74-24-0079624-000 Individual 7618.5 19/06/2024

Policy Number: 4-74-23-0000016-000

Date: 18-06-2024 Place: Mumbai

Year wise breakup of premium for the purpose of claiming Income Tax deduction u/s 80D (subject provisions of Income Tax Act) is provided as under:

Financial Year Year wise proportionate Premium amount*

2024-25 1,523.70
2025-26 1,523.70
2026-27 1,523.70
2027-28 1,523.70
2028-29 1,523.70

*Amount is rounded off to nearest rupee and is inclusive of all taxes and cess as applicable.

Note:
1. Premium paid in cash and premium paid towards credit protect cover do not qualify for deduction u/s 80D. Further premium paid for person other than family member &
parents (as defined under Income Tax Act) also don't qualify for deduction under section 80D
2. Deduction under section 80D of the Act is allowed to the person who pays premium out of his/her income chargeable to tax.
3. Tax laws are subject to change and any such change could have a retrospective effect. This letter should not be construed as tax, legal or investment opinion from us. For
specific suitability, you are requested to consult your tax advisor.
4. This receipt 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.

Stamp Duty :-
Consolidated Stamp Duty paid vide E-challan GRN no. MH015093118202324E dated 05/02/2024

Grievance Redressal
In case of a grievance, the Insured Person / Policyholder can contact Us with the details through our website: www.adityabirlacapital.com, Email:
care.healthinsurance@adityabirlacapital.com or Toll Free: 1800 270 7000. Address: Any of Our Branch offices or Corporate Office. For senior citizens, please contact
respective Branch Office of the Company or call at 1800 270 7000 or write an e- mail at seniorcitizen.healthinsurance@adityabirlacapital.com The Insured Person can
also walk-in and approach the grievance cell at any of our branches. If in case the Insured Person is not satisfied with the response, then they can contact our Head of
Customer Service at the following email carehead.healthinsurance@adityabirlacapital.com. If the Insured Person is still not satisfied with our redressal, he/she may
approach the nearest Insurance Ombudsman. The contact details of the Ombudsman offices are provided on our website and in the Policy.

Note: This certificate must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation of Policy or any alteration in the insurance
affecting the premium.

Important –
1) In case of payment by cheque, in the event of dishonour of cheque for any reason whatsoever, insurance provided under this document automatically stands cancelled
from the inception irrespective of whether a separate communication is sent or not
2) Insurance cover is subject to the terms and conditions mentioned in the Policy wordings provided to you with this Certificate of Insurance. For complete set of benefits,
terms, conditions & exclusions please refer policy wordings.
3) The assignment of Benefits under the Policy shall be allowed subject to applicable law.

Authorised signatory

Group Protect, Product UIN: ADIHLGP22023V032122.

Group Protect, Product UIN: ADIHLGP22023V032122.
Policy No: 4-74-23-0000016-000 COI No. GP-74-24-0079624-000
Coverage Start Date: 18/06/2024 Coverage End Date: 17/06/2029

Name Membership No. Relationship DOB

BANDI NARAYANA PT7913286 Self 07/07/1994

• This card is only identification and is not an authorization to proceed with the treatment or guarantee for payment.
• In case photo less identity cards issued to beneficiaries, acceptable proof of identity such as Aadhar Card/Passport/Driver
License /Ration Card/Voters ID/ PAN Card should be presented at the hospital.
• This non-transferable identification card is valid at selected Network Hospitals & will enable Card Holder to avail cashless
hospitalization only on pre-authorization by Aditya Birla Health Insurance Co. Ltd
• For latest updated network hospital list, log on to https://www.adityabirlahealth.com/healthinsurance/#!/provider-search