HAPPY FAMILY FLOATER-2015 POLICY SCHEDULE

UIN: IRDAI/HLT/OIC/P-H/V.II/450/15-16

Policy No. : 141200/48/2018/2922 Prev. Policy No. : 141200/48/2017/3142

Cover Note No. : - Cover Note Date : -
Insured's Code : 36374830 Issue Office Code : 141200
Insured Name : SANJAY K SHAH (GSTIN: ) Issue Office Name : AHMEDABAD DO II (GSTIN:
24AAACT0627R2Z4)
Address : 10/A MADHUKUNJ SOCT Address : KALIDAS CHAMBERS NR DINBAI
MANINAGAR EAST TOWER LALDARWAJA
NR OLD RLY CROSSING -
-
ABAD AHMEDABAD GUJARAT 380001

Tel./Fax/Email : / / / Tel./Fax/Email : 079 -25507888,25506489,25507471 /

079- 25509165 /
[email protected]
Agent/Broker Details
Dev.Off.Code : NA0000003823 SUBHASH U. KUHIKAR
Agent/Broker : BA0000049947 RAVINDRA K BARAIYA
Address : 38, SAUNDARYA PARK SOCIETY, MANINAGAR (E),
AHMEDABAD.,AHMEDABAD,GUJARAT,380008
Tel/Fax/Email : 9426579434/09426579434//NA

Period of Insurance : FROM 00:00 ON 03/05/2017 TO MIDNIGHT OF 02/05/2018

Collection No. & Dt. : CHQ 3056003024 - 27/04/2017
Gross Premium : 8,229 Service Tax 1234 Stamp Duty : .5 Total : 9,463

Co-insurance Details : Nil

TPA Details :
TPA ID YA0000000336
TPA Name M/S E-MEDITEK INSURANCE TPA LIMITED
Address : 577, Udyog Vihar Phase V, Gurgaon, Haryana. [email protected]
GURGAON 122016 Toll Free No. : 18001023242, 0124-4466600
Telephone No : FAX No. :

Number of persons covered 3 Plan Type SILVER Plan Sum Insured 300000
Particulars of the Persons covered :

Sr. Name of The Relationship Pre-Existing

Gender Date of Age Co-Pay PA Capital
No. Persons With Diseases
Birth (%) Sum Insured (INR)
Proposer

1 SANJAY K SHAH M 15/06/1979 37 Self 10

2 SARIKA S SHAH F 07/12/1978 38 Spouse 10
Unemployed

Place : AHMEDABAD For and on behalf of

Date : 27/04/2017 The Oriental Insurance Company Limited

In case of any query regarding the Policy please call Toll General Manager
Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupee Page 1 of 4
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
Attached to and forming part of policy number 141200/48/2018/2922

3 BHAVYA S SHAH M 24/02/2006 11 Dependant 10

Child
Nominee Details
Name Of the Nominee Relationship With the Insured Age Of the Nomine M/F/TG*

Optional Cover
Value
LIFE HARDSHIP BENEFIT NO
RESTORATION OF SI NO

Total Premium in words : Indian Rupees Nine Thousand Four Hundred Sixty-Three Only

The insurance under this policy is extended to cover risks of Domiciliary Hospitalisation up to 10 % of sum insured subject to maximum Rs
50000 only ( Fifty Thousand Only).
The insurance under this policy is extended to cover risks of :
Personal Accident Cover, Domiciliary Hospitalisation Limit, Daily cash allowance.
Deductible : Nil
The insurance under this policy is subject to conditions, clauses, warranties,endorsements as per forms attached.
The policy shall pay for hospitalisation expenses for medical/surgical treatment taken as an in-patient at any Nursing
Home/Hospital in INDIA as defined in the policy.

Warranted that in case the person covered under the policy has lodged any claim under the previous policy and the sum
insured is enhanced under the current policy, for a further claim for the same disease during the current policy, the earlier
limit of Sum Insured shall be applicable and not the enhanced sum insured.

Warranted that in case of dishonour of premium cheque(s) the Company shall not be liable under the policy and the policy
shall be void abinitio (from inception).

"We at Oriental continuously strive to ensure that you get the best possible treatment from our network hospitals.
Please contact your TPA or any of the Oriental offices for our preferred hospitals in your area before going for a
treatment. This will help us serve you in the best possible manner"

In witness whereof the undersigned being authorised by and on behalf of the Company has/have herein to set his/their hands
at AHMEDABAD DO II (GSTIN: 24AAACT0627R2Z4) on 27-APR-17.

Place : AHMEDABAD For and on behalf of

Date : 27/04/2017 The Oriental Insurance Company Limited

In case of any query regarding the Policy please call Toll General Manager
Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupee Page 2 of 4
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 Attached to and forming part of policy number 141200/48/2018/2922

1.Claim to be reported within 48 hrs of admission but before discharge.

2.Claim documents to be submitted within 15 days of discharge.

For complete details please refer to policy condition.

Policy History Data

Policy No. Period From Period To Insurer Name Sum Insured

141200/48/2011/2038 03-MAY-10 02-MAY-11 The Oriental Insurance Company Ltd. 100000

141200/48/2012/2409 03-MAY-11 02-MAY-12 The Oriental Insurance Company Ltd. 100000

141200/48/2013/2906 03-MAY-12 02-MAY-13 The Oriental Insurance Company Ltd. 100000

141200/48/2014/3074 03-MAY-13 02-MAY-14 The Oriental Insurance Company Ltd. 100000

141200/48/2015/3379 03-MAY-14 02-MAY-15 The Oriental Insurance Company Ltd. 100000

141200/48/2016/3004 03-MAY-15 02-MAY-16 The Oriental Insurance Company Ltd. 200000

141200/48/2017/3142 03-MAY-16 02-MAY-17 The Oriental Insurance Company Ltd. 300000

Claim History Data

Policy no. Claimant Nam Claim No. Claim OS Claim Paid

"In case of grievance related to any issue related to this policy the same may be addressed to the office In-Charge or the Grievance Officer
at above policy address. If the grievance remains pending, it may be escalated to Grievance Officer of the concerned Regional Office 3 RD
FLOOR NAVJEEVAN TRUST BUILDING,B/H GUJARAT VIDYAPEETH NAVJEEVAN,TRUST BUILDING OFF ASHRAM
ROAD,AHMEDABAD. The next escalation in case grievance remains unresolved is CSD, Head Office, situated at Oriental House, A-25/27,
Asaf Ali Road, New Delhi-110002.
If the insured is not satisfied with the resolution/reply provided by the company, he/she may approach the Office of Insurance Ombudsman,
within his/her jurisdiction. The list of offices of Ombudsman is available on Company's portal."

Place : AHMEDABAD For and on behalf of

Date : 27/04/2017 The Oriental Insurance Company Limited

In case of any query regarding the Policy please call Toll General Manager
Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupee Page 3 of 4
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
Attached to and forming part of policy number 141200/48/2018/2922

Entered By : MS. D B CHAKRABORTY

For and on behalf of
Examined By : S U Kuhikar The Oriental Insurance Company Limited

Policy Printed By : PRTL IP :

Policy Printed On : 10-SEP-17 23:25:37 MAC : General Manager

Authorised Signatory

Place : AHMEDABAD For and on behalf of

Date : 27/04/2017 The Oriental Insurance Company Limited

In case of any query regarding the Policy please call Toll General Manager
Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupee Page 4 of 4
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in