HDFC ERGO General Insurance Company Limited

2866202575611204000

8 0

Priteshkumar Kanubhai Vyas

B-2, Gayatri Krupa, Opp., Meghna App., Bhagyoday
Society, Chala, Vapi,Valsad Valsad
Gujarat, 396195
Contact No : 9377000389

We have secured your health last year and we are happy to have the privilege of serving you again this year as well.
Your Health insurance policy reference no 2866202575611204000 has been renewed successfully.
For your convenience we have implemented a Lifetime Validity Health Card. For you,this simply means that the Health card issued at the time of first policy purchase is
valid throughout and as long as your policy is active with us.
We look forward to serving you in future and wish you a safe and secure year ahead.

For HDFC ERGO General Insurance Company Limited

Arun Sharma
Head - Customer Experience Management

HDFC ERGO General Insurance Company Limited

TAX CERTIFICATE

Dear Priteshkumar Kanubhai Vyas,

Subject : Certificate for the purpose of deduction under section 80 D of Income Tax (Amendment) Act, 1986
This is to certify that we have received an amount of `7788.00(RUPEES SEVEN THOUSAND SEVEN HUNDRED EIGHTY EIGHT AND ZERO
PAISE)towards premium for my: health Medisure Super Top Up Insurance, Policy No.2866202575611204000 issued to PRITESHKUMAR KANUBHAI VYAS for
the period
29/12/2022 to 28/12/2023
For HDFC ERGO General Insurance Company Limited
Note: This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended from time to time.

Date : 28/12/2022
Policy Issuing Office: Mumbai Duly Constituted Attorney

2004/4125/CR 690/M-1

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 <p class="MsoNormal" style='margin-right:1px;'>HDFC ERGO General Insurance Company
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Limited.(Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Company Limited upto Sept 13, 2016).CIN: U66030MH2007PLC177117.
HDFC ERGO General Insurance Company Limited 2866202575611204000

my: health Medisure Super Top Up Insurance

2866202575611204000

Policy No. : 2866 2025 7561 1204 000 Issuance Date : 28/12/2022 0

Period of Insurance : From 29/12/2022 00:01 hrs hrs To 28/12/2023 Midnight

Invoice No. : 202575611204000 Premium Frequency : Yearly
Priteshkumar Kanubhai Vyas
B-2, Gayatri Krupa, Opp., Meghna App., Bhagyoday Society, Proposer Name : Priteshkumar Kanubhai Vyas Policy Type : Family Floater
Chala, Vapi,Valsad Valsad HSN Code : 997133 Previous Policy No. :2866202575611203000
Gujarat, 396195
Contact No : 9377000389
PAN No. :
EIA No. : Not provided
Payment Details : LH2212006942, Date : 28/12/2022, Bank Name :BizDirect
Email ID : [email protected]
Insured Person’s Details & Sum Insured
Insured's Name Relation with Gender Date of Nominee Name Nominee 1st Policy Sum Insured Deductible Pre Existing
policy holder Birth Relationship Inception (`) (`) Disease
SPOUSE
Priteshkumar Kanubhai Vyas Self Male 11/08/1975 Bhargavi P Vyas 29/12/2018 NA

SPOUSE
Bhargavi P Vyas Wife Female 08/05/1975 Priteshkumar K Vyas 29/12/2018 NA
2000000.00 500000
FATHER
Krutharth Pritesh Vyas Dependent Son Male 02/04/2001 Priteshkumar K Vyas 29/12/2018 NA

FATHER
Neer Pritesh Vyas Dependent Son Male 18/12/2006 Priteshkumar K Vyas 29/12/2018 NA

The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee
Premium Details (`)
Basic Premium 6600.00
Total Premium excluding Taxes 6600.00
Additional Loading 0.00
GST 18% : Central Tax 9%( `594.00)+ State Tax 9%( `594.00) & Kerala Flood Cess At 1% ( `0.00 ) 1188.00
Total Premium 7788.00
Special Conditions : Age proof/identity proof will be collected in event of claim under the policy.
Processing Centre HDFC ERGO General Insurance Company Ltd. 5th floor, Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
For any other query call toll-free 022 - 6234 6234 / 0120 - 6234 6234 or email us at [email protected] or log on to www.hdfcergo.com
I f the premium i s not realised the policy shall be void from inception.Consolidatedstamp duty for this Insurance Policy i s paid b y Demand Draft, vide Receipt/Challan no. LOA/CSD/303/2022/1381 dated
29-03-2022 as prescribed in Government of Maharashrtra Order No. Mudrank -2017/CR.97/M-1, dated 03/JAN/201.. Goods and Service Tax Registration No: 24AABCL5045N1ZE. Goods and Service Tax for this
invoice is not payable under reverse charge basis.
Branch :SHANTI COMPLEX ,SHOP NO # 205 ,2ND FLOOR ,SURVEY NO # 134 NATIONAL HIGHWAY NO # 48 ,BESIDE JALARAM MANDIR VALSAD, 396191. Phone
No. :+91-260-3051501
Agent Name :ANUP SHAH Agent Code :200571592285 For HDFC ERGO General Insurance Company Ltd
Scan the code for Instant Policy Info, Register/Track Claim, Renewal and Modifications in policy.

Duly Constituted Attorney

"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 <p class="MsoNormal" style='margin-right:1px;'>HDFC ERGO General Insurance Company
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Limited.(Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Company Limited upto Sept 13, 2016).CIN: U66030MH2007PLC177117.
 HDFC ERGO General Insurance Company Limited 4
Policy No.:2866202575611204000 This card is for identification purpose only.
Valid From: 29/12/2022 Renewal Date: 28 December
Card has to be presented to the Network Service Provider at the time of admission/ availing
Insured Name Date Of Birth Gender cashless hospitalization o r any other services. Insurance claim will be processed in accordance with
Priteshkumar Kanubhai Vyas 11/08/1975 Male the policy term & conditions. Card does not guarantee cashless hospitalization or any other service.
Bhargavi P Vyas 08/05/1975 Female For more details and updated list of Network Service Provider please refer our website or call our call
Krutharth Pritesh Vyas 02/04/2001 Male centre. This card is valid till the time policy is active.
Neer Pritesh Vyas 18/12/2006 Male
Customer Service No : 022 - 6234 6234 / 0120 - 6234 6234
Fax Number : 1860 2000 600
Email : [email protected]
Processing Centre : HDFC ERGO General Insurance Company Ltd. 5th floor,
Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
Website : www.hdfcergo.com

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 <p class="MsoNormal" style='margin-right:1px;'>HDFC ERGO General Insurance Company
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Limited.(Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Company Limited upto Sept 13, 2016).CIN: U66030MH2007PLC177117.