This Document is Digitally Signed

The Oriental Insurance Company Limited Signer: arti mathur

Date: Sunday, July 11, 2021 4:48 AM
Location: NOIDA

HAPPY FAMILY FLOATER-2015 POLICY SCHEDULE

UIN: OICHLIP445V032021

Policy No. : 192500/48/2022/465 Prev. Policy No. : 192500/48/2021/504

Cover Note No. : - Cover Note Date : -
Insured's Code : 56889544 Issue Office Code : 192500
Insured Name : MR. JAGANNATH CHIMALAPATI Issue Office Name : DO DURG (GSTIN:
(GSTIN: 0) 22AAACT0627R3Z7)
Address : NEAR HOUSE NO 532 HARI Address : NEAR RAJENDRA PARK CHOWK,
NAGAR KATULBOARD DURG CG G.E.ROAD
- DURG
-
- DURG CHATTISGARH 491001
DURG CHATTISGARH 491001
Tel./Fax/Email : / / 9893114333 / Tel./Fax/Email : 0788-2323251/ 2323252/ 4011585/
[email protected] 4051585 / 0788-2322737 /
virendra.jambhulkar@orientalinsuranc
e.co.in
Agent/Broker Details
Dev.Off.Code : NA0000007722 C.K.SHRIVASTAVA
Agent/Broker : BA0000097674 RAKESH GUPTA
Address : MIG-617,PADMANBHPUR,DURG,DURG,MADHYA PRADESH,491001
Tel/Fax/Email : 989300731//NA

Period of Insurance : FROM 00:00 ON 17/07/2021 TO MIDNIGHT OF 16/07/2022

Collection No. & Dt. : CC 9037002200 - 10/07/2021 GST INVOICE NO :222062229 UIN :0
Gross Premium : 8,154 GST 1468 Stamp Duty : .5 Total : 9,622

Co-insurance Details : Nil

TPA Details :
TPA ID : YA0000000335
TPA Name : M/S MEDSAVE HEALTH INSURANCE TPA LTD.
Address : F-701 A, LADO SARAI, MEHRAULI BEHIND GOLF COURSE [email protected]
DELHI 110030 Toll Free No. : 1800111142, 39001234, 011-
Telephone No : FAX No. : 29521061-66

Number of persons covered : 4 Plan Type : SILVER Plan Sum Insured : 200000
Particulars of the Persons covered :

Place : DURG For and on behalf of

Date : 10/07/2021 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupees Page 1 of 4
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 This Document is Digitally Signed

The Oriental Insurance Company Limited Signer: arti mathur

Date: Sunday, July 11, 2021 4:48 AM
Location: NOIDA

Attached to and forming part of policy number 192500/48/2022/465

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 JAGANNATH M 01/07/1973 48 Self NIL 10

CHIMALAPATI
2 SMT JYOTI F 06/12/1984 36 Spouse NIL 10
CHIMALAPATI Unemployed
3 KU. NANDINI F 27/07/2007 13 Dependant Child NIL 10
CHIMALAPATI
4 KU. SHREE LAXMI F 04/02/2011 10 Dependant Child NIL 10
CHIMALAPATI

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

Optional Covers
Value
LIFE HARDSHIP BENEFIT NO
RESTORATION OF SI NO

Total Premium in words : Indian Rupees Nine Thousand Six Hundred Twenty-Two 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.

In the event of a claim under the policy exceeding Rs. 1 lac or a claim for refund of premium exceeding Rs. 1 lac,the
insured will comply with the provisions of the AML policy of the Company.The AML policy is available in all our operaing
offices as well as Company's website.

Place : DURG For and on behalf of

Date : 10/07/2021 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupees Page 2 of 4
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 This Document is Digitally Signed

The Oriental Insurance Company Limited Signer: arti mathur

Date: Sunday, July 11, 2021 4:48 AM
Location: NOIDA

Attached to and forming part of policy number 192500/48/2022/465

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 DO DURG (GSTIN: 22AAACT0627R3Z7) on 10-JUL-21.

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

192500/48/2015/498 17-JUL-14 16-JUL-15 OICO DURG 300000

192500/48/2016/604 17-JUL-15 16-JUL-16 OICO DURG 3000000

192500/48/2013/572 17-JUL-12 16-JUL-13 OICO DURG 100000

192500/48/2014/506 17-JUL-13 16-JUL-14 OICO DURG 100000

192500/48/2017/587 17-JUL-16 16-JUL-17 The Oriental Insurance Company Ltd. 300000

192500/48/2018/599 17-JUL-17 16-JUL-18 The Oriental Insurance Company Ltd. 300000

192500/48/2019/595 17-JUL-18 16-JUL-19 The Oriental Insurance Company Ltd. 300000

192500/48/2020/519 17-JUL-19 16-JUL-20 The Oriental Insurance Company Ltd. 300000

Place : DURG For and on behalf of

Date : 10/07/2021 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupees Page 3 of 4
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 This Document is Digitally Signed

The Oriental Insurance Company Limited Signer: arti mathur

Date: Sunday, July 11, 2021 4:48 AM
Location: NOIDA

Attached to and forming part of policy number 192500/48/2022/465

192500/48/2021/504 17-JUL-20 16-JUL-21 The Oriental Insurance Company Ltd. 200000

Claim History Data

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

192500/48/2021/504 MR. JAGANNATH 192500/48/2022/00000047 .00 5,13,00.00

CHIMALAPATI

"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
R.K.PLAZA, PANCHPEDI NAKA,RING ROAD 1,,. 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."

Entered By : [email protected]
For and on behalf of
Policy Printed By : OICL IP : The Oriental Insurance Company Limited

Policy Printed On : 11-JUL-21 04:46:09 MAC :

Authorised Signatory

Place : DURG For and on behalf of

Date : 10/07/2021 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

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