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BlueDart / 38664062706 / M-20135

Policy No. : 0288584760 00

Name : Mr CHALAPATHI YARALAGADDA
Address : NO-14, A1 BLOCK
VIJAYANAGARA STAGE 3
MYSORE - MYSORE
KARNATAKA - 570017
7022001054

Regd Office : 15th floor, Tower A, Peninsula Bussiness Park, G.K Marg, Lower Parel, Mumbai - 400 013 Toll Free No. (24*7) : 1800 266 7780
Fax : 022 6693 8170 Email : [email protected] IRDA Of Indian Registration No : 108 Website : www.tataaig.com
CIN : U85110MH2000PLC128425 | UIN : TATHLIP21224V022021
Policy No. 0288584760 / M-20135 Page No. 1
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Intermediary name : DIRECT

Policy
Schedule } Intermediary code : NA
Intermediary contact no. : 24*7 Tollfree Helpline 1800-266-
7780
Issuing Office : MUMBAI
Client Id : 6090328644
Proposal no : CUSTP28880150571
Policy holder’s name : CHALAPATHI YARALAGADDA
Policy holder’s address : NO-14, A1 BLOCK
VIJAYANAGARA STAGE 3
MYSORE,570017
MYSORE KARNATAKA
7022001054

Policy Number : 0288584760 00

Product name : Tata AIG MediCare
Plan type : Floater Basis
Policy period : From 12/04/2021 00:00 hrs to 11/04/2022 on 11:59 PM
Business Type : NEW BUSINESS
Policy Tenure : 1 Year
Insured Persons Details :
Member Insured Insured Date Age Relation- Restore Sum Cumu- Accidental
ID person’s with TATA of Birth ship to Benefits Insured lative Death
name AIG General proposer % (Rs.) Bonus (Rs.)
Insurance (Rs.)
Co. Since

CUSTP288801 CHALAPATHI
12/04/2021 06/01/1990 31 Self 100 0.00
5057101031 YARALAGADDA

CUSTP288801 NEERAJA
12/04/2021 28/03/1997 24 spouse 100 500,000.00 0.00 0.00
5057102024 YARALAGADDA

CUSTP288801 RUDRANSH
12/04/2021 24/08/2020 0 Son 100 0.00
5057103000 YARLAGADDA

* For Family Floater policy, Sum Insured and cumulative bonus floats among the insured members of the family as mentioned above.

Nominee Details for Proposer:

Insured Name Nominee Name Relationship to Proposer
CHALAPATHI YARALAGADDA NEERAJA YARALAGADDA Wife
The nominee must be an immediate relative of the policyholder. For all other insured persons the policyholder shall be the nominee.

Regd Office : 15th floor, Tower A, Peninsula Bussiness Park, G.K Marg, Lower Parel, Mumbai - 400 013 Toll Free No. (24*7) : 1800 266 7780
Fax : 022 6693 8170 Email : [email protected] IRDA Of Indian Registration No : 108 Website : www.tataaig.com
CIN : U85110MH2000PLC128425 | UIN : TATHLIP21224V022021
Policy No. 0288584760 / M-20135 Page No. 2
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Benefits table
Net Premium: (Rs) 13464.72
Cover Coverage
Discounts: (Rs) 5236.00
Loading: (Rs) 0.00
In-Patient Treatment Upto Sum Insured
UGST/SGST (9%): (Rs)
Pre-Hospitalization expenses Upto 60 days CGST(9%): (Rs)
IGST(18%): (Rs) 2423.65
Post-Hospitalization expenses Upto 90 days Kerala Flood Cess @ 0 % (Rs) 0.00
Gross Premium: (Rs) 15888.00
Day Care Procedures Upto Sum Insured Gross Premium amount(in words) : Rupees Fifteen
Thousand Eight Hundred And Eighty Eight and Paise 00 Only
Organ Donor Upto Sum Insured

Domiciliary Treatment Upto Sum Insured

Claim Servicing Details:
Global cover Upto Sum Insured n Name : TAGIC Health Claims
n Website: www.tataaig.com
Bariatric Surgery Cover Upto Sum Insured
n Email: [email protected]
In-Patient Treatment - Dental Upto Sum Insured n Toll Free: 1800 266 7780 or 1800 229 966 (For
Senior Citizens)
Restore benefit Upto Sum Insured n Claims TATA AIG General Insurance Company
Administrator Limited,
Address: 5th and 6th Floor, Imperial Towers,
AYUSH Benefit Upto Sum Insured H.No 7-1-6-617/A, GHMC No - 615,616,
Ameerpet, Hyderabad – 500016, Telangana.
Upto Rs. 3000 per
Ambulance Cover
Hospitalization
Upto 1% of previous
Health Checkup Sum Insured; max.
Rs.10,000 Stamp Duty Registration Details
The stamp duty of Rs 1.00/-paid in cash or demand draft or by
Vaccination cover Upto Rs.5000 pay order,vide Receipt/Challan no:CSD/291/2021/1192 dated
the 24/03/2021
50% of actuals;
Hearing Aid
maximum Rs.10,000
Daily Cash for choosing 0.25% of base Sum For Tata AIG General Insurance Co. Ltd.
Shared Accommodation Insured; maximum
(If applicable) Rs. 2000 per day
0.25% of base Sum Authorized Signatory
Daily Cash for Accompanying
Insured; maximum
an Insured Child In the event of non-realization of premium, the
Rs. 2000 per day Company shall not be liable under the policy and the
policy shall stand cancelled ab initio (from inception).
Compassionate travel Upto Rs.20,000
Policy Servicing Address :
Consumables Benefit Upto Sum Insured A-6, 6th Floor, Trade World,Kamala Mills Compound,
Senapati Bapat Marg, Lower Parel, Mumbai-400013 Tel
Second Opinion Covered No: 022-66382333 Fax No: 022-66382390

Room Category No restriction

Regd Office : 15th floor, Tower A, Peninsula Bussiness Park, G.K Marg, Lower Parel, Mumbai - 400 013 Toll Free No. (24*7) : 1800 266 7780
Fax : 022 6693 8170 Email : [email protected] IRDA Of Indian Registration No : 108 Website : www.tataaig.com
CIN : U85110MH2000PLC128425 | UIN : TATHLIP21224V022021
Policy No. 0288584760 / M-20135 Page No. 3
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Receipt } Receipt No. : 102001020249519

Receipt Date : 12/04/2021
Policy No : 0288584760 00

Received with thanks from CHALAPATHI YARALAGADDA a sum of Rs. 15888.00 Rupees Fifteen Thousand Eight Hundred
Eighty Eight And Paise Zero Only vide Credit / Debit Card No 1001XXXXXXXX dated 12/04/2021 Name as in credit/debit card -
CHALAPATHI YARALAGADDA drawn on HSBC BANK, towards

Gross Premium (`) Utilized from the receipt for policy (`) Balance (`)

15888.00 15888.00 0.00

Tax Benefit
Letter } Certificate for the purpose of deduction under Section 80 D
of Income Tax (Amendment) Act, 1986*

This is to certify that the Proposer has paid Rs 15888.00 (Fifteen Thousand Eight Hundred Eighty Eight Rupees only.) towards
premium for health Policy No 0288584760 issued to CHALAPATHI YARALAGADDA for the period 12/04/2021 to 11/04/2022

For Tata AIG General Insurance Co. Ltd.

Authorized Signatory
Date of Issue : 21/06/2021
Place of Issue : MUMBAI
* Note
1. This is subject to the provisions of section 80D of the Income-tax Act,1961 as amended from time to time.
2. This certificate must be surrendered to the company in case of cancellation of this policy. In the event of incorrect representation of this declaration the liability shall
be upon the policyholder.
3. This certificate will not be issued if the premium payment has been made in cash/ demand draft.

*Tax benefit is available to the Premium payer. Tax benefits are not applicable on premium made in cash. The qualifying amounts under section 80D for self, spouse and
dependent children is Rs. 25,000. In case the proposer is aged 60 years or more during any time of the financial year, the qualifying amount shall be Rs. 50,000.
Additional deduction is available if premium is paid on behalf of the parents of the proposer. However, the aggregate deduction for the premium paid for self, family and
parents will be restricted to Rs. 50,000. The premium paid would be allowed as a deduction from the total income of the Proposer/ Assessee. The Porposer/ Assessee is
requested to consult his/ her tax consultant prior to taking deduction.

Note:
1. This is a computer generated receipt and does not require a signature.
2. Upon issuance of this Receipt, all previously issued temporary receipts, if any, related to this Policy shall be
considered null and void.
3. Amounts received by cheque shall be subject to realisation.
4. Any amount received in excess of the Premium is being/shall be refunded by the Company.
Revenue (consolidated) Stamp Duty duly paid vide challan No.CSD/200/2020/3048 date: 21/12/2020 for applicable cases.

GSTIN : 27AABCT3518Q1ZW MAHARASHTRA. Service Accounting Code : 997133

Regd Office : 15th floor, Tower A, Peninsula Bussiness Park, G.K Marg, Lower Parel, Mumbai - 400 013 Toll Free No. (24*7) : 1800 266 7780
Fax : 022 6693 8170 Email : [email protected] IRDA Of Indian Registration No : 108 Website : www.tataaig.com
CIN : U85110MH2000PLC128425 | UIN : TATHLIP21224V022021
Policy No. 0288584760 / M-20135 Page No. 4
CHALAPATHI YARALAGADDA, 31years, Male

M-20135 ( 1 to 3 )
Policy No. : 0288584760

Valid From : 12/04/2021

Member ID : CUSTP2888015057101031
NEERAJA YARALAGADDA, 24years, Female

M-20135 ( 2 to 3 )
Policy No. : 0288584760

Valid From : 12/04/2021

Member ID : CUSTP2888015057102024
RUDRANSH YARLAGADDA, 0years, Male

M-20135 ( 3 to 3 )
Policy No. : 0288584760

Valid From : 12/04/2021

Member ID : CUSTP2888015057103000
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Annexure to customer information sheet(CIS)- Benefit illustration in respect of policies offered on individual and family floater basis.

Age of the Coverage opted on individual Coverage opted on individual basis covering Coverage opted on family floater basis with
members basis covering each member of multiple members of the family under a single overall Sum Insured(only one sum insured
insured the family separately(at a single policy(Sum insured available for each member of available for entire family)
point of time) the family)

Premium (`) Sum Insured (`) Premium (`) Discount if Premium Sum Premium or Floater Premium Sum
any after Insured Consolidated discount after Insured (`)
Discount (`) premium for if any discount
(`) all members (`)
of the family
(`)

31 6724 28 % 4841.28

24 6724 28 % 4841.28 500000.00

0 5253 28 % 3782.16

Total Premium for all members of the Total Premium for all members of the family is Total Premium when policy is opted on floater
family is Rs____________when each Rs_________ when they are covered under a single basis is Rs 13464.72
member is covered separately policy

Sum Insured available for each Sum Insured available for each family member is Sum Insured of Rs 500000.00 is available for the
individual is Rs____________ Rs_________________. entire family

Note: Premium rates specified in the above illustration shall be standard premium rates without considering any loading. Also, the
premium rates shall be exclusive of taxes applicable.

Regd Office : 15th floor, Tower A, Peninsula Bussiness Park, G.K Marg, Lower Parel, Mumbai - 400 013 Toll Free No. (24*7) : 1800 266 7780
Fax : 022 6693 8170 Email : [email protected] IRDA Of Indian Registration No : 108 Website : www.tataaig.com
CIN : U85110MH2000PLC128425 | UIN : TATHLIP21224V022021
Policy No. 0288584760 / M-20135 Page No. 8