This document is digitally signed

Signer: ATUL JERATH

Date: Thursday, October 11, 2018 4:34 AM
Location: Pune

HAPPY FAMILY FLOATER-2015 POLICY SCHEDULE

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

Policy No. : 112300/48/2022/305 Prev. Policy No. : -

Cover Note No. : - Cover Note Date : -
Insured's Code : 90189099 Issue Office Code : 112300
Insured Name : ANKIT GOYAL (GSTIN: ) Issue Office Name : MCDO 18 (GSTIN:
27AAACT0627R4ZW)
Address : H NO.FCA 89, YADAV COLONY, Address : MAGNET HOUSE, 2ND FLOOR
NEAR RAMA OIL MILL, NAROTTAM MORARJI MARG
BALLABGARH, FARIDABAD, BALLARD ESTATE
HARYANA 121004 MUMBAI MAHARASHTRA 400038
-
FARIDABAD 121004
Tel./Fax/Email : / / 8851620195 / Tel./Fax/Email : 022-22662469 / 022-22662135 /
agankitgoyal@gmail.com pranayjoshi@orientalinsurance.co.in
Agent/Broker Details
Dev.Off.Code :
Agent/Broker : LF0000000005 3120 (EARLIER MARSH INDIA P LTD)
Address : 1, INDIA BULL CENTRE,TOWER-2, SENAPATI BAPAT MARG,ELPHINSTON
ROAD(W),,MUMBAI 400012,MUMBAI,MAHARASHTRA,400012
Tel/Fax/Email : 9820199485/9820199485//

Period of Insurance : FROM 00:00 ON 23/10/2022 TO MIDNIGHT OF 22/10/2023

Collection No. & Dt. : DC_I_INDCSH 3016000580 - 10/10/2022 GST INVOICE NO :271710952808 UIN :0
Gross Premium : 17,493 GST 3148 Stamp Duty : .8 Total : 20,642

Co-insurance Details : Nil

TPA Details :
TPA ID YA0000000331
TPA Name M/S VIPUL MEDCORP TPA PVT LTD
Address : 515, UDYOG VIHAR, PHASE V
GURGAON 122016 Toll Free No. : 1800 102 7477
Telephone No : FAX No. :

Number of persons covered 4 Plan Type SILVER Plan Sum Insured 500000
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 ANKIT GOYAL M 03/10/1986 37 Self 10

2 POONAM GOYAL F 30/12/1985 37 Spouse 10

Place : MUMBAI For and on behalf of

Date : 10/10/2022 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 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 112300/48/2019/305

3 RAKESH GOYAL M 05/10/1958 64 Dependant HEART 10

Parents DISEASE,
FISTULA FOR
DIALYSIS,
DIMNESS OF
VISION,
DIABETIC
4 GEETA GOYAL F 08/10/1969 53 Dependant 10
Parents
Nominee Details
Name Of the Nominee Relationship With the Insured Age Of the Nomine M/F/TG*
GEETA GOYAL REL_12 F

Optional Cover
Value
LIFE HARDSHIP BENEFIT NO
RESTORATION OF SI NO

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

EMPLOYEES COVERED UNDER GMC POLICIES ARE ANKIT GOYAL, POONAM GOYAL,HANISHA GOYAL GOYAL, VIDHI
RAKESH GOYAL, GEETA GOYAL.
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.
AS PER HR LETTER OF OPTUM GLOBAL SOLUTIONS (INDIA) PVT. LTD. COVERED UNDER NEW INDIA
ASSURANCE CO. LTD. GMC POLICY UNDER POL.NO.(NOT AVAILABLE YET) SINCE 2010 TILL 22.10.2018 FOR
SUM INSURED RS.500,000/- EMP.CODE000690788.

Place : MUMBAI For and on behalf of

Date : 10/10/2022 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 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 112300/48/2019/305

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 MCDO 18 (GSTIN: 27AAACT0627R4ZW) on 10-OCT-22.

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

11270034140400000059 23-SEP-14 22-SEP-15 THE NEW INDIA ASSURANCE CO. 500000

LTD.

11270034150400000049 23-SEP-15 22-SEP-16 THE NEW INDIA ASSURANCE CO. 500000

LTD.

99000034160400000019 23-SEP-16 22-SEP-17 THE NEW INDIA ASSURANCE CO. 500000

LTD.

99000034170400000054 23-SEP-17 22-SEP-18 THE NEW INDIA ASSURANCE CO. 500000

LTD.

Claim History Data

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

Place : MUMBAI For and on behalf of

Date : 10/10/2022 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 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 112300/48/2019/305

"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
ORIENTAL HOUSE, 2 FLOOR,7,JAMSHEDJI TATA ROAD,CHURCHGATE,MUMBAI. 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 : PRAKASH GOHIL

For and on behalf of
Examined By : MR. S B NAIR The Oriental Insurance Company Limited

Policy Printed By : P10_DEMO IP :

Policy Printed On : 11-OCT-22 04:36:45 MAC : General Manager

Authorised Signatory

Place : MUMBAI For and on behalf of

Date : 10/10/2022 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 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