HDFC ERGO General Insurance Company Limited

Certificate of Insurance 2855205426810200000

HDFC ERGO Group Protect

2855205426810200000

MR RAKIBUR RAHMAN
46 KALONGPAR PATH
NEAR TINIALI DEKATUP SENSUWA
NAGAON, ASSAM, 782002
Contact No. 9387695526

Date :16/05/2023

Dear MR RAKIBUR RAHMAN

Thank you for choosing HDFC ERGO as your preferred insurance partner.We welcome you to be a part of our family!

Your coverage of insurance under the HDFC ERGO Group Protect Certificate reference no 2855205426810200000 i s confirmed on the basis of the information and declaration
provided by you.

The details of coverage are mentioned in the enclosed certificate of insurance.

We value your relationship with us and assure you our best services at all times and we look forward to serve you.
This certificate of insurance can be renewed subject to outstanding loan tenure and loan amount at the expiry of the certificate, Please contact HDFC ERGO General Insurance
company limited for renewal.
For HDFC ERGO General Insurance Company Ltd.

Authorized Signature

HDFC ERGO General Insurance Company Limited

Tax Certificate
Dear MR RAKIBUR RAHMAN,

Subject : Certificate for the purpose of deduction under section 80 D of Income Tax (Amendment) Act, 1986

This i s to certify that we have received an amount of ` 614 towards premium for HDFC ERGO Group Protect, Certificate No. 2855205426810200000 issued to MR
RAKIBUR RAHMAN for the period 15/05/2023 to 14/05/2026.

Note : This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended from time to time.
This certificate must be surrendered to the company in case of cancellation of this policy. In event of incorrect representation of this declaration the liability shall be
upon the policy holder.

For HDFC ERGO General Insurance Company Ltd.

Date : 16/05/2023
Policy issuance office : Mumbai

Duly Constituted Attorney

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLGP22214V012122. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
 HDFC ERGO General Insurance Company Limited
Certificate of Insurance 2855205426810200000

HDFC ERGO Group Protect

2855205426810200000

Certificate No. :2855 2054 2681 0200 000 Issuance Date : 16/05/2023
Period of Insurance : From 15/05/2023 13:01 hrs To 14/05/2026 Midnight
Invoice No. :205426810200000 Premium Frequency :Single
Proposer Name :Mr Rakibur Rahman
MR RAKIBUR RAHMAN HSN Code :997133 eIA :Not provided
46 KALONGPAR PATH Customer Id :101559787363 Policy Type :Individual
NEAR TINIALI DEKATUP SENSUWA Master Policy No. :2999205332074800000
NAGAON, ASSAM, 782002
Contact No. 9387695526 Master Policy Holder :HDFC BANK LTD
Name
Loan Account No. :458077827
Lending Institution :HDFC Bank Ltd
Email ID :rakiburrahman170@gmail.com
Payment Details : TW EMI Protect 15.5.23 , Date: 15/05/2023
Insured Person Details
Cumulative
Relation with Aggregate
Name of 1st Policy Sum Insured Bonus Pre-existin
Group member ID policy holder* Gender DOB Deductible In
Insured Person Inception In Rs. Amount in g Disease
Rs.
Rs
RAKIBUR RAHMAN 2023310028171009 Applicant Male 15/10/2002 15/05/2023 30000 0 0 NO
*Relationship is relation of Insured with policyholder
Nominee Details
Insured Name Nominee Name Nominee Relationship Appointee Name Appointee Relationship
RAKIBUR RAHMAN ZAHID ALI BROTHER
The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee.
Schedule of Coverage in Rs.
Insured Name Coverages Sum Insured
Sum Insured= 30000
EMI Amount /Fixed Amount= 2500 , Fraction of EMI/Fixed Amount = 2, Annual capping of EMI/ Fixed Amount =
RAKIBUR
EMI Hospitalization 4
RAHMAN
EMI/ Fixed Amount Trigger days = 2days,4days
Count of EMI/ Fixed Amount Per trigger = 2,4

Premium Details (`)

Particulars RAKIBUR RAHMAN
Base Premium (A) 520
Optional Cover Premium (B) 0
Medical Underwriting Loading (C) 0
Total Premium (D=A+B+C) 520
Discounts (E) 0
Goods & Service Tax (GST) (F) 94
Gross Premium (G) 520
Grand Total - Premium excluding GST (H) 520
Grand Total - Premium including GST (I) 614

For any other query call 022-62346234 / 0120-62346234 , WhatsApp number: 8169500500 OR email us at care@hdfcergo.com OR log onto www.hdfcergo.com
Contact Details for Senior Citizen: 022 6242 6226 | Email id: seniorcitizen@hdfcergo.com.

For claim services Phone - 022-62346234/0120-62346234 , Email :healthclaims@hdfcergo.com

Processing Centre: HDFC ERGO General Insurance Company Ltd. 5th floor, Tower 1, Stellar IT Park, C-25, Sector-62, Noida-201301.
If the premium is not realised the policy shall be void from inception.Consolidated stamp duty for this Insurance Policy is paid by Demand Draft, vide Receipt/Challan noNO.LOA/CSD/477/2022/4252 dated
29/09/2022 as prescribed in Government of Maharashtra Order No. Mudrank-2017/CR.97/M-1, dated the 09th January 2018. Goods & Services Tax Registration No: 27AABCL5045N1Z8GST for this invoice is not
payable under reverse charge basis. I/ We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under sub-rule (4) of
rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule
Branch :leela business park, 6th flr, andheri - kurla rd, mumbai
For HDFC ERGO General Insurance Company Ltd.
Agent Name : HDFC BANK LTD
Agent Code : 201587086428 Tel No. : 91-22-61606161

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 UIN: HDFHLGP22214V012122. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
 HDFC ERGO General Insurance Company Limited

2855205426810200000

HDFC ERGO General Insurance Company Limited 1

Policy No.:2855205426810200000 This card is for identification purpose only.
Valid From: 15/05/2023 Renewal Date: 14 May
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 the policy term & conditions. Card does not guarantee cashless hospitalization or any other
service. For more details and updated list of Network Service Provider please refer our website or
RAKIBUR RAHMAN 15/10/2002 Male call our call centre. This card is valid till the time policy is active.

Customer Service No : 022 - 6234 6234 / 0120 - 6234 6234

:
Email : healthclaims@hdfcergo.com
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 UIN: HDFHLGP22214V012122. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
 HDFC ERGO General Insurance Company Limited
e- Enrollment form 2855205426810200000

HDFC ERGO Group Protect

Enrollment Form No :2855 2054 2681 0200 000

Period of Insurance : From 15/05/2023 13:01 hrs To 14/05/2026 Midnight
Invoice No. :205426810200000 Premium Frequency :Single
Proposer Name :Mr Rakibur Rahman :India
MR RAKIBUR RAHMAN HSN Code :997133 eIA :Not provided
46 KALONGPAR PATH Customer Id :101559787363 Policy Type :Individual
NEAR TINIALI DEKATUP SENSUWA Master Policy No. :2999205332074800000
NAGAON, ASSAM, 782002 Master Policy Holder :HDFC BANK LTD
Contact No. 9387695526 Name
Loan Account No. :458077827
Lending Institution :HDFC Bank Ltd
Email ID :rakiburrahman170@gmail.com
Payment Details : TW EMI Protect 15.5.23 , Date: 15/05/2023
Insured Person Details
Cumulative
Aggregate
Name of Relation with 1st Policy Sum Insured Bonus Pre-existing
Group member ID Gender DOB Deductible In
Insured Person policy holder* Inception In Rs. Amount in Disease
Rs.
Rs
15/10/200
RAKIBUR RAHMAN 2023310028171009 Applicant Male 15/05/2023 30000 0 0 NO
2
*Relationship is relation of Insured with policyholder
Nominee Details
Insured Name Nominee Name Nominee Relationship Appointee Name Appointee Relationship
RAKIBUR RAHMAN ZAHID ALI BROTHER

The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee.
Schedule of Coverage in Rs.
Insured Name Coverages Sum Insured
Sum Insured= 30000
EMI Amount /Fixed Amount= 2500 , Fraction of EMI/Fixed Amount = 2, Annual capping of EMI/ Fixed Amount =
RAKIBUR
EMI Hospitalization 4
RAHMAN
EMI/ Fixed Amount Trigger days = 2days,4days
Count of EMI/ Fixed Amount Per trigger = 2,4

Premium Details (`)

Particulars RAKIBUR RAHMAN
Base Premium (A) 520
Optional Cover Premium (B) 0
Medical Underwriting Loading (C) 0
Total Premium (D=A+B+C) 520
Discounts (E) 0
Goods & Service Tax (GST) (F) 94
Gross Premium (G) 520
Grand Total - Premium excluding GST (H) 520
Grand Total - Premium including GST (I) 614
Good Health Declaration

Are you suffering from OR are you diagnosed with OR do you have symptoms related to OR are you on regular Medication OR Have you undergone any of the below procedure OR Are you under
regular follow up of Doctors for any of the below Ailments / complaints / symptoms / Diseases? Coronary Heart diseases, heart valve diseases, Congenital Heart diseases, Cancer, Carcinoma in
situ, Osteo-Arthritis, Joint replacement, Intervertebral disc disease, Chronic Kidney diseases, Dialysis, Osteo-Arthritis, Joint replacement, Intervertebral disc disease, Chronic Liver Diseases,
Hepatitis B, C, E, Cirrhosis, Gall stones, Pancreatitis, Congenital Diseases, Auto Immune diseases, Major Organ transplant, HIV & AIDS, Uterine Fibroid, Uterine prolapse, Chronic Obstructive
pulmonary diseases, Stroke, Paralysis and Brain tumour. NO

Declaration & Warranty on behalf of all Persons Proposed to be Insured

I/We hereby declare on my behalf and on behalf of all persons proposed to be insured that the above statements are true and complete in all respects to the best of my knowledge and that I/We am/are
authorized to propose on behalf of these other persons. I understand that the information provided b y me will form the basis of insurance policy, is subject to the Board approved under writing policy of the
Insurance company and that the policy will come into force only after full receipt to the premium chargeable.
I/We further declare that I/We will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been submitted but before communication of the
risk acceptance by the company.
I/We declare and further consent to the company. Seeking medical information from any hospital who at any time has attended on the life to be insured/ proposer or from any past or present employer concerning
anything which affects the physical and mental health of the life to be assured/proposer and seeking information from any insurance company to which an application or insurance on the life to be assured/proposer
has been made for the purpose of underwriting the proposal and /or claim settlement.
I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposalunderwriting and/ or claims settlement and with any Governmental and/or
Regulatory Authority

Declaration & Warranty on behalf of Insurer:

Note: The liability of the company does not commence until the acceptance of the proposal has been formally intimated by the insured and full premium has been realized by the company.

We are under no obligation to accept any proposal for insurance. The Proposer agrees that the receipt of the Proposal Form by HDFC ERGO General Insurance Company Limited along with the premium payment
does not tantamount to the acceptance of the Proposal for insurance b y HDFC ERGO General Insurance Company Limited and does not result in a concluded contract of insurance. The acceptance of the

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLGP22214V012122. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
 HDFC ERGO General Insurance Company Limited
e- Enrollment form 2855205426810200000

HDFC ERGO Group Protect

does not tantamount to the acceptance of the Proposal for insurance b y HDFC ERGO General Insurance Company Limited and does not result in a concluded contract of insurance. The acceptance of the
Proposal for insurance shall be at the Company's sole and absolute discretion and upon full realization of the premium payment .
In the event of acceptance of the Proposal for insurance by HDFC ERGO General Insurance Company Limited, such acceptance shall be specifically intimated to the Proposer by HDFC ERGO General Insurance
Company Limited along with the date from which the insurance Cover shall become effective. HDFC ERGO General Insurance Company Limited shall not be liable for any claim in respect of an event giving rise to
a claim covered under the Policy of Insurance that has occurred prior to policy issuance i s not covered under this policy(Your proposal form will be considered after HDFCERGO General Insurance Company
Limited receives premium payment.)

Fraud Warning: This policy shall be voidable at the option of the Company in the event of mis-representation, mis-description or non-disclosure of any material particulars by the Proposer.Any person who,
knowingly and with intent to fraud the insurance company or any other person, files a proposal for insurance containing any false information, or conceals or the purpose of misleading, Information concerning any
fact material thereto, commits a fraudulent insurance act, which will render the policy voidable at the sole discretion of the insurance company and result in a denial of insurance benefits.

Anti-Rebating Warning :As per Section 41 of the Insurance Act 1938,as amended, the practice of rebating is prohibited, as follows: No person shall allow or offer to allow, either directly or indirectly, as an
inducement to any person to take out or renew or continue an insurance policy in respect to any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any
rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectus
or tables of the insurer. Violation of Section41 of the Insurance Act 1938, as amended, shall be punishable with a fine which may extend to Rs. 10Lakhs.

Assignment Clause: : It is here by declared and agreed that

1. From the Policy Start Date ,the monies payable b y the Company to the Insured and all rights , title , benefits and interest of the Insured under this Policy in section stand assigned in favour of the “Bank /
Financial institution as named in the Schedule of this Policy ”;
2.Upon any monies becoming payable under this Policy the same shall be paid b y the Company to the “ Bank / Financial institution as named in Schedule of this Policy ” without any reference / notice to the
Insured , but not exceeding the Principal Out standing a s defined under the Policy . In the event of any monies pay able under this Policy exceeding the Principal Out standing , the Company shall pay such
monies as exceeding the Principal Outstanding to the Insured /Nominee ;
3.The receipt of such monies in the manner aforesaid by the Bank/Financial Institution as named in the Schedule of this Policy and the Insured shall completely discharge the Company from all liability under the
Policy and shall be binding on the Insured and the heirs,executors, administrators, successors or legal representatives of the Insured, as the case may be.
4.That any adjustment, settlement , compromise o r reference to arbitration in connection with any dispute between the Company and the insured or any of them arising under or in connection with this policy if
made b y the Financier shall be valid and binding on all partiesinsured here under but not so as to impair rights of the Financier to recover the full amount of any claim it may have on other parties insured here
under but not so as to impair .

General Insurance Declaration: I have understood the Coverage & Benefits payable under the plan. I understand that the insurance plan opted by me is on a voluntary basis and is as per my requirement I am
aware that there are similar insurance plans available in the market I have read and understood the features of policy and agree to proceed with my application HDFC Bank has arrangement with 3 General
Insurance Companies - HDFC ERGO General Insurance Company Limited, Bharti AXA General Insurance Company Limited & Bajaj Allianz General Insurance Company Limited & relevant details of the products
have been disclosed to me .Please note: The commission has been disclosed in HDFC Bank branches & Bank’s website for your reference.

Consent for Transfer into Loan Account Number

I Rakibur Rahman hereby declare, agree and confirm that: From the Certificate Risk Start Date, any claim payable b y the Company under this Certificate of Insurance shall be deposited directly in the loan
account number :458077827 maintained b y the Bank /Financial Institution a s named in the Certificate of Insurance '.In the event of any claims becoming payable under this certificate of Insurance , the same
shall be deposited by the Company in the aforementioned loan account held with the 'Bank/Financial Institution as named in the Certificate of Insurance ' without any reference / notice to the undersigned, but not
exceeding the Principal Outstanding a s defined under the certificate .In the event of any claims payable under this certificate exceeding the Principal Outstanding, the Company shall pay such claim amount
exceeding the Principal Outstanding to the undersigned. Upon receipt of such claim amount in the manner aforesaid by the Bank/Financial Institution as named in the certificate of insurance and the Insured shall
completely discharge the Company from all liability, claims under the certificate of Insurance and shall be binding on the undersigned and the heirs, executors, administrators, successors or legal representatives of
the Insured, as the case may be .

Disclaimer : Proposal Form and Policy Schedule have been generated basis details entered by proposer / insured on Online Platform (either on HDFCERGO.com or its affiliated Online Channels (IRDAI Licensed
Intermediaries). For any modification, kindly visit URL https://www.hdfcergo.com/customer-care/customer-support.html and register your service request or write to us at care@hdfcergo.com
Branch :leela business park, 6th flr, andheri - kurla rd, mumbai

Agent Name : HDFC BANK LTD

Agent Code : 201587086428 Tel No. : 91-22-61606161

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 UIN: HDFHLGP22214V012122. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com