5/28/23, 11:15 PM IOB Health

Policy No. 2850/61412585/02/000

J SANGEETHA
17/1, PERAMASAMY PILLAI STREET,
KARAIKAL,,
KARAIKAL,
PONDICHERRY- 609602,

sangeethaar104@gmail.com

Dear J SANGEETHA,

We are extremely thankful to you for your renewal instructions and payment of premium for IOB HEALTH CARE PLUS POLICY - CUM TAX INVOICE. We
appreciate this opportunity to be of service to you and we are going to be with you every step of the way.

To make your insurance experience seamless, we have introduced below tech-based solutions.

USGI PULZ App - One stop solution for all your insurance needs. Now enjoy below complimentary value added benefits with our app.

Insurance Wallet – Manage insurance policies on the go with buy and renew Option
Claim Management – Intimate claim online and track claim status
Complete Auto Care Solutions – Online car service appointment, road side assistance, extended warranty, buy spare parts and accessories, sell car
online, self-drive car discount, tips to maintain your vehicle.
24X7 Road Side Assistance* – In case you are in distress due to flat tyre, drained battery, minor repairing or towing of vehicle in case of break down or
accident of your vehicle, Key locked in car or lost, fuel run dry or arrangement of taxi/ ambulance
Location based Service – Find nearest pharmacy, blood bank, wellness center, lab test center, online medicine stores. Also you can track your daily
activity, set reminders, and maintain your health profile and much more

* Subject to Terms and conditions of Universal Sompo Policy covering the vehicle with RSA cover

AI-Powered Virtual Agent

Helps you to intimate claim with ease

We’re committed to offer you best-in-class services. For any query, call us on our toll-free number 1-800- 200-4030 (Other Users),
1-800-22-4030 (MTNL/BSNL Users), or mail us at contactus@universalsompo.com. You can also drop by at one of our branches. For more information visit our
website www.universalsompo.com

Please verify the details in the attached policy copy. In case of any disagreement, discrepancy, or clarification that you may need, please let us know within 15
days of policy received.

You can also visit below link to check the hospital list or scan the QR code.

LINK https://universalsompo.com/cashless-hospitals/Hospital
Thanks again for choosing Universal Sompo, look forward to a long and healthy relationship.

Scan to check Hospital List Regd. No. 134 Scan to download USGI Pulz App

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IOB HEALTH CARE PLUS POLICY - CUM TAX INVOICE

INTERMEDIARY DETAILS
Intermediary Name INDIAN OVERSEAS BANK Phone Number 44-28191102
Intermediary Code 200471025418 Email healthcare@iobnet.co.in

POLICY ISSUANCE DETAILS

Policy Number 2850/61412585/02/000 Policy Type Renewal Business
Branch Name KARAIKAL Invoice Number 3322PR0000099832
Manual Covernote Number NA Loan Account number 003301000024518
Policy/Invoice Issued Date 28/05/2022 Premium for Health Insurance 8,700.00
Premium for Personal
Membership No 003301000024518 230.00
Accident
Name of the Proposer J SANGEETHA Bank Account No NA
Proposer Id 101395587592 Premium 8,930.00
17/1, PERAMASAMY PILLAI STREET, ,
Proposer Address/Place of KARAIKAL, , KARAIKAL , KARAIKAL ,
Supply PONDICHERRY(34) PIN - 609602 ,Tel No -
,Mobile No - ,GSTIN - 0
From : 00:00 of 16/06/2022 To : 23:59 of
Period of Insurance IGST(18%) 1607
15/06/2023
Type of Cover Health,PA
Health - Floater Sum Insured 500,000 Total Amount Payable 10,537
Personal Accident - Floater Total Amount Payable (in Rupees Ten Thousand Five Hundred Thirty-
500,000
Sum Insured words) Seven Only
Optional Extention for
Name of the Nominee JEGANATHAN YES
Personal Accident
CHENNAI - II BRANCH OFFICE G-1, NO 6, CATHEDRAL GARDEN ROAD, NUNGAMBAKKAM, CHENNAI , PIN - 600034 , TAMIL
Policy Issuance Office
NADU(33) , GSTIN - 33AAACU8917F1ZD

Personal Accident
Name of Insured Date of Birth Gender Relationship with Proposer Pre-Existing Disease Declared Hospitalization Cover
Cover
J SANGEETHA 16/01/1986 Female Self No Yes Yes
A T KUMARAVELU 01/08/1978 Male Spouse No Yes Yes
ATK TEJAA 28/11/2009 Female Child 1 No Yes Yes

Previous Policy Details

Previous Insurer Previous Policy Previous Policy Previous Policy Start Previous Policy End Previous Policy Claim
Name Number Year Date Date Status
UNIVERSAL SOMPO 2850/61412585/01/000 2021 16/06/2021 15/06/2022 NO
UNIVERSAL SOMPO 2850/61412585/00/001 2020 16/06/2020 15/06/2021 NO

* Personal Accident Coverage is not applicable to Dependent Parents.

Clauses/Endorsements attached to Continue health insurance cover in India from any of the insurers without break: 16/06/2011 Period of insurance
the policy: without break : 11 years.

Special Condition: Medical History / Medical Declaration is collected in Annexure. 2817/51534322/08/000 It is hereby agreed and declared that, sum
insured under the captioned policy is being enhanced by Rs. 2,00,000/-(Rupees Two Lacs Only) w.e.f policy inception. The total sum insured of the captioned
policy stands revised from Rs. 3,00,000/- to Rs. 5,00,000/-. The fresh countdown shall start for waiting period of pre-existing disease, 30 days waiting period
and 1st year exclusion for incremental sum insured of Rs. 2,00,000/-. Incremental Sum Insured of Rs. 2,00,000/- will not be applicable for any surgery
/Treatment and its related causes and complications taken during the policy period where claim status not shared. The total policy premium should be read as
of Rs. 9,239/- is hereby charged and recovered from insured. All other terms and conditions of the policy remain unaltered.
Copayment: 20% on each and every claim of all those above age 55 years
IN WITNESS WHEREOF the undersigned being duly authorised by and on behalf of the company has/have here onto set his/their hands
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5/28/23, 11:15 PM IOB Health

Collection No 2018013864 Dated 28/05/2022

Examined By: Underwriter:

For Universal Sompo General Insurance Co.Ltd.

Authorized Signatory
Consolidated stamp duty Rs.0.50 paid towards Insurance policy stamp vide receipt no. LOA/CSD/301/2022/1379 dated 29/03/2022 of General
Stamp Office Mumbai.
Disclaimer: This Policy is null and void ab initio, if the cheque/any valid negotiable Instrument as receipted by this company via this receipt is
dishonoured by the bank. Issuance of the receipt is not a proof of risk acceptance.
IN WITNESS WHEREOF this Policy has been signed at Mumbai in lieu of e-covernote No. NA

GSTIN No : 33AAACU8917F1ZD
USGI IRDA Registration No. 134
SAC Code : 997133

IRDAI UIN NO:- UNIHLIP21411V032021

SP Name-SP Code:-

Resolving Issues - Please read your Policy & Policy Schedule:

The Policy & Policy schedule set out the terms of your contract with us. Please read this carefully to ensure that the cover meets your needs.
* Please visit our website www.universalsompo.com to know more about the policy coverage, benefits, and exclusions.
* Kindly write to us on contactus@universalsompo.com to get the copy of the policy wordings, if required.

Claim Disclaimer:
In the unfortunate event of any claim under the policy, please intimate IMMEDIATELY to our Call Centre at Toll Free Numbers: 1800 22 4030 / 1800
200 4030 or Email at contactclaims@universalsompo.com. Please note that no delay should be allowed to occur in notifying a claim on the policy as
the same may prejudice liability.

N.B. The benefits provided under the policy and/or terms and conditions of the policy including premium rates may be subject to change on
renewal, with prior approval from IRDAI.

In Case of any discrepancy, complaint or grievance, please feel free to contact us within 15 days of receipt of the policy.

Address: Universal Sompo General Insurance Co.Ltd. Airoli Office-Unit No.601 & 602,A wing, 6th floor, Reliable Tech Park, Cloud City Campus, Gut no
31, Mouje Elthan, Thane Belapur Road, Airoli, Navi Mumbai - 400708

Toll Free Numbers:1800 22 4030 / 1800 200 4030

Grievance Redressal Officer Number:022-41690824

Website: www.universalsompo.com

E-mail Address: contactus@universalsompo.com.

Note: Please include your policy number for any communication with us

Universal Sompo General Insurance Co.Ltd. shall abide by Insurance Regulatory and Development Authority (Protection of Policyholder’s Interests)
Regulations 2017. Under this regulation and with an objective to provide a forum to Personal Lines policy holders for resolution of claims related
complaints, Insurance Ombudsman has been constituted under the aegis of Governing Body of Insurance Council. For further Information you could
refer https://www.cioins.co.in/ombudsman.

This document is system generated on 28/05/2023 23:16:06

TPA Name : UNIVERSAL SOMPO-HEALTH SERVE

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Premium Certificate for the purpose of deduction under Section 80D of Income Tax Act

This is to certify that Shri/Smt J SANGEETHA has paid Rs. 10537 towards premium for IOB HEALTHCARE PLUS INSURANCE POLICY under Policy
No. 2850/61412585/02/000 for the period from 16/06/2022 to 15/06/2023 vide Collection No. 2018013864 Collection Date 28/05/2022.

For Universal Sompo General Insurance Co. Ltd.

USGI IRDA Registration No. 134

Authorized Signatory

This document is computer generated on 28/05/2023 23:16:06

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