Policy Document

Insurance Certificate
Mr. Sourav Baksi
17/ 1 A Sashi Bhusan Banerjee
Road,
Lic Market,
Behala Silpara Opp. Mamta
Jwelars,
Kolkata,
-,
West Bengal - 700008

Branch Office
Policy Number
Policy Commencement
Date
Policy Expiry date
Sum Insured (Rs.)
Loyalty Benefit
Total Sum Insured
Heartbeat Individual
Heartbeat Family Floater
Heartbeat Family First
Plan opted for
Policy Period
Renewal Due Date

NOC
30339144201501
From 18/06/2015 00:00 a.m.
To 17/06/2016 23:59 p.m.
5,50,000
Increase in Sum Assured
5,50,000
No
Yes
No
Heartbeat Gold 05 Lacs 2
Adults
1 year
17/06/2016

Original Policyholder Details at the Time of First Risk Inception

Original Policyholder Name
Sourav Baksi
Original Policyholders address

17/ 1 A Sashi Bhusan Banerjee Road,

Lic Market,
Behala Silpara Opp. Mamta Jwelars,
Kolkata,
-,
West Bengal - 700008

Premium Details
Net
Premium
(Rs.)

Service Tax
(Rs.)

Education
Cess (Rs.)

13,119.00

1,837.00

0.00

Insured Details
Name of the Insured
Person (s)

Age

Secondary
& Higher
Education
Cess (Rs.)
0.00

Gross
Premium
(Rs.)

Gross Premium (Rs.) (in words)

14,956.00

Fourteen Thousand Nine Hundred

Fifty Six Only

Mr. Sourav Baksi

28

Gender Relationship
with the
Policy Holder
M
Applicant

Ms. Bithika Sahana

26

Spouse

Pre Existing
Condition#

Personal Waiting
Period*

None

None

None

None

(* - Please refer clause 4.d of Pa rt II of the s chedule)

( # - Pre Existing Condi tions as dis closed by the cus tomer or dis covered by us during medi cal underwri ting)

Cover Details
Particulars
Individual Sum Insured (only in case of Family First)
Floater Sum Insured (only in case of Family First)
Sum Insured

Details
NA
NA
5,00,000

Co-pay (applicable at 65 years and above)

Name of the Insured Person(s)
Max Bupa Contribution in
1st Policy Year
Mr. Sourav Baksi

100

Max Bupa Contribution in 2nd

Policy Year (applicable for 2 year
policies only)
NA

Ms. Bithika Sahana

100

NA

Permanent Exclusions (if any):

1
2
3

Optional Benefit/Feature Details

Optional Benefit/Feature (only for Silver SI options
of Individual and Family Floater Plans)

Effective [Y/N]

Deductible

Optional Benefit/Feature

Contribution of Max Bupa

Co-pay below 65 years

Emergency Medical Evacuation (outside India)

Applicable Region (Only for Platinum Policies)

No

Nominee Details
Nominee Name

Mina Baksi

Relationship

Mother

Agent Details

Agent Name
NA

Agent
Code
NA

Agent
Agent
Agent Address
Contact No. Landline No
NA
NA
,

The stamp duty of Re.1 (Rupee one only) vide in challan no. F.10(16210)/ COS(HQ)/CD dated 16th October 2014
through e-stamp certificate No.IN-DL31147224239846M dated 10th November 2014.
Service Tax Registration No.: AAFCM7916HST001.

For and on behalf of Max Bupa Health Insurance Co. Ltd.

Somesh Chandr a
Chief Operations Officer & Chief Quality Officer

Location: New Delhi

Date: 16/06/2015