Digitally signed by Padmesh Nair

Date: 2018.09.25 11:27:11 +05:30

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195615961
Mr Tushar Mahendrabhai Dave
30 Picnicpark Society
B/H Navyug College
Rander Road
Surat, Surat
Gujarat - 395009
India
Contact No.: 9909921612
Policy No.: 190200/21001/2000292595-01
Code Intermediary Name Contact No
80199299 SHAH SWEETY D 9909502990

Renewal of Your Individual Personal Accident Policy

Dear Mr Tushar Mahendrabhai Dave,

Thank You for renewing the policy with us.

We are pleased to enclose your renewed Policy Schedule for the period 27-Sep-2018 to 26-Sep-2019

To know more about policy related information and value added offers, you may re-register yourself at our website using your unique member
ID and policy number as mentioned in the policy schedule.

In case of any query, please feel free to write to customerservice@apollomunichinsurance.com or call us at our 24 hours toll free number
1800-102-0333. Our customer care team will be happy to assist you.

Warm Regards,

Location : Gurgaon
Date : 22-Sep-2018
Authorized Signatory

Note:-
- Please visit our website www.apollomunichinsurance.com to access information about our company, the customer service touch
points including the Grievance handling process and various forms that you can use for service support. You will also get latest updates
on products, policy wordings which you can download for your reference and record.

- Please update us with your latest contact details (in case of any change) so that same can be updated in our records .You can either
write back to us or call us on our toll free no. 1800-102-0333.

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 SCHEDULE - Individual Personal Accident Standard

Issuing / Servicing Office : Surat Branch Office, 1004, Upper Ground Floor21st Century
Business Center,Rustampura, Ring Road, Gujarat - 395002
PH : 02616536512
GSTIN : 24AAGCA1654H1ZY
Policy Holder's Name : Mr Tushar Mahendrabhai Dave
GSTIN/ UIN (if any) of Policy Holder :
Policy Holder's Address : 30 Picnicpark Society
B/H Navyug College
Rander Road
Surat, Surat
Gujarat - 395009
India
Policy Holder State Name & Code : Gujarat(24)
Intermediary Code : 80199299
Intermediary Name : SHAH SWEETY D
Intermediary Contact No : 9909502990

Policy Number : 190200/21001/2000292595-01

First Policy inception date : 27-Sep-2017
Policy Issuance Date : 21-Sep-2018
Description/ Harmonized System Of Nomenclature Code : Accident and Health insurance Services/9971
Policy Period : From 00:00 hrs on 27-Sep-2018 To 24:00 hrs on 26-Sep-2019
Place of Supply : Surat (Gujarat)

Insured Persons Details :

Relationship
Date of Birth Age Sum Insured Cumulative
Member ID Insured Person's Name to Benefits
(DD-MM-YYYY) (Years) (Rs) Bonus*
Policyholder
Mr Tushar Mahendrabhai Accidental Death 1000000
10012899000 06-Feb-1972 46 Policy Holder 50000
Dave Temporary Total Disablement 500000

For details of all benefits under this policy, please refer to the schedule of benefits enclosed.

*The cumulative bonus (CB) shown in the Policy Schedule is provisional. The CB calculated on the Expiry Date, shall only be considered as
final. However, in case of any change in provisional CB, the same shall be intimated to You by Us through a separate endorsement.

Nominee Name : Mrs Falguni Tushardave Relationship to Policyholder : Wife

The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee.

Premium Calculation :-
Net Premium (Rs.) 1274.00
Discounts (Rs.) 0.00
Loadings (Rs.) 0.00
Taxable Premium (Rs.) 1274.00
CGST@9% (Rs.) 114.66
SGST/UTGST@9% (Rs.) 114.66
IGST@0% (Rs.) 0.00
Any other Cess or Taxes (Rs.) 0.00
Gross Premium (Rs.) 1503.32
Gross Premium amount (in words) Rupees One Thousand Five Hundred Three and Paisa
Thirty-Two Only

The stamp duty of Rs. 1.00 /- (Rupees One Only) paid vide No.F.10(783)/COS(HQ)/Con.duty/08. (Not applicable for the state of Jammu & Kashmir).

Original for Recipient/ Duplicate for Supplier

Whether tax is payable on reverse charge basis No

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 For and on behalf of Apollo Munich Health Insurance Company Limited

Location : Gurgaon
Date : 22-Sep-2018 Authorized Signatory

Page 3 of 3