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United India Insurance Company Limited Veer Sawarkar Bhavan J.M Page 1 of 329 UNITED INDIA INSURANCE COMPANY LIMITED VEER SAWARKAR BHAVAN J.M. ROAD,, PUNE PUNE - 411005 MAHARASHTRA PH: (020) 25534038,(020) 25533306 FAX: (20) 25535621 EMAIL: GROUP HEALTH POLICY UIN NO. IRDA/NL-HLT/UII/P-H/V.1/236/13-14 POLICY NO.: 1630002819P102019104 ( DUPLICATE ) PERIOD OF INSURANCE FROM 00:00 Hrs on 02/04/2019 To Midnight on 01/04/2020 Insured MS BANK OF MAHARASHTRA - HEAD OFFICE LOKMANGAL CENTRAL OFFICE,1501,SHIVAJINAGAR,DIST.PUNE. 1717392756 PUNE MAHARASHTRA 411005 IMPORTANT NOTICE: KINDLY UPDATE YOUR AADHAAR NO. AND PAN/FORM 60. PLEASE IGNORE IF ALREADY UPDATED. Agent Name : Agent Code : Mobile/Landline Number/Email : The genuineness of the policy can be verified through "Verify Your Policy" link at www.uiic.co.in For any Information, Service Requests and Grievances please write to [email protected] For ID Cards & Claim Intimations Please contact the TPA mentioned in the Policy document. Regd Office: 24 Whites Road, Chennai-600014,Head Office: No.19,Lane IV,Nungambakkam High Road, Chennai-600034. Website: http://www.uiic.co.in Printed By : AMI47500 @ 19/12/2019 2:59:57 PM http://gccore.uiic.in/Configurator/HTMLReportSource/1vgigr3ifvv4ic45c5rxag45Tailor... 19/12/2019 Page 2 of 329 POLICY NO.:1630002819P102019104 UIN NO. IRDA/NL-HLT/UII/P-H/V.1/236/13-14 GROUP HEALTH POLICY SCHEDULE Policy No. 1630002819P102019104 Previous Policy No. 1630002818P100677836 Name/ID MS BANK OF MAHARASHTRA - HEAD OFFICE/23015887727 Tel. (O) Tel.(R) Fax Insured Detail EMail Business/Occupation None Period of From 00:00 Hours of 02/04/2019 To Midnight of 01/04/2020 Insurance Coinsurance UIIC 163000 : 100% No.of Employees 2345 No.of Lives 4715 Coverage Details:- Cover Group Sum Insured( ) Premium( ) Hospitalization 792,100,000.00 28,132,797.72 Total Sum Insured 792,100,000.00 Premium 28,132,797.72 Insured Details As Per Annexure Attached. Premium: 30,005,198.00 CGST(9%): 2,700,468.00 SGST(9%): 2,700,468.00 Stamp Duty: 1.00 Total: 35,406,134.00 Receipt Number : 10116300019112780389 Receipt Date: 11/12/2019 Development Officer Code/ Agent Code: http://gccore.uiic.in/Configurator/HTMLReportSource/1vgigr3ifvv4ic45c5rxag45Tailor... 19/12/2019 Page 3 of 329 POLICY NO.:1630002819P102019104 UIN NO. IRDA/NL-HLT/UII/P-H/V.1/236/13-14 Underwriter Remarks Other terms & conditions would be as per Standard GMP Policy except : 1) One time entry option restricted upto 65 years of age. 2) Further terms and conditions as per salient features and broad terms as attached with the policy forming part of standard GMP policy. This Schedule and the attached policy shall be read together as one contract and any word or expression to which a specific meaning has been attached in any part of this Policy or of the Schedule shall bear the same meaning wherever it may appear. Customer GST/UIN No.: 27AACCB0774B1Z4 Office GST No.: 27AAACU5552C1ZJ SAC Code: 9971 Invoice No. & Date: 2819I102019104 & 10/05/2019 Amount Subject to Reverse Charges-NIL Anti Money Laundering Clause:-In the event of a claim under the policy exceeding 1 lakh or a claim for refund of premium exceeding 1 lakh, the insured will comply with the provisions of AML policy of the company. The AML policy is available in all our operating offices as well as Company's web site. Integrity - A way of Life. Please take pledge through the link https://pledge.cvc.nic.in. Date of Proposal and Declaration: 02/04/2019 IN WITNESS WHEREOF, this policy has been signed at DO SHIVAJINAGAR 163000 on this 09th day of December 2019 For and On behalf of United India Insurance Co. Ltd. Affix Policy Stamp here. Authorized Signatory Underwritten & Approved By - AMI47500 ( DO UNDERWRITER ) http://gccore.uiic.in/Configurator/HTMLReportSource/1vgigr3ifvv4ic45c5rxag45Tailor... 19/12/2019 Page 4 of 329 POLICY NO.: 1630002819P102019104 UIN NO. IRDA/NL-HLT/UII/P-H/V.1/236/13-14 Details of TPA Please contact the following TPA for Issue of Identity Cards, Cashless Approvals & Claims Settlement. Name of TPA HEALTHINDIA INSURANCE TPA SERVICES PVT. LTD. Address HEALTH INDIA TPA SERVICES PVT. LTD., Anand Commercial Co. Compound, 103-B, L.B.S. Marg, Gandhi Nagar, Vikhroli (West), Mumbai - 400083, Pin Code : 400083, Fax No : Toll Free number 1800 2201 02 / Sr.Citizens Tol Contact Details For General Enquiries For Cashless For Claim intimation For Grievances approval Telephone Numbers 1800 2201 02 022-66867545 / 559 02266867548 / 549 02266867546 / 540 / 517 / 9594983965 (Dr Bharti) Email IDs [email protected] [email protected] [email protected] [email protected] / [email protected] http://gccore.uiic.in/Configurator/HTMLReportSource/1vgigr3ifvv4ic45c5rxag45Tailor... 19/12/2019 Page 5 of 329 Annexure: POLICY NO.: 1630002819P102019104 UIN NO. IRDA/NL-HLT/UII/P-H/V.1/236/13-14 Name GroupPerson Sum Insured Name Age Sex Relation Occupation Premium of TPA No. ID. Insured Health India AWANTIKA BHASKAR TPA 1 1 79.4602739726027 Female Self Employed 300000 17300 GODBOLE Services Pvt.Ltd. Health India MURLIDHAR KRISHNAJI TPA 2 1 79.3178082191781 Male Self Employed 600000 31753 GORE Services Pvt.Ltd. Health India MR. ANAND VISHNUPANT TPA 3 1 82.3972602739726 Male Self Employed 300000 17300 HALBE Services Pvt.Ltd. Health India Un- TPA 3 2 SUNANDA A HALBE 71.7945205479452 Female Spouse Employed Services Pvt.Ltd. Health India TPA 4 1 JYOTI DIWAKAR KANE 75.9506849315069 Female Self Employed 100000 5900 Services Pvt.Ltd. Health India MR VASANT DAMODAR TPA 5 1 83.8164383561644 Male Self Employed 200000 0 RANADE Services Pvt.Ltd. Health India MADHAV ANANT TPA 6 1 78.7315068493151 Male Self Employed 400000 17806.71222 DESHMUKH Services Pvt.Ltd. Health India SUNITA MADHAV Un- TPA 6 2 71.6739726027397 Female Spouse DESHMUKH Employed Services Pvt.Ltd. Health India PUJARI KRISHNAJI TPA 7 1 76.5123287671233 Male Self Employed 400000 17806.71222 GANESH Services Pvt.Ltd. Health India MEENAKSHI KRISHNAJI Un- TPA 7 2 73.0465753424658 Female Spouse PUJARI Employed Services Pvt.Ltd. Health India TPA 8 1 SURESH V DESHPANDE 71.9013698630137 Male Self Employed 200000 9350 Services Pvt.Ltd. Health India Un- TPA 8 2 SUREKHA S DESHPANDE 67.9753424657534 Female Spouse Employed Services Pvt.Ltd. Health India KIRITKUMAR VITTHAL TPA 9 1 73.3643835616438 Male Self Employed 400000 15619.923 LIMAYE Services Pvt.Ltd. Health Un- India 9 2 SMITA KIRITKUMAR 64.0821917808219 Female Spouse TPA Employed Services http://gccore.uiic.in/Configurator/HTMLReportSource/1vgigr3ifvv4ic45c5rxag45Tailor... 19/12/2019 Page 6 of 329 Pvt.Ltd. Health India TPA 10 1 MEHTA VASANT KRISHNAJI 78.3698630136986 Male Self Employed 200000 13000 Services Pvt.Ltd. Health India Un- TPA 10 2 MEHTA SULBHA VASANT 75.1397260273973 Female Spouse Employed Services Pvt.Ltd. Health India TPA 11 1 SULBHA DAMODAR APHALE 79.013698630137 Female Self Employed 400000 21902.2560306 Services Pvt.Ltd. Health India SANJIVANI PANDURANG TPA 12 1 71.6767123287671 Female Self Employed 300000 14050 SHINDE Services Pvt.Ltd. Health India PRABHAKAR ANANT TPA 13 1 82.6767123287671 Male Self Employed 100000 7300 PHAWADE Services Pvt.Ltd. Health India Un- TPA 13 2 BHARATI P.PHAWEADE 69.5561643835617 Female Spouse Employed Services Pvt.Ltd. Health India MADHAVI MADHUSUDAN TPA 14 1 72.8054794520548 Female Self Employed 100000 5900 TATKE Services Pvt.Ltd. Health India PRABHAKAR GOPAL TPA 15 1 75.3917808219178 Male Self Employed 600000 25815 DIWANJI Services Pvt.Ltd. Health India HEMANGI PRABHAKAR Un- TPA 15 2 71.9945205479452 Female Spouse DIWANJI Employed Services Pvt.Ltd. Health India HASABNIS JAYANT TPA 16 1 83.2849315068493 Male Self Employed 200000 0 SHRINIWAS Services Pvt.Ltd. Health India Un- TPA 16 2 URMILA JAYANT HASABNIS 80.1671232876712 Female Spouse Employed Services Pvt.Ltd. Health India TPA 17 1 ARUN MAHADEV BHIDE 75.7753424657534 Male Self Employed 500000 21772.49976 Services Pvt.Ltd. Health India Un- TPA 17 2 ARUNA ARUN BHIDE 68.4219178082192 Female Spouse Employed Services Pvt.Ltd. Health India MR LAXMAN GOVIND TPA 18 1 76.6958904109589 Male Self Employed 300000 14050 ABHYANKAR Services Pvt.Ltd. Health MRS JYOTSNA LAXMAN Un- India 18 2 72.0219178082192 Female Spouse ABHYANKAR Employed TPA Services http://gccore.uiic.in/Configurator/HTMLReportSource/1vgigr3ifvv4ic45c5rxag45Tailor... 19/12/2019 Page 7 of 329 Pvt.Ltd. Health India SHRIDHAR SITARAM TPA 19 1 79.2931506849315 Male Self Employed 200000 13000 DHARAP Services Pvt.Ltd. Health India HALBE MADHUKAR TPA 20 1 78.9698630136986 Male Self Employed 300000 17300 PANDURANG Services Pvt.Ltd. Health India Un- TPA 20 2 VASUDHA M HALBE 76.427397260274 Female Spouse Employed Services Pvt.Ltd. Health India TPA 21 1 KETKAR SUDHIR SHANKAR 77.7287671232877 Male Self Employed 400000 21902.2560306 Services Pvt.Ltd. Health India Un- TPA 21 2 REKHA SUDHIR KETKAR 74.6027397260274 Female Spouse Employed Services Pvt.Ltd. Health India SAROJA SHARAD CHANDRA TPA 22 1 77.7890410958904 Female Self Employed 100000 7300 PARUNDEKAR Services Pvt.Ltd. Health India SMT. NIRMAL RAJARAM TPA 23 1 78.5315068493151 Female Self Employed 300000 17300 APTE Services Pvt.Ltd. Health India TPA 24 1 VINITA MOHAN PARANJAPE 68.9260273972603 Female Self Employed 400000 15619.923 Services Pvt.Ltd. Health India SUDHAKAR RAMCHANDRA TPA 25 1 80.6876712328767 Male Self Employed 200000 13000 JOSHI Services Pvt.Ltd. Health India Un- TPA 25 2 ALKA SUDHAKAR JOSHI 73.4356164383562 Female Spouse Employed Services Pvt.Ltd. Health India MURLIDHAR BHASKAR TPA 26 1 78.2164383561644 Male Self Employed 200000 10600 PURANIK Services Pvt.Ltd. Health India KALYANI MURLIDHAR Un- TPA 26 2 72.5534246575343 Female Spouse PURANIK Employed Services Pvt.Ltd. Health India BALWANT KRISHNAJI TPA 27 1 78.9150684931507 Male Self Employed 200000 13000 JOSHI Services Pvt.Ltd. Health India TPA 28 1 MR. DARAVADE VITTHAL B 79.6 Male Self Employed 100000 7300 Services Pvt.Ltd.
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