Signed
by:Reliance
General Insurance
Company Limited
Date:2022.03.04
RELIANCE GENERAL INSURANCE COMPANY LTD
Certificate of Insurance under Group Personal Accident (GPA)
Policy Issuing Office: Policy Servicing Office:
Reliance General Insurance Company Limited 6th Floor, Oberoi 6th Floor, Oberoi Commerz, International Business Park,Oberoi
Commerz, International Business Park,Oberoi Garden City, Off Garden City, Off Western Express Highway,Goregaon (East), Mumbai
Western Express Highway, Goregaon (East), Mumbai – 400 063. – 400 063, MUMBAI, MUMBAI, MAHARASHTRA - 400055 Phone No.
: 022 33031000
Office Contact No : 9003136144
Certificate Number : 920292229141001219 Master Policy Number : 920292129140000065
Tax Invoice No & Date Y030322030351 & 03-Mar-2022
Group Policy Holder : EQUITAS ONLINE
Name of the Insured [Link] Jothiramalingam
Person:
Communication Perambur CHENNAI TAMIL NADU 600011
Address & Place of
Supply:
Period of Insurance : From : 24-Feb-22 To : 23-Feb-23
Age : 31 Years Gender : Female
Sum Insured : Rs. 200000.00/- only.
Nominee Name : V. Jothiramalingam Relationship : Spouse Identification 100009235967
Number:
GSTIN / UIN of Insured : NA
As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th September of the next
financial year
Consolidated Stamp duty Paid vide Letter of Authorization No. [Link]/CSD/254/2022/(Validity Period Dt.15/02/2022 to 30/07/2022)/426
dated 25 Jan 2022 at General Stamp Office, Mumbai.
** Not Applicable for the State of Jammu & Kashmir
Scope of Cover
NA
Special Condition :-
[Link] policy is applicable to all CASA account holders of Equitas Small Finance Bank.
[Link] benefit of claim under AD and PTD is applicable only once during the policy/cover period Accordingly, if the Insured Person/ Nominee /
Legal Heir reports a claim under Benefit AD and PTD and the same is acknowledged by the Company, then no further claim can be reported
under these Benefits and Certificate of Insurance becomes in-operative.
[Link] Company's total liability for per card holder / person in aggregate shall not exceed Sum Insured (as per subjectivity) or Rs. 25,00,000
whichever is lower irrespective of no. of Covers/Policies issued. . Given such scenario the first policy will be taken in to consideration.
[Link] sum insured cannot be more than 100 times of the monthly gainful income or sum insured specified whichever is less, subject to
condition that no customer is involved in any hazardous activity.
[Link] proof for availing the compensation at the time of claim is mandatory. Income proof shall mean the previous year’s returns filed with
the Income Tax Department or salary certificate of month prior to date of accident at the time of claim.
[Link] the event of any incorrect representation, the liability shall be upon the Policyholder
[Link] case of any claim made under the policy no premium shall be refunded on cancellation of the policy.
Exclusion
1-Payment of benefits shall not be available in respect of death, injury or disablement directly or indirectly arising out of or contributed to by or traceable to any
disability existing on the date of issue of the policy.
2-Intentional self-injury, suicide or attempted suicide or whilst under the influence of intoxicating liquor or drugs.
3-Venereal disease or insanity.
4-Servicing -on duty with any armed forces.
5-War, war-like situation, invasion or in consequence thereof or nuclear risk.
6-Payment of compensation in respect of death, permanent total disablement of Insured person arising or resulting from the Insured Person committing any breach
of law with criminal intent.
7-Crew of aircraft and ship; naval, military, airforce personnel, policemen, firemen, fishermen are excluded from scope of this policy.
8-Animal Bite /Insect Bite is not covered.
9-Perils of the sea are excluded from the scope of the policy.
10-Any loss sustained while performing or participating in any of the following occupations or events shall not be covered - Working in mines, explosives, electrical
installations on high tension electric lines, racing, circus personnel, skiing, mountaineering, hunting, gliding, river rafting, winter sports, ice hockey, polo and
occupations of similar hazard.
11-Epidemic/Pandemic.
12-Risk category 3 people are out if the scope of the policy
The above list of exclusions is not exhaustive. Kindly refer Policy Terms and conditions.
Claims Settlement Procedure
Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park,Oberoi Garden City,
Off Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identity No. U66603MH2000PLC128300. UIN No. RELPAGP01001V010001 PAN No. AABCR6747B. Trade Logo displayed above belongs to Anil
Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.
Page 1 of 4
Premium Details
EQUITAS ONLINE GPA PLAN
Coverage Description Table of Benefit SI (in Rs.) Premium (in Rs.)
D + PTD B 200000.00 110.00
Basic Premium 110.00
IGST : (18.00) 19.80
Total Premium 130.00
Grievance clause:
Reliance General Insurance Company Ltd. For resolution of any query or grievance, Insured may contact the respective branch office of the
Company or may call at 1800 3009 or may write an email at [Link]@[Link]. In case the insured is not satisfied with the
response of the office, insured may contact the Nodal Grievance Officer of the Company at [Link]@[Link]. In the event
of unsatisfactory response from the Nodal Grievance Officer, insured may email to Head Grievance Officer at
[Link]@[Link]. In the event of unsatisfactory response from the Head Grievance Officer, he/she may, subject to
vested jurisdiction, approach the Insurance Ombudsman for the redressal of grievance. Details of the offices of the Insurance Ombudsman
are available at IRDAI website [Link] or on company website [Link] or on [Link]. The insured may
also contact the following office of the Insurance Ombudsman within whose territorial jurisdiction the branch or office of the Company is
located. Office of the Insurance Ombudsman,3rd Floor,Jeevan Seva Annexe,S. V. Road,Santacruz (W), Mumbai - 400 054. Tel.: 022 -
26106552 / 26106960 Fax: 022 - 26106052 Email: [Link]@[Link] | Shri. A. K. Sahoo Office of the Insurance
Ombudsman,Jeevan Darshan Bldg.,3rd Floor,C.T.S. No.s. 195 to 198,N.C. Kelkar Road,Narayan Peth, Pune – 411 030. Tel.: 020-41312555
Email: [Link]@[Link]
Reliance General Insurance Company Ltd.
Authorized Signatory
In case of any assistance with claims, please contact us on 1800 3009 (Toll Free) or email us at [Link]@[Link]. This document
shall be treated as a tax invoice as per rule 9(2) of the Goods and Services Tax invoice rule.
Note: The policy wording with detailed terms, conditions and exclusions are available on our website [Link]
Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park,Oberoi Garden City,
Off Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identity No. U66603MH2000PLC128300. UIN No. RELPAGP01001V010001 PAN No. AABCR6747B. Trade Logo displayed above belongs to Anil
Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.
Page 2 of 4
Group Personal Accident Policy Application / Enrolment Form UIN - RELPAGP01001V010001.
Application Form No.
Please note:
1. To be filled and signed by Applicant
2. This Application form shall be the basis of contract for Cover.
Customer Information
Account No. 100009235967 Customer ID:
Applicant's Full Name [Link] Jothiramalingam
Applicant's Address Perambur CHENNAI TAMIL NADU 600011
Country India Pin Code 600011
State TAMIL NADU Phone No. 9003136144
Gender Female Email Id kavikk3@[Link]
Age 31 Occupation Salaried
Type of Occupation
PAN No. Aadhar No.
Sum Insured Rs. 200000.00
Do you have a GST Registration Number. No
If yes, please specify NA
Group Personal Accident Policy Number 920292129140000065
Policy Period: Policy Start Date 24 Feb 2022 to Policy End Date 23 Feb 2023
Cover Tenure 1
Details of existing physical defect or infirmity, if any of the person/s proposed for insurance
Nomination Details
Name of Nominee D.O.B Relationship with Proposer Address of Nominee
NA 24 May 1977
Bank Details
Bank Account Holder Name [Link] Jothiramalingam
Bank Account No.: Account:
Name of the Bank
Branch
MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque
issued by the bank)
IFSC Code (11 character code appearing on your cheque leaf)
I understand that any refund due on the premium payment / any payment /claims will be directly credited to my aforesaid Bank
Account.*
*As per IRDAI, It's mandatory that all payments made to the insured only through electronic mode.
Declaration & Warranty on Behalf of All Persons Proposed to be Insured
I. I have read and understood the brochure, prospectus, sales literature & Policy wordings and confirm to abide by the same.
ii. I agree and understand that this application is part of group personal accident policy no. 920292129140000065 and Issued to
EQUITAS ONLINE For covering This policy is applicable to all CASA account holders of Equitas Small Finance Bank.
iii. I understand and agree that the company will make an auto debit from my bank account at the time of renewal of the group
personal accident policy .
iv. I understand that the information provided by me will form the basis of the insurance cover and is subject to the Board
approved underwriting group personal accident policy of the insurance company and that the policy will come into force only after
full receipt of the premium chargeable.
v. I further declare that I 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
Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park,Oberoi Garden City,
Off Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identity No. U66603MH2000PLC128300. UIN No. RELPAGP01001V010001 PAN No. AABCR6747B. Trade Logo displayed above belongs to Anil
Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.
Page 3 of 4
vi. I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has
attended on the person to be insured/proposer or from any past or present employer concerning anything which affects the
physical or mental health of the person to be insured/proposer and seeking information from any insurer to whom an application
for insurance on the person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim
settlement.
vii. I authorize the company to share information pertaining to my application including the medical records for the sole purpose of
proposal underwriting and/or claims settlement and with any Governmental and /or Regulatory Authority.
viii. I understand that the group personal accident policy shall become void at the option of the company, in the event of any
untrue or incorrect statement, misrepresentation, non-description or non-disclosure of any material fact in the Application
form/personal statement, declaration and connected documents or any material information having been withheld by me or anyone
acting on my behalf.
ix. Receipt of the Application by the Company shall not be construed as acceptance of my application. I hereby agree that the
insurance coverage shall commence only on realization of full premium and on receipt of complete medical reports (wherever
applicable) and subject to underwriting by the Company. The Company at its sole discretion reserves the right to accept or reject
any application form without assigning any reason thereof.
x. I hereby declare that the person(s) proposed to be Insured would submit to medical examinations, before the nominated doctors
of the Company, or undergo diagnostic or other medical tests, as suggested by the Company for its underwriting.
xi. I consent to provide a valid age proof and identity proof at the time of claims or any other time when required by the Company.
xii. I consent to receive information from the Company through physical, electronic or telecommunication means from time to time.
xiii. I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or
particulars given by me are true and complete in all respects to the best of my knowledge and that I am authorised to propose on
behalf of these other persons.
xiv. I/We here by state that the above mentioned address shall be taken as address on record for the purpose of GST
xv. I/We hereby confirm that the contents of the proposal form and connected documents have been fully explained to me/us and
I/We have fully understood the significance of the proposed contract
Place: Date:03 Mar 2022 Applicants Signature:________________________
Annexure 1
Risk Classification:
Risk Class I Person engaged in administrative, managerial and similar functions like bankers, teachers etc.
Risk Class II Builder, contractor & engineers engaged in superintending functions only, paid drivers of light
motor vehicle, cash carrying employees, garage & motor mechanics, machine operators &
persons engaged in occupations of similar hazard.
Risk Class III Person engaged in hazardous occupations like working in underground mines, explosives,
magazines, electrical installation with high tension supply and those engaged in
occupations/activities of similar hazard.
Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park,Oberoi Garden City,
Off Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identity No. U66603MH2000PLC128300. UIN No. RELPAGP01001V010001 PAN No. AABCR6747B. Trade Logo displayed above belongs to Anil
Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.
Page 4 of 4
