Trejhara

Mrs. MANISHA GROVER

35,PRABHAT
NAGAR,MEERUT,MEERUT,MEERUT,MEERUT,ME
ERUT,UTTAR PRADESH,250001,9359359659

Welcome on board.
Your Reliance Health Infinity Insurance
number 920222428240187007 is now
live, to access your policy anytime,
anywhere, download our Reliance Selfi
App and enjoy a host of special
features.

IRDAI Registration No. 103. Reliance General Insurance Company Limited An ISO 9001:2015 Certified Company
Registered & Corporate Office: 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off. Western Express Highway, Goregaon (E),
Mumbai-400063. Corporate Identity No. U66603MH2000PLC128300.Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private
Limited and used by Reliance General Insurance Company Limited under License.
Reliance Health Infinity Insurance UIN:RELHLIP23120V042223
Page 1 of 24
 Digitally signed by Reliance
General Insurance
Company Limited
Date: 2024.02.29 09:10:28
IST
Trejhara

RELIANCE HEALTH INFINITY INSURANCE- POLICY SCHEDULE

POLICYHOLDER DETAILS

Policy Number : 920222428240187007 Proposal No : R22022457827

Policyholder Name : Mrs. MANISHA GROVER Policy Issuance Date : 29/02/2024

Tax Invoice No. & Date : R22022457827 & 29/02/2024 GSTIN/UIN of Policyholder :
Correspondence Address & 35,PRABHAT 6th Floor, Oberoi Commerz, Oberoi
Place of Supply NAGAR,MEERUT,MEERUT,MEER Policy Issuing Branch & Garden City, Off. Western Express
: :
UT,MEERUT,MEERUT,UTTAR Date Highway, Goregaon (East) MUMBAI
PRADESH,250001 MUMBAI MAHARASHTRA 400063
Contact No : 9359359659 Email ID : [email protected]
Date of Birth : 17/04/1984 Business Type : Renewal
Gender : Female Zone : B

POLICY DETAILS
Base Sum Insured : 1000000
Cover Type : Floater Policy Tenure : 1 year
Policy Period Start Date & Policy Period End Date &
: 01/03/2024 At 00:01 Hrs : 28/02/2025 At 23:59 Hrs.
Time: Time
Previous Policy No. & end 200422328240007481
: Renewable Date : 01/03/2025
Date: 29/02/2024
Premium Payment
: None
Frequency
MORE OPTIONS BENEFITS OPTED: Opt Out Free Addon

NOMINEE DETAILS
Name of Nominee : Gaurav . Relationship with Policyholder : Spouse
35,PRABHAT
NAGAR,MEERUT,MEERUT,MEERUT,
Date of Birth : 01/07/1983 Address of Nominee :
MEERUT,MEERUT,UTTAR
PRADESH,250001
Contact No. / Mobile No. : 9359359659 Email ID :

INTERMEDIARY DETAILS
EFFICIENT INSURANCE BROKERS PVT 13BRG239 7400063232

Intermediary Name Intermediary Code Intermediary Contact No POSP ID

NA NA
VLE Name VLE ID VLE Contact No

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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 Trejhara

DETAILS OF INSURED PERSON MEMBER 1 MEMBER 2 MEMBER 3 MEMBER 4

Name of the Insured Person : Mrs. MANISHA GROVER Mr. Gaurav . Miss. Ashti Gaur
Gender : Female Male Female
Date of Birth : 17/04/1984 01/07/1983 31/07/2015
Relationship with Policyholder : Self Spouse Daughter
Insured with the Company, since : 01/03/2023 01/03/2023 01/03/2023
Date of First Enrollment : 01/03/2023 01/03/2023 01/03/2023
UHID : 28242230172112 28242230172113 28242230172114
Any Pre-existing Disease : No Yes No
Pre-existing Disease – Name Any other ailment /
:
condition not listed above-
Pre-existing Disease – Since : NA 02/2017 NA
Permanent exclusions (if any ) as
: NA
agreed by the customer
Special Remarks/Conditions : NA NA NA
ABHA Number or ABHA ID : NA NA NA

PREMIUM DETAILS AMOUNT DISCOUNT DETAILS

Zone B Girl Child Discount

Base Premium 17859.00 Renewal Discount

Addon Premium (If any) -803.65 BMI Discount/Loading

Loading (if any) 0.00 Female Proposer Discount

Discount (if any) 6249.84 Opt Out Free Addon Discount

OPD cover Premium 0 Zone B Optional Cover Discount

Net Premium Excluding Taxes and Levis 10805.00

IGST (18.00%) 1944.90
Total Premium including taxes and levies 12750.00
GSTIN :27AABCR6747B1ZG, HSN : 997133, Description of services : Accident and Health Insurance Service
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 Authorisation "NO ENF-1/LOA/ENF-1/CSD/52/2024/(Validity Period Dt.01/02/2024 to Dt.01/12/2024)/1163
Date 31-01- 2024” at General Stamp Office, Mumbai. ** Not Applicable for the State of Jammu & Kashmir

WAITING PERIOD/COPAYMENT

• 36 Months Pre-Existing Disease waiting period (Code: Excl01 )

• 24 Months of waiting period for specified disease / procedure (Code:Excl02)
Zone wise Co-Payment: 20% Zone wise Co-payment applicable, in case of claims being administered from Delhi, New Delhi & NCR including
Faridabad, Noida, Ghaziabad, Gurugram, Noida, Gautam Buddha Nagar, Mumbai & Suburbs, MMR (Mumbai Metropolitan Region), Navi
Mumbai & Suburbs, Thane City & Suburbs, Mira Road, Bhayandar, Panvel, Kalyan & Dombivali, State of Gujarat, Kolkata & Suburbs
CONTACT DETAILS FOR POLICY SERVICING CONTACT DETAILS FOR CLAIM SERVICING
Name: Reliance General Insurance Company Limited Name: Reliance General Insurance Company Limited
Correspondence Address: Reliance General Insurance. Correspondence Address: Reliance General Insurance.
Winway Building 2nd and 3rd Floor, 11/12 Block No - 4, No. 1-89/3/B/40 to 42/ks/301, 3rd floor, Krishe Block
Old No - 67, South Tukoganj, Indore (M.P) - 452001 Krishe Sapphire, Madhapur, Hyderabad - 500081
Email ID : [email protected] Email ID : [email protected]
Contact No.: 022-4890 3009 (paid) Contact No.: 022-4890 3009 (paid)
Website: www.reliancegeneral.co.in Website: www.reliancegeneral.co.in

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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POLICY EXCLUSIONS
01. Investigation & Evaluation (Code:Excl04) 21. External Congenital Anomaly
02. Rest Cure, rehabilitation and respite care (Code:Excl05 22. Hearing aids
03. Obesity/ Weight Control (Code:Excl06) 23. Hormonal therapies
04. Change-of-Gender treatments (Code:Excl07) 24. Non-medical necessary treatment
05. Cosmetic or Plastic Surgery (Code:Excl08) 25. Medical Supplies
06. Hazardous or Adventure sports (Code:Excl09) 26. Non-medical expenses
07. Breach of law (Code:Excl10) 27. Outpatient treatment
08. Excluded Providers (Code:Excl11) 28. Overseas treatment
09. Substance Abuse and Alcohol (Code:Excl12) 29. Peritoneal Dialysis
10. Wellness and Rejuvenation (Code:Excl13) 30. Prosthetic and other devices
11. Dietary Supplements & Substances (Code:Excl14) 31. Charges other than reasonable and customary charges
12. Refractive Error (Code:Excl15) 32. Self-injury or suicide
13. Unproven Treatments-Code (Code:Excl16) 33. Spinal subluxation, manipulation and muscle stimulation
14. Sterility and Infertility (Code:Excl17) 34. Treatment by a family member
15. Maternity Expenses (Code:Excl18) 35. Treatment outside discipline
In addition to above below mentioned are Specific Exclusions 36. Vaccination and immunization
applicable to this Policy 37. Nuclear attack
16. Alternative Treatment 38. War
17. Circumcision
18. Convalescence or Rehabilitation
19. Dental Treatment
20. Unprescribed drugs or treatment

PLEASE NOTE
The Policy has been issued based on the information provided by the Proposer in the Proposal Form or medical test reports or through
Interactive Voice Response(IVR)/online web service or through any other oral or written form of communication which is the basis of evaluating
the Health status of the proposed Insured Persons as on Proposed date of Insurance. *Please note that in the event of this information provided
by the Proposer being found incorrect, the policy would become void and all the benefits under the policy shall stand forfeited.
Subject otherwise to the terms and conditions of Policy Wording attached
In case of any discrepancy, the Policyholder is requested to let us know immediately. You can write to us at [email protected] or
call us at 022 4890 3009(Paid) for necessary changes/rectification.
In the event of any incorrect representation, the liability shall be upon the Policyholder.

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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GRIEVANCE CLAUSE
For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 02248903009 or may write
an email at [email protected]. In case the insured is not satisfied with the response of the office, insured may contact the Nodal
Grievance Officer of the Company at [email protected]. In the event of unsatisfactory response from the Nodal Grievance Officer,
insured may email to Head Grievance Officer at [email protected]. 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 www.irda.gov.in or on company website www.reliancegeneral.co.in or on
www.gbic.co.in. 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.
Details of the offices of the Insurance Ombudsman are
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: [email protected]
IRDAI / (IGMS/Call Centre):
Through IGMS, Insured can register the complaint online and track its status. For registration please visit IRDAI website www.irdai.gov.in.
Helpline number: 022 4890 3009 (Paid)
Timings: 8 AM to 8 PM -- (Monday to Saturday)
PLEASE NOTE
This document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services Tax Rules 2017.
In the event of non-realization of premium, this policy document automatically stands cancelled from inception, irrespective of whether a
separate communication is sent or not
In witness whereof this Policy has been signed at Mumbai on policy tax invoice date in lieu of Proposal No. as mentioned in the policy

For Reliance General Insurance Co. Ltd.

Authorised Signatory

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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Trejhara

This is to certify that Reliance General Insurance Company Limited has received an amount
of 12750.00 from Mrs. MANISHA GROVER towards payment of health insurance premium for policy
920222428240187007 for the period 01/03/2024 to 28/02/2025 issued on 29/02/2024.
The premium paid for this policy is eligible for applicable benefits under section 80D of the Income Tax Act, 1961
and amendments thereof.
Note :
• Any amount paid in cash towards the premium would not qualify for tax benefits as mentioned above.
• Health insurance premium for multiple year policy is eligible for proportionate deduction in the years in which
the health insurance continues to be effective. For your eligibility and deductions, please refer to provisions of
Income Tax Act 1961 and/or consult your tax consultant.
• The Policy Schedule in original must be surrendered to the Company in case of cancellation of the Policy.

For Reliance General Insurance Co. Ltd.

Authorised Signatory

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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Coverage Summary:

Sum Insured (in 1000000 lakhs

lakhs)
Benefit Cover Name Limits
. No(Reference
Policy
Wordings)

3.1: Basic Benefits

3.1.1 Inpatient Care Covered

Sum Insured (in Rs) Special Treatment limits (in Rs)

3.1.2 Special Treatment >=10lakhs 100% of S.I

3.1.3 Day Care Procedures Within Sum Insured

Domiciliary Within Sum Insured
3.1.4
Hospitalisation
3.1.5 Organ Donor Within Sum Insured
3.1.6 AYUSH Benefit Within Sum Insured
3.1.7 Pre-Hospitalisation
Covered upto 90 days, Within Sum Insured
Medical Expenses
3.1.8 Post-Hospitalisation
Covered, upto 180 days, Within Sum Insured
Medical Expenses
3.1.9 Emergency Ambulance Within Sum Insured
3.1.10 Transportation Benefit Maximum upto Rs. 500 per Hospitalization(Within Sum Insured)
3.1.11 Restore Benefit On subsequent claim, one restore up to 100% of Sum Insured for unrelated illness/injury

3.3 Renewal Benefit – Stay Healthy Discount

Renewal Benefit Stay Upto 10% discount on renewal premium
3.3
Healthy Discount

3.4 Add Ons Covers*

3.4.2 Limitless Cover
3.4.2.1 Consumables Cover Within Sum Insured
3.4.2.2 On subsequent claim.
Policies with Sum Insured 5 lakhs: Unlimited restore of S.I on unrelated illness or injury,
sub-limit of 100% of Sum Insured for related illness/injury.
Unlimited Restore Benefit Policies with Sum Insured >=10lakhs
Unlimited restore of S.I on related or unrelated illness or injury
This benefit supersedes Basic Benefit 3.1.11 Restore Benefit

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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3.4.11 Reduction in Room Rent Room Category Options: Single Private AC Room
Note-
The maximum liability of the Company to pay the claims under this Policy is limited to
i. Sum Insured
ii. Double Cover (if applicable)
iii. More Cover (if applicable)
iv. Super Charger (if applicable)
v. Restore Benefit or Unlimited Restore Benefit
vi. OPD Cover (if applicable)
Please refer the policy wordings for detailed information and understanding of the coverages.

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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RELIANCE HEALTH INFINITY INSURANCE- PROPOSAL FORM

Proposal Form No : R22022457827
PLEASE NOTE:
1. To be filled and signed by Proposer and all fields are mandatory to be filled.
2. This proposal shall be the basis of contract for Policy issuance
3. Reliance General Insurance Company Ltd. (the Company) is under no obligation to accept any proposal for insurance. The liability of the Company
does not commence until the proposal is accepted and underwritten by the Company and premium is received. If the Company accepts a proposal
for insurance, it shall be subject to the Policy Terms and Conditions

ABOUT INTERMEDIARY
EFFICIENT INSURANCE BROKERS PVT
Intermediary Name : Intermediary Code : 13BRG239
LTD
Branch Name : Corporate Office(Servicing) Branch Code : 9202
Sales Manage Name : Hyd Telesales Sales Manager Code :
ABOUT YOU (PROPOSER)
Name of the Proposer : Mrs. MANISHA GROVER :
Date of Birth : 17/04/1984 Gender : Female
Email id : [email protected] Alternative Email id :
Mobile No. : 9359359659 Alternative Mobile No. :
Contact Number : Occupation : Teacher
Annual Income : 500000.00
35,PRABHAT
NAGAR,MEERUT,MEERUT,MEERUT,M
Current Address :
EERUT,MEERUT,UTTAR
PRADESH,250001
City : MEERUT State : UTTAR PRADESH
Pin code : 250001

AVAIL FOR ZONE B DISCOUNT?

Yes: Discount of 20% shall apply. Copay of 20% shall apply if treatment is taken in Zone A: Delhi, New Delhi & NCR including Faridabad, Noida,
Ghaziabad, Gurugram, Noida, Gautam Buddha Nagar, Mumbai & Suburbs, MMR (Mumbai Metropolitan Region), Navi Mumbai & Suburbs,
Thane City & Suburbs, Mira Road, Bhayandar, Panvel, Kalyan & Dombivali, State of Gujarat, Kolkata & Suburbs.
No

Permanent address
City : MEERUT State : UTTAR PRADESH Pin code : 250001

OTHER DETAILS
Pan No : AXDPG0099B GST in (if any) :
Source of Funds : Annual Income : 500000.00
Do you have an e-Insurance
: Yes No
Account (e-IA)?

if No, I hereby declare that “I would like to receive my insurance policy and all the information related to the proposed insurance policy
through insurance repository”

if Yes, e-Insurance Account (eIA) No

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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 Trejhara

Reliance General Insurance Company Limited Existing Policy No (if applicable):

Reliance Group Shareholder (1) Folio Number or (2) DP Id & Client Id No. (if applicable):

I would like to share my Consumer Credit Information with Reliance General Insurance for evaluation of additional discount on my policy.
(If Yes, please sign the consent form attached)

No, I would not like additional discount on my policy

PREMIUM DETAILS
Payment frequency : None
Payment by: : Online
Payer Name: : Mrs. MANISHA GROVER Bank Name :
Cheque/DD/Card Number : Cheque/DD Date :
Amount in figures (Rs.) : Amount in words: Rupees :

Note- In case the payment is made through Cheque/DD then please issue an a/c payee instrument in favour of “Reliance General Insurance
Limited”. In case the payment is made through Credit/Debit Card the Card needs to be in the name of Proposer

PRODUCT DETAILS (Tick/ Fill the required option) (All fields are mandatory)
Cover Type : Floater
Sum Insured (Rs) : 1000000
Policy Term : 1
More Options Benefit(s) opted* : Opt Out Free Addon

ADD ON COVERS (Tick the required option)

LIMITLESS COVER: Consumables Covers, Unlimited Restore Benefit : Yes

SMART PROTECTOR: Super Charger, Air Ambulance :

If Yes, limit required for Super Charger No

MOTHER AND CHILD :

No
Maternity Cover, New-born Baby and Vaccination Cover
If Yes, choose the Maternity limit:
(Note: 2 lakhs option not available for Sum Insured 5 lakhs)
MATERNITY WAITING PERIOD REQUIRED:

OPD COVER :

If yes, Choose any one limit: No

MEDICAL EQUIPMENT COVER : No

DOUBLE COVER : No
HOME CARE TREATMENT : No
CHANGE IN PRE-EXISTING WAITING PERIOD :
If Yes, choose the required option: 36 Months

No
REDUCTION IN SPECIFIC WAITING PERIOD :
24 Months

REDUCTION IN ROOM RENT* Yes

If Yes, choose one: :
Single Private AC Room

VOLUNTARY COPAYMENT* : No

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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No
VOLUNTARY AGGREGATE DEDUCTIBLE* :

Note*
More Options and Add On Covers marked * are available for S.I Rs 3 lakhs. All other Add On Covers are available for Sum Insured 5 lakhs and
above OPD Cover can be purchased for Insured Persons up to age 60 years (for floater policies, age of the eldest member shall be considered).

NOMINEE DETAILS
In the event of the death of an Insured Person any payment due under the Policy shall become payable to the Nominee in accordance with the
Policy terms and conditions. The Nominee must be an immediate relative of the Proposer. Nominee for any of the persons proposed to be
insured shall be the Proposer.
Name : Gaurav .
Email : Mobile No : 9359359659
Date of Birth : 01/07/1983 Relationship with proposer : Spouse

DETAILS OF PERSON(S) PROPOSED TO BE INSURED

PERSONAL DETAILS MEMBER 1 MEMBER 2 MEMBER 3 MEMBER 4

Name of insurance person : Mrs. MANISHA GROVER Mr. Gaurav . Miss. Ashti Gaur
Gender (M/F/Others) : Female Male Female
Date of Birth (DD/MM/YYYY) : 17/04/1984 01/07/1983 31/07/2015
gaurav.insurance19@gm gaurav.insurance19@gm gaurav.insurance19@gm
Email :
ail.com ail.com ail.com
Relation with Proposer : Self Spouse Daughter
Occupation : Teacher
ABHA Number or ABHA ID : NA NA NA

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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PED Questions MEMBER 1 MEMBER 2 MEMBER 3 MEMBER 4

1) Was any person proposed to be insured diagnosed

with any of these medical conditions OR has any pre : No Yes No
existing disease
Any other ailment /
condition not listed
Diseases name : NA NA
above ( fracture left
leg )
Diseases Since : NA 02/2017 NA
Treatment Taken : NA NA NA
Exact diagnosis : NA fracture left leg NA
Diagnosis Date : NA NA NA
Consulting Date : NA NA NA
Hospital Name : NA NA NA
2) Has planned a surgery If Yes, please provide the :
No No No
below details
a) Please share details for your surgery
Exact diagnosis : No No No
Diagnosis Date : No No No
Consulting Date : No No No
Hospital Name : No No No
3) Takes medicines regularly If Yes, please provide the :
No No No
below details
a) Please share details for your current medication
Exact diagnosis : No No No
Diagnosis Date : No No No
Consulting Date : No No No
Hospital Name : No No No

4) Has been advised investigation or further tests If Yes,

: No No No
please provide the below details
a) Please provide details about investigation suggested
by your doctor
Date of tests : No No No
Type of tests : No No No
Findings of tests : No No No
5) Was hospitalized in past If Yes, please provide the
: No No No
below details
a) Please share details for your past medical condition

Exact diagnosis : No No No
Diagnosis Date : No No No
Consulting Date : No No No
Hospital Name : No No No

b) Please share details of your past medical condition : No No No

6) Is expecting a baby If Yes, please provide the below

: No No No
details
a) Please share your expected delivery date with us : No No No
7) Does any of the persons proposed to be insured use
: No No No
tobacco products/cigarettes or drink alcohol?
8) Has any of the persons to be insured ever filed a
: No No No
claim with their current / previous Insurer ?
Please Describe No No No
9) Has any proposal of life insurance, Critical illness or
health insurance been declined, cancelled or charged : No No No
a higher premium ?
Please Describe : No No No

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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Note: The Company may apply a risk loading upto 150% on the premium payable (based upon the declarations made in the Proposal form
and the health status of the members proposed to be insured). These loadings would be applied from the first policy and its subsequent renewals
with the Company.

Attending Physician’s Detail

Name of Family Physician: :
Contact Number : E-mail ID :

DECLARATION & WARRANTY ON BEHALF OF ALL PERSONS PROPOSED TO BE INSURED

I/We 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/We am/are authorized to propose on behalf of these
other persons.
I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting
policy of the insurance company and that the policy will come into force only after full payment of the premium chargeable
I/We further declare that I/We 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.
I/We declare and consent to the company seeking medical information from any doctor or hospital who 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 assured /proposer and seeking information from any insurance company to which an application for insurance on the life to be assured /
proposer has been made for the purpose of underwriting the proposal and / or claim settlement.
I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal
under writing and / or claims settlement and with any Governmental and / or Regulatory authority.

OTHER DECLARATIONS & AUTHORIZATIONS

I consent to receive information from the Company through physical, electronic or telecommunication means from time to time
I hereby state that the above-mentioned address shall be taken as address on record for the purpose of GST.
I hereby confirm that the contents of the proposal form and connected documents have been fully explained to me/us and I have fully
understood the significance of the proposed contract.
I understand that the Policy shall become void at the Company’s option, in the event of misrepresentation, mis-description or non-disclosure of
any material fact in the Proposal form/personal statement, declaration and connected documents or any material information having been
withheld by me or anyone acting on my behalf.
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.
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.
I agree and undertake to convey to the Company any change/alterations carried out in the risk proposed for insurance after submission of this
Proposal form.
I authorize the Company to auto renew the policy issued against this proposal form for 2024 years. I understand and agree that the renewal
would be effective subject to receipt of applicable premium before the due date. The premium applicable would be as per age and premium
rates on the due date of renewal
I hereby submit my Aadhaar number or Virtual ID and give my consent for use of my Aadhaar details to authenticate me from UIDAI and link my
Aadhar with all the policies of Reliance General Insurance Company Limited that I am associated with. I hereby warrant and represent that I
have been duly authorised to submit the Aadhaar number or Virtual ID of the insured, nominees and appointees (as the case may be), and
consent to the linkage of such Aadhaar details with all policies of Reliance General Insurance Company Limited that they are associated with.
I hereby permit/authorise Reliance General Insurance Company Limited to collect, store, communicate and process information relating to the
Policy(ies) and all transactions related therewith, including sharing and disclosing to public authorities, of any confidential information as
required by law and to send me information in relation to the Policy and General Insurance products & services, irrespective of whether I am
registered with the National Customer Preference Register (NCPR) [formerly the National Do Not Call Registry (NDNC)] or not.
To protect the environment and save paper, I hereby give my consent to Reliance General Insurance Company Limited to send me the executed
Policy copy and all related documents and other communications in electronic form by way of email to the aforesaid email id instead of physical
form and also to share all such documents and any updates & alerts via Whatsapp on my registered mobile number with the Company.
I hereby authorise Reliance General Insurance Company Limited to collect, store and share the information provided by me for the purposes as
detailed under the Reliance General Insurance Company Limited Privacy Policy [Link to the policy] and the Terms of Use [Link to terms of use]
which I acknowledge to have been read and understood by me and shall be bound by the same, subject to the understanding that use and
transmission of such personal information shall be done in a secure and confidential manner and that I shall have the right to withdraw such
consent at any given time by intimating as such to Reliance General Insurance Company Limited.

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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AML GUIDELINES
I/We hereby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been /will be paid out of
proceeds of crime related to any of the offense listed in Prevention of Money Laundering Act,2002
I understand that the Company has the right to call for document to established sources of funds
The Insurance Company has right to cancel the insurance contract in case I am/have been found guilty by competent court of law under any of
the statutes, directly or indirectly governing the prevention of money laundering in India

YOUR SIGNATURE (PROPOSER)* DATE & TIME PLACE

Corporate
29/02/2024 09:02:40
Office(Servicing)
AGENT / INTERMEDIARY’S DECLARATION [IN CASE BUSINESS IS SOURCED THROUGH AN AGENT / INTERMEDIARY] [AGENT /
INTERMEDIARY CONFIRMED USING A TICK BOX PROVIDED FOR RECORDING FOLLOWING CONSENT].

I, EFFICIENT INSURANCE BROKERS PVT LTD In my capacity as an Insurance Advisor/ Specified Person of the Corporate Agent/Insurance Web
Aggregator/Authorized employee of the Broker/Relationship Officer, do hereby declare that I have explained all the contents of this Proposal
Form, including the nature of the questions contained in this Proposal Form to the Proposer including statement(s), information and response(s)
submitted by him/her in this Proposal Form to questions contained herein or any details sought herein will form the basis of the Contract of
Insurance between Reliance General Insurance Company Limited and the Proposer, if this Proposal is accepted by Reliance General Insurance
Company Limited for issuance of the Policy. I have further explained that if any untrue statement(s)/ information/response(s) is/are contained in
this Proposal Form/including addendum(s), affidavits, statements, submissions, furnished/to be furnished and furthermore if there has been a
non-disclosure of any material fact, the policy issued to his/her favor pursuant to this Proposal may be treated by Reliance General Insurance
Company Limitedas null and void and all premiums paid under the Policy may be forfeited to Reliance General Insurance Company Limited.
The content of this form and its particulars have been explained by me in vernacular to the proposer who has understood and confirmed the
same. I confirm that to the best of my knowledge all the material facts about the prospect and the insured relevant to insurance underwriting,
including any adverse habits or income inconsistency has been disclosed herewith

Agent / Intermediary Name: Agent / Intermediary Code: License No.

EFFICIENT INSURANCE BROKERS PVT LTD 13BRG239

Signature of Agent / Intermediary: Date:

29/02/2024

Date & Time: Place: Signature of Proposer:

29/02/2024 09:02:40 Corporate Office(Servicing)

PROHIBITION OF REBATES - SECTION 41 OF THE INSURANCE ACT, 1938 AS AMENDED BY INSURANCE LAWS (AMENDMENT) ACT, 2015
1.No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance
in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the
premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be
allowed in accordance with the published prospectuses or tables of the insurer.
2.Any person making default in complying with the provision of this section shall be liable for a penalty which may extend to ten lakh rupees.

FOR OFFICE USE ONLY

Channel Name : SP Code (For Bancassurance Channel)
Customer Relationship
Branch Code : 9202
Number
(For Bancassurance Channel)
Campaign Code : Business Type Renewal
Reliance General Insurance SAP Urban/Social/Rural
Id

Reliance Health Infinity Insurance UIN RELHLIP23120V042223 RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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CUSTOMER INFORMATION SHEET / KNOW YOUR POLICY

This document provides key information about your policy. You are also advised to go through
your policy document.

POLICY
SI
TITLE DESCRIPTION CLAUSE
NO
NUMBER
1. Name of
Insurance
Product / Reliance Health Infinity Insurance
Policy

2. Policy number 920222428240187007

3. Type of
Insurance Indemnity (Where insured losses are covered up to the Sum Insured
Product / under the policy)
Policy
4. Sum Insured Floater Sum Insured - 1000000 (Where all members under the policy
(Basis) have a single sum insured limit which may be utilized by any or all
members
5. Policy A. Basic Benefits: 3.1
Coverage
a. Inpatient Care: Covers medical expenses incurred during
(What the
Hospitalization due to an illness or accident for period more than 24 3.1.1
policy
hours.
covers?)
b. Special Treatment: Covers for the medical expenses incurred
during the Policy Year on Inpatient Treatment or Daycare Treatment or 3.1.2
Domiciliary Treatment of listed Special Treatments.
c. Day Care Procedures: Medical expenses incurred for Day Care
Treatment which is surgical procedure, chemotherapy or radiotherapy
3.1.3
or hemodialysis taken by an Insured person during the Policy Period
at a Hospital or Day Care Centre.
d. Domiciliary Hospitalisation: Medical expenses for medical
treatment at home for a period exceeding 3 consecutive days which 3.1.4
would otherwise have necessitated hospitalisation.
e. Organ Donor: Medical expenses on harvesting the organ from the
3.1.5
donor for organ transplantation.
f. AYUSH Benefit: The Medical Expenses for In-patient Treatment
3.1.6
taken under Ayurveda, Unani, Sidha and Homeopathy
g. Pre-Hospitalisation Medical Expenses: Covers expenses incurred
3.1.7
90 days prior to the date of hospitalisation.

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h. Post-Hospitalisation Medical Expenses: Covers expenses

3.1.8
incurred up to 180 days from the date of discharge
i. Emergency Ambulance: Actual expenses incurred per
Hospitalization for utilizing ambulance service for transporting the
Insured Person to the nearest Hospital with adequate facilities in
3.1.9
case of an emergency or from one hospital to another for medically
necessary treatment.

j. Transportation Benefit: Reasonable expenses incurred upto Rs

500 per Hospitalization for utilizing a registered radio cab operator’s
services for transporting the Insured Person to and/or from the 3.1.10
Hospital.
k. Restore Benefit: On subsequent claim, one reinstatement up to
3.1.11
100% of Sum Insured for unrelated illness/ injury.
B. More Options Benefits The insured may choose one of the
following More Options Benefits, which will be applied to the policy
with no additional premium. If policy is renewed without any break,
3.2
such More option benefit with no additional premium will be offered
for the next Policy period. The insured can also choose any of the
other More options benefits by paying an additional premium.
l. MoreTime:
m.
n.
C. MoreGlobal:
Renewal
MoreCover:
Benefit-Stay
The
Benefit
Additional
policycovers
period
Healthy
SumEmergency
will
Insured
Discount
be extended
limit
Care
The
for payment
on
by
Insured
one
treatment
month
Person
of further
ofinillness
will
case
be "get upto" 10% discount at the time of Renewal for carrying out an
3.3
annual health check-up and sharing the results of the same with the
Company.
D. Add On Covers 3.4
p. Limitless Cover: On Opting for Voluntary Co-payment, the
i. Consumables Cover: This benefit pays the Reasonable and
Customary expenses which are listed in 3.4.2
Annexure -A List I as Optional Items.
ii. Unlimited Restore Benefit: On subsequent claim.
Policies with Sum Insured>=10lakhs 3.4.2.1
Unlimited restore of S.I on related or unrelated illness/injury
This benefit supersedes Basic Benefit - Restore Benefit 3.4.2.2
s.
q. OPD
v. HomeCover:
Smart Care OPD Cover
Protector
Treatment:
This
This has
benefit
Cover 2provides
This
The plans:
indemnifies
benefit
benefitan
indemnifies
provides
This
additional
the Cover
Insured
thethe
100%
indemnifies
Reasonable
Person
Insured
of Sum
up
for
the
the medical expenses incurred towards Home Care Treatment for 3.4.8
any of the treatments (listed in the Policy wordings)under the Policy.
y. Reduction in Room Rent: This benefit gives ThisThis
benefit
an option
benefit
allows
toreduces
the
Policyholder to change the allowable Room Category. 3.4.11

The benefit gives

This benefit
an option
gives
to

Reliance Health Infinity Insurance. UIN :RELHLIP23120V042223. RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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6. Exclusions The following is a partial list of the policy exclusions (Please refer to 4
the policy wording for the complete list of exclusions):
a. Investigation & Evaluation (Code:Excl04)
b. Rest Cure, rehabilitation and respite care (Code:Excl05)
c. Obesity/ Weight Control (Code:Excl06)
d. Change-of-Gender treatments (Code:Excl07)
e. Cosmetic or Plastic Surgery (Code: Excl08)
f. Hazardous or Adventure sports(Code:Excl09)
g. Breach of law (Code: Excl10)
h. Excluded Providers (Code:Excl11)
i. Substance Abuse and Alcohol (Code: Excl12)
j. Wellness and Rejuvenation (Code:Excl13)
k. Dietary Supplements & Substances (Code: Excl14)
l. Refractive Error (Code: Excl15)
m. Unproven Treatments (Code: Excl16)
n. Sterility and Infertility (Code: Excl17)
o. Maternity Expenses (Code: Excl 18)
Specific Exclusions
p. Alternative Treatments
q. Circumcision
r. Convalescence or Rehabilitation
s. Dental Treatments
t. Unprescribed Drugs or treatments
u. External Congenital Anomaly
v. Hearing aids
w. Hormonal therapies
x. Non-Medically necessary treatment
y. Medical Supplies
aa. Non-medical expenses
ab. Outpatient Treatment (OPD)
ac. Overseas Treatment
ad. Peritoneal Dialysis
ae. Prosthetic and other devices
af. Charges other than Reasonable and Customary
ag. Self-Injury or suicide
ah. Spinal subluxation, manipulation and muscle stimulation
ai. Treatment by a family member
aj. Treatment Outside discipline
ak. Vaccination and immunization
al. Nuclear Attack
am. War (whether declared or not)

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7. Waiting period Initial waiting Period: 30 days for all illnesses (not applicable in case of 4.1
• Time period continuous renewal or accidents)
during which
specified Specific Waiting periods (Not applicable for claims arising due to an 4.1.2
diseases / accident):24 Months for 4 diseases/procedures
treatments
are not 4.1.1
Pre-existing diseases: Covered after 36 Months
covered
• It is counted 15 days Waiting Period for treatment of Covid-19 4.2.1
from the
beginning of
the policy
coverage.
8. Financial In case of a claim, this policy requires you to share the following costs: 3.1.1
limits of Expenses exceeding the following Sub-Limits a. Special Treatment:a.
coverage Special Treatment:
i. Sub-limit (It
is a S.I>=10L-100% of S.I
predefined b. More Cover
limit and the
insurance Sum Insured (in Rs) More Cover Sum Insured (in Rs)
company will
not pay any 1000000 3,00,000
amount in c. Transportation Benefit: Rs 500 per Hospitalization 3.1.10
excess of this
limit) e. Air
d. MoreAmbulance:
Global: Planned
S.I 1crores:
Treatment
7.5%up
of to
Sum
Sum
Insured
Insured
or or
RsRs
5 Lakhs
50 lakhs 3.4.3.2
whichever is higher
ii.Co-payment 35% sub-limit for prescription
1lakh
drugs on OPD limit
Co-Payments/Deductible
(It is a
specified
amount
/percentage of
the
admissible
claim amount
m. Zone wise Co-Payment: 20% Zone wise Co-payment applicable, in
to be paid by
case of claims being administered from a zone different from the policy
policyholder/
pricing zone
insured).
iii. Deductible Not Applicable
(It is a
specified
amount:
• up to which
an insurance

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 Trejhara

company will
not pay any
claim, and
• which will be
deducted
from total
claim amount
(if claim
amount is
more than the
specified
amount)

iv. Any other Not Applicable

limit (as
applicable)

9. Claims / Please contact Company at least 48 hrs prior to an event which might Annexur
Claims give rise to a claim. For any emergency situations, kindly contact the e-III
Procedure Company within 24 hours of the event.
For any claim related query, information or assistance You can also
contact Our Help Line at 022 4890 3009(Paid) or visit Our website
www.reliancegeneral.co.in
or e-mail Us at [email protected]
Details of procedure to be followed for cashless service as well as for
reimbursement of claim including pre and post hospitalization.Turn
Around Time (TAT) for claims settlement:
TAT for preauthorization of cashless facility - 2 hours
TAT for cashless final bill authorization: 1 hour.
Provide the details /web link for following:
Network Hospital details
Reliance General Insurance Locator
rgi-locator.appspot.com
Helpline number : +91 22 4890 3009 (Paid number)
Hospitals which are blacklisted or from where no claims will be accepted
by insurer
https://www.reliancegeneral.co.in/downloads/Black_List_Hospital.pdf
Downloading/getting claim form
https://www.reliancegeneral.co.in/insurance/claims/claim-page-health
10. Policy Any issues related with respect to policy, kindly Annexur
servicing E-mail us at [email protected] e-II
and for correspondence contact us Reliance General Insurance
Company Limited
Correspondence Address – Reliance General Insurance., Winway
Building 2nd & 3rd Floor, 11/12 Block No-4, Old no-67,

Reliance Health Infinity Insurance. UIN :RELHLIP23120V042223. RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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 Trejhara
Building 2nd & 3rd Floor, 11/12 Block No-4, Old no-67,
South Tukoganj, Indore (M.P) - 452001
Contact No.- 022- 41112600

11. Grievances/ Details of Grievance redressal officer refer the link 5.1.17
Complaints "http://www.reliancegeneral.co.in/"https://www.reliancegeneral.co.in/
Insurance/About-Us/Grievance-Redressal.aspx
IRDAI Integrated Grievance Management System -
https://igms.irda.gov.in/
Insurance Ombudsman - The contact details of the Insurance
Ombudsman offices have been provided as Annexure-B of Policy
document
12. Things to Free Look Period:-The Free Look Period shall be applicable on new 5.1.15
remember individual health insurance policies and not on renewals or at the time of
porting/migrating the policy.
The Insured Person shall be allowed free look period of fifteen days(30
days if the policy is sold through distance marketing or if the Policy
Period is 3 years)from date of receipt of the policy document to review the
terms and conditions of the Policy, and to return the same if not
acceptable.
If the Insured has not made any claim during the Free Look Period,the
Insured shall be entitled to
i. a refund of the premium paid less any expenses incurred by the
Company on medical examination of the insured person and the stamp
duty charges or
ii. where the risk has already commenced and the option of return of the
policy is exercised by the insured person, a deduction towards the
proportionate risk premium for period of cover or
iii. Where only a part of the insurance coverage has commenced, such
proportionate premium commensurate with the insurance coverage
during such period

Policy Renewal: Except on grounds of fraud, moral hazard or

misrepresentation or non- cooperation, renewal of your policy shall not
be denied, provided the policy is not withdrawn.

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When your policy is due for renewal, you may migrate to another policy 5.1.8
with us (subject to underwriting guidelines of company) or port your 5.1.9
policy to another insurer.
Migration:- The Insured Person will have the option to migrate the Policy
to other health insurance products/plans offered by the Company by
applying for migration of the Policy atleast 30 days before the Policy
renewal date as per lRDAl guidelines on Migration. If such person is
presently covered and has been continuously covered without any lapses
under any health insurance product/plan offered by the Company, the
Insured Person will get the accrued continuity benefits in waiting periods
as per lRDAl guidelines on migration.
Portability:- The Insured Person will have the option to port the Policy to
other insurers by applying to such insurer to port the entire Policy along
with all the members of the family, if any, at least 45 days before, but not
earlier than 60 days from the Policy renewal date as per lRDAl guidelines
related to portability. If such person is presently covered and has been
continuously covered without any lapses under any health insurance
policy with an Indian General/Health insurer, the proposed Insured
Person will get the accrued continuity benefits in Waiting Periods as per
lRDAl guidelines on portability.
Change in Sum Insured: 5.1.13
Sum Insured can be changed (increased/decreased) only at the time of
renewal, subject to underwriting by the company. For increase in SI, the
waiting period if any shall start afresh only for the enhanced portion of the
sum insured.

Moratorium Period: 5.1.12

After completion of eight continuous years under the Policy no look back
to be applied. This period of eight years is called as Moratorium Period.
The moratorium would be applicable for the Sums Insured of the first
policy and subsequently completion of 8 continuous years would be
applicable from date of enhancement of Sums Insured only on the
enhanced limits. After the expiry of Moratorium Period no health
insurance claim shall be contestable except for proven fraud and
permanent exclusions specified in the policy contract. The policies would
however be subject to all limits, sub limits, copayments, deductibles as
per the policy contract.
13. Your Please disclose all pre-existing disease/s or condition/s before buying a
obligations policy. Non-disclosure may affect the claim settlement. Disclosure of
5.1.1
other material information during the policy period.) Insurer to specify the
material information

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The enclosed Customer Information Sheet bearing reference number "CIS\920222428240187007" is

essential part of your policy schedule, Kindly review it carefully.

Declaration by the Policy Holder

I have read the above and confirm having noted the details.

Place: MEERUT , UTTAR PRADESH

Date: 29/02/2024 09:02:40 _________________________

(Signature of the Policy Holder)

Note:

In case of any conflict, the terms and conditions mentioned in the policy document shall prevail.

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Premium Illustration

Benefit Illustration in respect of policies offered on Individual and Family Floater basis
Coverage opted
on individual
basis covering Coverage opted on individual basis
Age of the Coverage opted on family floater basis with
each member of covering multiple members of the family
members overall Sum insured (Only one sum insured
the family under a single policy (Sum insured is
insured is available for the entire family)
separately (at a available for each member of the family)
single point in
time)

Premium or
Premium consolidated Premium
Sum Sum Floater Sum
Premium Premium Discount after premium for after
insured insured discount, insured
(Rs.) (Rs.) , if any discount all members discount
(Rs.) (Rs.) if any (Rs.)
(Rs.) of family (Rs.)
(Rs.)
5,00,00
51 12907 12907 11,616 5,00,000
0
5,00,00
44 8501 8501 7,651 5,00,000
0
10% 23,897 0% 23,897 500,000
5,00,00
23 6299 6299 5,669 5,00,000
0
5,00,00
18 5199 5199 4,679 5,00,000
0
Total Premium for all members of the
family Total Premium for all members of the family is Total Premium when policy is
is Rs.32,906 when each member is Rs. 29,616 when they are covered under a single opted on floater basis is Rs.
covered policy. 23,897
separately.
Sum insured available for each individual is Sum insured available for each family member is Sum insured of Rs 5 lakhs is
Rs.5 lakhs Rs.5 lakhs available for the entire family.
Note: Premium rates specified in the above illustration are standard premium rates without any discount for Rest of India zone.
Also, the premium rates are exclusive of taxes applicable.

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POLICY NO :920222428240187007 VALID UPTO: 28/02/2025 REG. MOBILE NO: 9359359659

Insured Name Date Of Birth UHID

Mrs. MANISHA GROVER 17/04/1984 28242230172112

Mr. Gaurav . 01/07/1983 28242230172113

Miss. Ashti Gaur 31/07/2015 28242230172114

Please quote your UHID No. for assistance

This card is invalid if the policy is cancelled
Immediate intimation to RCare is a must in case of
hospitalization
To avail cashless facility at our Network Hospitals, please
carry your Health Card & Photo ID proof at the Hospital
Helpdesk
Updated list of Network Hospitals is available on
www.reliancegeneral.co.in

RCare Health:
Reliance General Insurance, No.1-89/3/B/40 to 42/ks/301, 3rd floor, Krishe Block, Krishe
Sapphire, Madhapur, Hyderabad - 500081.
IRDAI Reg. No. 103. Reliance General Insurance Company Limited
Registered & Corporate Office: 6th Floor, Oberoi Commerz, International Business Park,
Oberoi Garden City, Off. Western Express Highway, Goregaon (E), Mumbai-400063. Trade
Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used
by Reliance General Insurance Company Limited under License.

RGI/MCOM/CO/RHII-PS/Ver. 2.0/050922

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