A Reliance Capital Company

www.reliancegeneral.co.in

Reliance Health-Individual Mediclaim Insurance Endorsement Schedule

Policy Issuing Office: Policy Servicing Branch Office:
Reliance General Insurance Co. Ltd.,
Reliance General Insurance Co. Ltd,
570, Naigaum Cross Road,
Next to Royal Industrial Estate, RELIANCE GENERAL INSURANCE CO LTD
Wadala (W), Mumbai – 400031 3 RD FLOOR PALAI PLAZA OPP PRITAM HOTEL
DADAR T. T
MUMBAI 400014

Intermediary Code: 13BRG142-11010

Name of the Insured Mr JAI B VORA
Correspondence Address of the Insured 11th FLOOR , 16 ENTERPRISES BUILDING
FORJEET HILL ROAD, TARDEO MUMBAI
MAHARASHTRA - 400036
India

Policy No: 1101702811000027 Policy Period:From 07/05/2010 to 06/05/2011

Endorsement No. 71001 Endorsement Effective Date: 07/05/2010
Type of Endorsement: Nil

Not withstanding anything to the contrary contained in the policy, it is hereby declared and agreed that The correct occupation of Mrs. Radhika Vora is "Working Executive".All
other terms and conditions of the policy remain unchanged.
Subject otherwise to terms, exclusions, conditions, limitations and warranties of the Policy.

Premium Details Net Premium Service Tax (10% of Net Education Cess (.2% of Secondary and Higher Total Premium
Premium) Service Tax) Education Cess
(.1% of Service Tax)
Policy Premium (Including 5238.00 523.80 10.48 5.24 5777.52
all previous
Endorsement/s)
Premium relating to this 0.00 0.00 0.00 0.00 0.00
Endorsement

Final Premium after 5238.00 523.80 10.48 5.24 5777.52

Endorsement

Service Tax Reg.No. AABSR6747BST001

Category-General Insurance Business Service 00440005

Note: In the event of dishonor of the cheque, this endorsement 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 24/05/2010. For any assistance with claims, please contact us on 1 800 3002 8282 (toll free)and 3989 8232 (local
charges apply) or email us at services.rgicl@relianceada.com

For and on behalf of Reliance General Insurance Company Limited

Authorized Signatory