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CERTIFICATE OF INSURANCE
Attached to and Forming part of G.P.A Policy No.:361201/42/17/8200000021
Certificate No : NIC/GPA-4738
Issue Office Code : 361201
Insured Name : CHINTA
Address : DEORAJPUR, PIPRA, HATA, DISTT- Issue Office Name : BO GHAZIABAD
KUSHINAGAR DEVRAJPUR -274203 Address
: 65,NAVYUG MARKET,GHAZIABAD,UTTAR
: PRADESH,PIN-201001
Uttar Pradesh INDIA :
:
Tel. : 0120-2790069,2794178
Tel. / Fax / Email :0
Fax : 0120-2791094
9794373715
Email : 361201@nic.co.in
Period of Insurance : 5/5/2017 To 4/5/2018

Premium Rs. 266.80/- (Inclusive ST)

Particulars of the Persons Covered

Sr. No. Name of Person Covered. Age Sum Insured

Person Accident Section 80 % Hospitalization Section 20 %

1. CHINTA [4837785] 39 320000 /- 80000 /-

Assignee Detail

Sr.No. Name. Assignee Name Relationship Share %

1. CHINTA [4837785] DURGESH HUSBAND 100%

Total Sum Insured in words : Indian Rs. Four Lacs

The Insurance under the certificate is subjected to conditions, clauses, warranties, endorsement of Policy.

Place.: GHAZIABAD
Date.: 5/5/2017 For National Insurance Company Limited.

Authorized Signatory.

Note: 1. No claim will be entertained if loss information is received after 7 days from the Date of loss.
2. One Person can avail of benefits under only one certificate of Insurance.