-143849.76Total Premium

Service Tax

Premium for the policy Period -126184.00

-17665.76

Notwithstanding anything contrary to the terms & conditions of the policy, the following endorsement/s should be read as attached to and forming part of the Policy No. 4211-400401-15-5000202-00-000

The name/names of the following Insured Person/s is/ are stand/s deleted from the aforesaid policy number with effect from date of leaving.

In view thereof an Additional / Refund premium inclusive of Service Tax is charged and Collected / Refund from the Insured as per details below

Subject otherwise to the terms, conditions, and limitations of the Policy and Endorsements thereon if any.

Signed at: MumbaiOn Date : 24/08/2015

Period of Policy :

Correspondence Address :

Insured : M/s. Mahindra Retail Pvt Ltd

Attached to and forming part of the Policy No. : 4211-400401-15-5000202-00-000

Effective Date of Endorsement : 04/07/2015

Endorsement Number : 003

REFUND ENDORSEMENT

From : 04/07/2015

To : 03/07/2016

Rs

Rs

Rs

Service Tax Registration No. : AABCL9950ASD001IRDA Regn. No. 150 CIN No. U66000MH2010PLC209656

"Awarded for ‘Outstanding Customer Service’ across Insurance Industry by ET Edge – An Initiative by Economic Times"

Endorsement Schedule For Group Health

Sadhana House, Ground Floor,570 P.B. Marg, Worli, MumbaiWorli,Mumbai 400018Maharashtra

Sr.

No.Emp Code Name Relation Gender DOB Age WEF Sum Insured

1 23006058 Nilam Doshi Self Female 31-12-1983 32 05/07/2015 50000

2 23006058 Kunal Shah Husband Male 02-11-1978 37 05/07/2015

3 23062195 Ghouse Mihiuddin Self Male 03-08-1986 29 05/07/2015 50000

4 23062195 Sonima Wife Female 07-07-1988 27 05/07/2015

5 23072014 Sowmya J Silva Self Female 05-01-1988 28 05/07/2015 50000

6 23072014 Jsilva Sowmya Husband Male 07-04-1983 32 05/07/2015

7 23072863 Khushboo Khan Self Female 14-11-1991 24 05/07/2015 50000

8 23076490 Lilly Leena Mary Self Female 01-08-1986 29 07/07/2015 50000

9 23082431 Dixit Vinodbhai Chavda Self Male 13-02-1986 29 05/07/2015 50000

10 23090688 Ishaq Ali Mohd Self Male 01-01-1980 36 25/07/2015 50000

11 23105286 Abhilash T D Self Male 05-03-1990 25 10/08/2015 50000

12 23105854 Hari Krishna Self Male 15-06-1987 28 10/08/2015 50000

13 23105854 Anantha Wife Female 18-03-1989 26 10/08/2015

14 23105854 Pridhveesh Sai Daughter Female 22-07-2008 7 10/08/2015

15 23105854 Siri Daughter Female 02-01-2012 4 10/08/2015

16 23112018 Ravish Ranjan Self Male 05-04-1989 26 31/07/2015 50000

17 23112335 Nimdem Lepcha Self Female 03-07-1988 27 10/08/2015 50000

18 23113277 Suleman Chause Self Male 14-03-1976 39 10/08/2015 50000

19 23113277 Massrath Begum Wife Female 24-05-1984 31 10/08/2015

20 23113277 Amaan Chause Son Male 24-09-2010 5 10/08/2015

21 23113277 Ayaan Chause Son Male 14-03-2012 3 10/08/2015

22 23113419 Tshring Lama Self Male 05-06-1988 27 10/08/2015 50000

23 23116736 K Late Immanuel Husband Male 14-07-1980 35 10/08/2015

24 23116738 Reddy Late K V Ramana Husband Male 18-06-1978 37 10/08/2015

25 23123681 Santosh Babu Poluneni Self Male 03-05-1986 29 10/08/2015 50000

26 23128701 Brijanarayan - Self Male 07-07-1991 24 29/07/2015 50000

27 23148186 Sangeeta Ramteke Self Female 14-09-1991 24 10/08/2015 50000

28 23151098 Anuranjitha Gogu Self Female 28-03-1994 21 10/08/2015 50000

29 23006030 S Vijayshree Self Female 03-09-1969 46 28/07/2015 200000

30 23006030 Selvamoney K Husband Male 16-07-1966 49 28/07/2015

31 23006030 Abhishek G Son Male 12-08-1996 19 28/07/2015

32 23006030 Adhithi S Daughter Female 14-09-2004 11 28/07/2015

33 23006115 Anwer Alvi Self Male 03-10-1980 35 31/07/2015 200000

34 23006116 Meenakshi Sundaram Self Male 21-05-1980 35 30/07/2015 200000

35 23006116 Ashwini Sundaram Wife Female 06-03-1984 31 30/07/2015

36 23006116 Vaibhav Sundaram Son Male 06-08-2010 5 30/07/2015

37 23077652 Kishore Singh Chauhan Self Male 20-07-1983 32 05/07/2015 200000

38 23077652 Priya Sankhla Wife Female 20-07-1990 25 05/07/2015

39 23083058 Kotipalli Santosh Kumar Self Male 29-08-1984 31 05/07/2015 200000

40 23083058 Anusha Wife Female 21-07-1993 22 05/07/2015

41 23083058 Yakshitha Daughter Female 19-04-2014 1 05/07/2015

42 23100913 Venkatesh Vk Self Male 01-01-1981 35 13/07/2015 200000

43 23101632 Dinesh Pheiroijam Self Male 19-02-1979 36 26/07/2015 200000

44 23101632 Sashibala Pheiroijam Wife Female 31-12-1980 35 26/07/2015

45 23101632 Pheiroijam Master Son Male 17-09-2006 9 26/07/2015

46 23101948 Reshma C Naik Self Female 11-05-1983 32 31/07/2015 200000

47 23101948 Aglawe Prasad P Husband Male 13-09-1984 31 31/07/2015

48 23101948 Veer Prasad Aglawe Son Male 07-05-2013 2 31/07/2015

49 211406 K Venkataraman Self Male 29-09-1961 54 12/07/2015 500000

50 211406 Gopi Venkataraman Wife Female 01-07-1964 51 12/07/2015

51 211406 Maithili Venkataraman Daughter Female 01-10-1993 22 12/07/2015

Annexure forming part of Endorsement No. 44211-400401-15-5000202-00-003

Deletion