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

Endorsement Schedule For Group Health

REFUND ENDORSEMENT
Endorsement Number : 003
Effective Date of Endorsement : 04/07/2015
Attached to and forming part of the Policy No. : 4211-400401-15-5000202-00-000
Insured : M/s. Mahindra Retail Pvt Ltd
Correspondence Address :

Sadhana House, Ground Floor,

570 P.B. Marg, Worli,
Mumbai
Worli,Mumbai 400018
Maharashtra

Period of Policy :
From : 04/07/2015
To

: 03/07/2016

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
Premium for the policy Period

Rs

-126184.00

Service Tax

Rs

-17665.76

Total Premium

Rs

-143849.76

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

Service Tax Registration No. : AABCL9950ASD001

IRDA Regn. No. 150
CIN No. U66000MH2010PLC209656

Signed at: Mumbai

On Date : 24/08/2015

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

Deletion
Sr.
Emp Code
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51

23006058
23006058
23062195
23062195
23072014
23072014
23072863
23076490
23082431
23090688
23105286
23105854
23105854
23105854
23105854
23112018
23112335
23113277
23113277
23113277
23113277
23113419
23116736
23116738
23123681
23128701
23148186
23151098
23006030
23006030
23006030
23006030
23006115
23006116
23006116
23006116
23077652
23077652
23083058
23083058
23083058
23100913
23101632
23101632
23101632
23101948
23101948
23101948
211406
211406
211406

Name

Relation

Gender

DOB

Age

WEF

Sum Insured

Nilam Doshi
Kunal Shah
Ghouse Mihiuddin
Sonima
Sowmya J Silva
Jsilva Sowmya
Khushboo Khan
Lilly Leena Mary
Dixit Vinodbhai Chavda
Ishaq Ali Mohd
Abhilash T D
Hari Krishna
Anantha
Pridhveesh Sai
Siri
Ravish Ranjan
Nimdem Lepcha
Suleman Chause
Massrath Begum
Amaan Chause
Ayaan Chause
Tshring Lama
K Late Immanuel
Reddy Late K V Ramana
Santosh Babu Poluneni
Brijanarayan Sangeeta Ramteke
Anuranjitha Gogu
S Vijayshree
Selvamoney K
Abhishek G
Adhithi S
Anwer Alvi
Meenakshi Sundaram
Ashwini Sundaram
Vaibhav Sundaram
Kishore Singh Chauhan
Priya Sankhla
Kotipalli Santosh Kumar
Anusha
Yakshitha
Venkatesh Vk
Dinesh Pheiroijam
Sashibala Pheiroijam
Pheiroijam Master
Reshma C Naik
Aglawe Prasad P
Veer Prasad Aglawe
K Venkataraman
Gopi Venkataraman
Maithili Venkataraman

Self
Husband
Self
Wife
Self
Husband
Self
Self
Self
Self
Self
Self
Wife
Daughter
Daughter
Self
Self
Self
Wife
Son
Son
Self
Husband
Husband
Self
Self
Self
Self
Self
Husband
Son
Daughter
Self
Self
Wife
Son
Self
Wife
Self
Wife
Daughter
Self
Self
Wife
Son
Self
Husband
Son
Self
Wife
Daughter

Female
Male
Male
Female
Female
Male
Female
Female
Male
Male
Male
Male
Female
Female
Female
Male
Female
Male
Female
Male
Male
Male
Male
Male
Male
Male
Female
Female
Female
Male
Male
Female
Male
Male
Female
Male
Male
Female
Male
Female
Female
Male
Male
Female
Male
Female
Male
Male
Male
Female
Female

31-12-1983
02-11-1978
03-08-1986
07-07-1988
05-01-1988
07-04-1983
14-11-1991
01-08-1986
13-02-1986
01-01-1980
05-03-1990
15-06-1987
18-03-1989
22-07-2008
02-01-2012
05-04-1989
03-07-1988
14-03-1976
24-05-1984
24-09-2010
14-03-2012
05-06-1988
14-07-1980
18-06-1978
03-05-1986
07-07-1991
14-09-1991
28-03-1994
03-09-1969
16-07-1966
12-08-1996
14-09-2004
03-10-1980
21-05-1980
06-03-1984
06-08-2010
20-07-1983
20-07-1990
29-08-1984
21-07-1993
19-04-2014
01-01-1981
19-02-1979
31-12-1980
17-09-2006
11-05-1983
13-09-1984
07-05-2013
29-09-1961
01-07-1964
01-10-1993

32
37
29
27
28
32
24
29
29
36
25
28
26
7
4
26
27
39
31
5
3
27
35
37
29
24
24
21
46
49
19
11
35
35
31
5
32
25
31
22
1
35
36
35
9
32
31
2
54
51
22

05/07/2015
05/07/2015
05/07/2015
05/07/2015
05/07/2015
05/07/2015
05/07/2015
07/07/2015
05/07/2015
25/07/2015
10/08/2015
10/08/2015
10/08/2015
10/08/2015
10/08/2015
31/07/2015
10/08/2015
10/08/2015
10/08/2015
10/08/2015
10/08/2015
10/08/2015
10/08/2015
10/08/2015
10/08/2015
29/07/2015
10/08/2015
10/08/2015
28/07/2015
28/07/2015
28/07/2015
28/07/2015
31/07/2015
30/07/2015
30/07/2015
30/07/2015
05/07/2015
05/07/2015
05/07/2015
05/07/2015
05/07/2015
13/07/2015
26/07/2015
26/07/2015
26/07/2015
31/07/2015
31/07/2015
31/07/2015
12/07/2015
12/07/2015
12/07/2015

50000
50000
50000
50000
50000
50000
50000
50000
50000

50000
50000
50000

50000

50000
50000
50000
50000
200000

200000
200000

200000
200000

200000
200000

200000

500000