Receipt No. _________

FILL THE FORM IN CAPITAL LETTERS ONLY

Full NameName Middle Name Name

Name:

JIO ID (16 digit)

Gender M FDOB Age

*IMP: If you still haven’t received the 16 digit JIO ID, then also send JIO Membership form along with this form

Address: _________________________________________________________________________________

_________________________________________________________________________________

Pincode

(Area) (City) (State)

Mobile:

Mobile:

Email ID:

Individual Dental Insurance cover of Rs. 25,000/- per year:Rs. 1725 per person (including tax)

*DD / Pay order should be made in favor of

*Cash/Cheque/NEFT will not be accepted *Premium can also be paid online, please visit our website www.jio.net.in

Bank Name: _______________________________________ Branch Name: ____________________

Demand Draft/Pay Order no.: ________________ Amount: ___________ Date: D M YD M Y Y Y

Please courier your duly filled form with documents and DD/ Pay order at : JIO Ocare, C/O Plan Dental LLP - 4th Floor, C-wing, Trade World, Kamala Mills Compound, Senapati

Bapat Marg, Lower Parel (W), Mumbai - 400013 | Help line No.: 022 61530202

**JIO has the Right to Terminate (Reject) this application, if any details provided are inappropriate.

: I have read and understood all the terms & conditions relating to the Dental Insurance Scheme. I abide to follow them and accept all the changes / modifications / amendments / etc. and the rule and conditions of the scheme. I also hereby confirm that all the details mentioned by me are correct and to best of my knowledge. In all matters the decision of JIO will be final.For more details please visit website : http://www.jio.net.in

Declaration

Signature of Proposer

# All the fields are compulsory

Residence No:

STD Phone No.

( or age 1 to 100)F

+ 9 1

+ 9 1

Parent/Guardian JIO ID(16 digit) :

Relationship :

In case of minor;

Since this is a group dental insurance policy, all policy holders will receive their policies at the same time - 18 days after the last date of enrollment

Terms and conditions applicable to dental Insurance component of the Dental subscription plan:

a. Insurance cover as a part of Dental subscription plan for subscribers is subject to their association in the parent organization, JIO here.b. This is a reimbursement based policyc. AGE LIMIT- 01 year onwardsd. PRE-EXISTING DISEASES are covered from Day Onee. CLAIM SUBMISSION of documents for reimbursement claims have to be submitted within 30 days of treatmentf. JIOJAC card copy should be submitted at the time of claim submission.g. Claim will be submitted via E- Claim procedure to OCARE for Dental Insurance.h. Post Submission Claims will be reimbursed in 15 working days via NEFT/Cheque/DD paymentsI. In case of a change of status, the same shall be communicated to the Ocare office immediately.j. Only treatments at the PDP (preferred dentists providers) will be covered.k. Patient seeking treatment will have to undergo a pre and post treatment OPG (full mouth x-ray) at a network center as a required protocol, unless otherwise indicated.l. The patient will be required to pay the dentist at the end of the treatment and file for reimbursement thereafter.m. Any claims for orthodontic treatment, defined as treatment undertaken by a dentist for the prevention and correction of irregularities/misalignment of teeth, for cosmetic reasons will not be covered.n. Claim must be filed within 30 days from the date of completion of treatment. However, the Company may at its absolute discretion consider waiver of this condition in extreme cases of hardship where the inability to file the claim is proved to the satisfaction of the Company. However such claims would invite additional 10% co-payment over and above payable amount as per policy terms and conditions.o. Since this is a group dental insurance policy, all policy holders will receive their policies at the same time - 18 days after the last date of enrollment

Treatment

Impaction/surgical 6000/year

Metal 2000/year

8000/year

400/year

4000/year

4000/year

4000/year

Impaction/surgical 6000/year

Metal 2000/year

8000/year

400/year

4000/year

2000/year

4000/year

TreatmentSub Limits/Capping Sub Limits/Capping

Orthodontic treatmentOrthodontics

Space maintainer

For Age: 18+ years

We strive to provide you maximum cover and benefits; however, we would like you to know some of the major exclusions under the policy.a. Tooth/Teeth fillings and Restorations b. Dental Implants c. Aesthetic and Cosmetic Procedures d. Teeth Whitening e. Tooth Jewelry

BhiwandiShree Bhairav Dental Clinic,571, Ground Floor, Nakoda Bldg, Shivaji ChowkBhiwandi-421302Time: 9AM-2PM; 4PM-8PM

KhetwadiShop 1 , Ground Floor, Manish Apartment,11th Khetwadi Back Road,Grant Road, Mumbai 400004Time: 10AM-1PM; 5PM-9PM

MazgaonShop No 1, Alka apartments,Opp St Peters School, Near Sales Tax Office, Shivdas Champsi Marg , Mazgaon-400010Time: 10AM-10PM

BorivliSai Dental Clinic, Shop No 10, Sanjoba Apartments, Plot no 88, Gorai 2, Near Pragati School, Borivli WestTime: 10AM-6PM

MulundThe Smile Dr., C-3, Jyoti Hill View CHS,Dr. R.P Road, Opp. Dhanlaxmi Bank,Near Vardhaman Nagar,Mulund-West, Mumbai-400080Time: 10AM-1PM; 5PM-8PM

BhayandarHappy Smile Dental Clinic,Shop No 10, A 2 Veet Raag Building,Near Bawan Jinalaya Jain temple,Dev-Chand Nagar road,Bhayandar West,Dist Thane 401101Time:9:30AM - 1:00 PM & 5:30 PM - 9:30 PM

VashiSmilessence Dental Clinic,Shop 13, Bhavana Chs, Plot 47, Sector 12, Vashi-Navi MumbaiTime: 4PM-9.30PM

PanvelSmilessence, 201, 2nd floor,Shiva Complex, Plot No 6,Sector 19, New Panvel East,Time: 10AM-1PM

Grant Road#4, Saraswati Mandir, Nana Chowk, Near Kennedy Bridge,Opp. Jyoti Studio Compound, MumbaiTime: 10AM-2PM; 5PM-8PM

Lower ParelWhite Clove Services Pvt. Ltd,4th floor, Trade World,Kamala Mills,Lower Parel, Mumbai 13Time: 9.30AM-7PM

GhatkoparNo. 205, Vishwa Society, RB road,Junction of 60 ft Rd & Hingwala Rd,Ghatkopar East, MumbaiTime: 12:30pm to 5:30 pm

BhandupSmile32 Dental Clinic, Shop No. 6,Khimji Naagar Chawl, Bhatipada Road,Bhanudp-West, Mumbai-400078Time: 9.30AM-1.30PM; 5.30PM-9.30PM

Thane211, Arcadia, Hiranandani Estate,Ghodbunder Road,Thane-West 400607Time: 10AM-2PM; 5.30PM-9PM

ChemburShop no 5, Bldg no 83,Opp Dynamic Gym, Amchi shala lane,Tilak Nagar, ChemburTime: 10AM-8.30PM

Vile-ParlePlot no.7,Jalaram Niwas,KD Road,Next to Puranmal hotel,Near Mithibai college,Ville Parle (W)Time: 10AM-1PM; 5PM-8PM

Collection Centers for Enrollment Form and DD

Inspiration & Blessings – Gurudev Shri Naypadmasagarji Maharajsaheb

&

An initiative to ensure the health of all Jain Shravak & Shravikas

SHRAVAK AROGYAM

Muni Shri DhyanpadmasagarjiVidushi Sadhvi Shri Maynashreeji

Muni Shri Akshaypadmasagarji Sadhvi Shri Siddhimaynashreeji