FGH/UW/GRP/59/02

GROUP PERSONAL ACCIDENT

Certificate of Insurance
This certificate of Insurance is issued under the Group Personal Accident – Group issued to Shashank kejariwal provided by Future Generali India
Insurance Company Limited.
Future Generali India Insurance Co Ltd, Tower 3, 6th floor, India Bulls Finance Centre, Senapati Bapat Marg Elphinstone (W),
Policy Servicing Office
Mumbai 400 013
Master Policy Number FGP-10-19-7003347-00-000 Certificate Number 1004906707
Insured Name Shashank kejariwal Period of Insurance From 20/10/2019 To Midnight 19/10/2020
Intermediary Code FG&G Distribution Limited / 60060302 Easy day Card Number 1004906707
1 2 3,Lucknow,Uttar Pradesh
Address

Insured Details
Name of the Insured Person/s Age / DOB Gender Nominee Name Relation with insured
Shashank kejariwal Male Renu kejariwal Mother
Scope of cover & Benefit
As per the covers selected under Master Policy

Total Sum Insured (in words) : Rs – Two Lakhs only

Sr No. Table of Benefits % of benefits
1 Accidental Death 100%
Major Exclusions
1. Intentional self-injury (including but not limited to the use or misuse of any intoxicating drugs or alcohol).
2. Accident while under the influence of alcohol or drugs.
3. Participation in an actual or attempted felony, riot, crime, misdemeanour or civil commotion.
4. Any accident of which a contributing cause was the insured person’s actual or attempted commission of, or wilful participation in, an illegal act or any
violation or attempted violation of the law or his resistance to arrest.
5. Whilst engaging in Aviation or Ballooning or whilst mounting into, dismounting from or travelling in any balloon or aircraft other than as passenger (fare
paying or otherwise) in any duly licenced standard type of aircraft.
6. Participating in motor racing or trial run as a driver, co-driver or passenger.
7. Curative treatments or interventions that the insured person carries out or have carried out on the body.
8. War, invasion, acts of foreign enemies, hostilities (whether war be declared or not), civil war, commotion unrest, rebellion, revolution, insurrection, military
or usurped power or confiscation or nationalization or requisition of or damage or under the order of any Government or public authority.
9. Nuclear energy, radiation.
10. Any existing disablement prior to the inception of the policy.
All other terms and condition, exclusion as per the Group Personal Accident (Revised) Insurance Policy Wordings

Important : In case of payment by cheque, in the event of dishonour of cheque for any reason whatsoever, insurance provided under this document shall
automatically stand cancelled from the inception date irrespective of whether a separate communication is sent or not.
The aforesaid information is only a brief description of coverage’s and exclusions under the Policy. For detailed terms and conditions and policy wordings,
Future Generali’s Future Group PA Policy or visit our website at general.futuregenerali.in
Premium
The premium of Rs. 50/- for this policy is paid by Group Master/Policyholder – “Future Retail Limited” which is inclusive of all taxes

Date Of Issue 20/10/2019 For Future Generali India Insurance Co. Ltd.

Place Mumbai

(Authorised Signatory)
This certificate is not valid unless it is countersigned by an authorised signatory
Corporate & Registered Office : 6th Floor, Tower – 3, Indiabulls Finance Center, Senapati Bapat Marg, Elphinstone Road, Mumbai – 400013.
Care Lines : 1800-220-233, 1860-500-3333, 022-67837800, Email fghealth@futuregenerali.in
: , website : general.futuregenerali.in

CIN No. U66030MH2006PLC165287

 Procedure for Registering a claim
Insured or someone claiming on Insured’s behalf must inform Us in writing immediately and in any event within 15 days. In case of death of Insured Person,
someone claiming on his/ her behalf must inform Us in writing immediately and send Us a copy of the Post Mortem report, FIR or any other document that we
ask for within 15 days.
Documents to be submitted in the event of a claim.
Submit the duly filled in claim form signed by nominee/legal heir along with the NEFT mandate details and cancelled cheque with the following documents:
• Duly Completed Claim Form signed by Nominee/legal heir of the Insured Person
• Attested copy of Death Certificate
• Burial Certificate (wherever applicable).
• Attested copy of Statement of Witness, if any lodged with police authorities.
• Attested copy of FIR / Panchanama / Inquest Panchanama.
• Attested copy of Post Mortem Report (only if conducted).
• Attested copy of Viscera report if any (Only if Post Mortem is conducted).
• NEFT details & cancelled cheque of the Nominee/Claimant
• Original Policy copy
• KYC of Claimant/Nominee/Legal Heir

UIN: IRDAI/HLT/FGII/P-P(G)/V.I/48/2016-17
Group Personal Accident – Certificate Of Insurance