HDFC ERGO General Insurance Company Limited 2919100384737300000

Policy Schedule
Policy No. 2919 1003 8473 7300 000

Travel Insurance Policy

GSTIN: 27AAACB5340H1ZY 0
Proposer Name MR. KUNAL DEVENDRARAO RODE PAN No.
Corr. Address/ PLOT NO 96 VAISHNAVDEVI SQUARE DESHPANDE Permanent PLOT NO 96 VAISHNAVDEVI SQUARE DESHPANDE LAYOUT 1
Place of Supply LAYOUT WARDHAMANNAGAR Address WARDHAMANNAGAR
NAGPUR, MAHARASHTRA, 440008 NAGPUR, MAHARASHTRA, 440008
Mobile 9665100622 Phone - E Mail MARKNAGPUR@GMAIL.COM Overseas Ph. No. Policy Issuance Date 26/11/2018
Insurance Plan Single Trip Excl USA / Canada Countries of Visit Worldwide excluding USA and Canada
Travel days per trip Period of Insurance From Date & Time 27/11/2018 00:01 hrs To Date & Time 25/01/2019 Midnight
Maximum any one life limit (US$) 100000 Operative Time* As mentioned below
*Operative Time: A trip outside the territorial limits of the country of residence. The insurance starts from the time an Insured Person leaves the territorial limits of the country of residence, and ends when an
Insured Person returns to the territorial limits of the country of residence.
Insured Person's Details & Sum Insured
Insured’s Name Category Gender Date of Birth Passport No. Nominee Name Relationship
Kunal Devendrarao Rode Self Male 30/01/1984 R1972209 DEEPTI KUNAL RODE Spouse
Coverage Details
Benefits Sum Insured (US$) Deductible (US$)
Emergency Medical Expenses(EME) 100000 100
Accidental Death - Common Carrier 5000 Nil
Accidental Death 15000 Nil
Permanent Disablement - Common Carrier 5000 Nil
Hospital Cash 15 per day/Max 150 1 Day
Emergency Dental Treatment 500 150
Loss of Baggage & Personal Documents 250 30
Medical Evacuation Included in EME Nil
Repatriation Included in EME Nil
Loss of Checked Baggage 1000 Max 50% Per Bag/10% Per Item
Delay of Checked Baggage 200 12 Hours/$10 per 8 Hours
Permanent Disablement / Table B 15000 Nil
Personal Liability 100000 200
Financial Emergency Assistance 700 Nil
Hijack Distress Allowance 75 per Day/Max 450 1 Day
Flight Delay 10 per Hour/Max 120 6 Hours
Hotel Accomodation 3000 Nil
Premium Details (`)

Basic Premium 1,761.00

Loadings 0.00

GST 18% : Central Tax 9%( `158.50)+ State Tax 9%( `158.50) 316.98
Total Premium 2,078.00

Payment Details
Cheque No./DD/Fund Transfer Date Bank Name
RT1811009110 26/11/2018 BizDirect

Special Conditions

Exclusions

List of Endorsements
Endt No Description Effective Date End Date Premium (In ` )

Invoice No. 100384737300000 HSN Code 9971

We shall not be liable to make any payment under this policy in connection with or in respect of any Illness or injury directly or indirectly caused by or contributed to by nuclear weapons/materials or
contributed to by or arising from ionising radiation or contamination by radioactivity by any nuclear fuel or from any nuclear waste or from the combustion of nuclear fuel.
I f the premium i s not realised the policy shall be void from inception. The stamp duty of 0.50 paid by Demand Draft, vide Receipt/Challan no. CSD/137/2018/3774/18 dated 30/08/2018 as prescribed in
Government Notification Revenue and Forest Department No. Mudrank 2004/4125/CR 690/M-1,dated 31/12/2004.,dated 31/12/2004.Goods and Service Tax Registration No: 27AABCL5045N1Z8 .
Goods and Service Tax for this invoice is not payable under reverse charge basis.
Branch :LEELA BUSINESS PARK, 6TH FLR, ANDHERI - KURLA RD, MUMBAI, 400059. Phone No. :+91-22-66383600
For HDFC ERGO General Insurance Company Ltd.

Duly Constituted Attorney

The Policy wording attached herewith includes all the standard coverage offered by the Company to its customers. Your entitlement for coverage/benefits shall be restricted to the coverage/benefits as
mentioned in this policy schedule. For any clarification please call our toll free number.

HDFC ERGO General Insurance Company Limited.(Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016).CIN: U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District
(Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Toll Free Number: 1800 2700 700 Te.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | care@hdfcergo.com | www.hdfcergo.com.
UIN : HDE-MO-P14-40-V02-14-15 IRDAI Reg No.146
HDFC ERGO General Insurance Company Limited 2919100384737300000

Proposal No. 2919 1003 8473 7300 000

Travel Insurance - Proposal Form For Retail Travel
Insurance Policy 0
Proposer Name MR. KUNAL DEVENDRARAO RODE Proposer DOB 30-01-1984
Correspondence PLOT NO 96 VAISHNAVDEVI SQUARE DESHPANDE Permanent PLOT NO 96 VAISHNAVDEVI SQUARE DESHPANDE LAYOUT
Address LAYOUT WARDHAMANNAGAR Address WARDHAMANNAGAR
NAGPUR, MAHARASHTRA, 440008 NAGPUR, MAHARASHTRA, 440008
Mobile 9665100622 Phone - E Mail MARKNAGPUR@GMAIL.COM Overseas Ph. No.

Physician Name Physician Mobile No.

Insurance Plan Single Trip Excl USA / Canada Countries of Visit Worldwide excluding USA and Canada
Travel days per trip Period of Insurance From Date & Time 27/11/2018 00:01 hrs To Date & Time 25/01/2019 Midnight
Maximum any one life limit (US$) 100000 Operative Time* As mentioned below

*Operative Time: A trip outside the territorial limits of the country of residence. The insurance starts from the time an Insured Person leaves the territorial limits of the country of residence, and ends when an
Insured Person returns to the territorial limits of the country of residence.
Insured Person's Details & Sum Insured
Insured’s Name Category Gender Date of Birth Passport No. Nominee Name Relationship
Kunal Devendrarao Rode Self Male 30/01/1984 R1972209 DEEPTI KUNAL RODE Spouse

Premium Details (`)

Basic Premium 1,761.00

Loadings 0.00

GST 18% : Central Tax 9%( `158.50)+ State Tax 9%( `158.50) 316.98
Total Premium 2,078.00

Payment Details
Cheque No./DD/Fund Transfer Date Bank Name
RT1811009110 26/11/2018 BizDirect

Proposer declaration

DECLARATION ON BEHALF OF ALL PERSONS TO BE INSURED : I/We hereby understand, declare, consent and authorize the Company to use personal health details and financial information, as
provided to the Company for underwritingthe risk. I/We hereby also understand, declare, consent and authorize the Company that the Company shall have right to retain the aforementioned information
anddisseminate the same to its service provider(s) for providing services related to insurance.

Anti rebate clause

Prohibition of Rebates (Section 41 of Insurance Act, 1938 as amended) : 1. No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or
renew o r continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the
policy, nor shall any person taking out o r renewing o r continuing a policy accept any rebate, except such rebate a s may be allowed in accordance with the published prospectuses or tables of the
insurer: provided that acceptance by an insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be acceptance of a rebate
of premium within the meaning of this sub-section if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed
by the insurer.

2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees..

Exclusions

Disclaimer : Proposal Form and Policy Schedule have been generated basis details entered by proposer / insured on Online Platform (either on HDFCERGO.com or its affiliated Online Channels (IRDAI
Licensed Intermediaries). For any modification, kindly visit URL https://www.hdfcergo.com/customer-care/customer-support.html and register your service request o r write to u s at
care@hdfcergo.com

Customer Name: KUNAL DEVENDRARAO RODE PAN No. :

HDFC ERGO General Insurance Company Limited.(Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016).CIN:
U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service Address: D-301, 3rd Floor, Eastern
Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Toll Free Number: 1800 2700 700 Te.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | care@hdfcergo.com |