Visitors Insurance ϥϳέ΋΍ίϟ΍ϰϠϋϥϳϣ΄Ηϟ΍

Policy Schedule ϥϳϣ΄Ηϟ΍ΔϘϳΛϭϝϭΩΟ

̼́͵̯̘̓ͱ̴̹̘̓͛௛̀௜̺͙̹͂̚௛̡
Name of the Company ϥϳϣ΄Ηϟ΍Δϛέηϡγ΍
Aljazira Takaful Ta͛awuni Company
Policy No: 315471817122021 ΔϘϳΛϭϟ΍ϡϗέ
Policyholder Details ΔϘϳΛϭϟ΍ϝϣΎΣΕΎϧΎϳΑ
Policyholder Name: SHAURYA USAPKAR ΔϘϳΛϭϟ΍ϝϣΎΣ

Nationality: IND ΔϳγϧΟϟ΍

Purpose of visit ΔϳϠ΋ΎϋΓέΎϳί ΓέΎϳίϟ΍ϥϣνέϐϟ΍
Reference Number: ϊΟέϣϟ΍ϡϗέ
Postal Address: 504 I 39 POONAM SAGAR COMPLEX OPP SHANTI ϱΩϳέΑϟ΍ϥ΍ϭϧόϟ΍
NAGAR SECTOR 9 MIRA ROAD EAST THANE
MAHARASHTRA
Telephone No in homecountry: ΔϣΎϗϹ΍ΩϠΑϲϓϑΗΎϬϟ΍ϡϗέ
Marital Status: SINGLE ϪϳϋΎϣΗΟϷ΍ϩΎΟΣϟ΍
Telephone No in Destination: ΩϭλϘϣϟ΍ΩϠΑϟ΍ϲϓϑΗΎϬϟ΍ϡϗέ
Fax No in Destination: ΩϭλϘϣϟ΍ΩϠΑϟ΍ϲϓαϛΎϔϟ΍ϡϗέ
Mobile Number: ϝ΍ϭΟϟ΍ϑΗΎϬϟ΍ϡϗέ
Type of Insurance ϥϳϣ΄Ηϟ΍ωϭϧ
Insurance for the visitors fo the kingdom of Saudi Arabia ͂̀͡͵̯̠̺͙͂௬̗௛̯̺͙̹͂Ͼ̻̻Ͼ̺ͳ௬̸̻̺͙̓͡ͳ̀௛͙ͅ௜̺͙̓Ͼ̮ͳ௬̻̔௪̺͙
Product: Visit Visa ΞΗϧϣϟ΍
Provider's Network: C ϥϳΩϭίϣϟ΍ΔϛΑη

Policy / Insurance Period ϥϳϣ΄Ηϟ΍ΓΩϣΔϘϳΛϭϟ΍ΓΩϣ

From 21-12-2021 ϥϣ
To 21-12-2022 ϰϟ·
Both dates included ͳ௬̞̀ͣ̓௪̺͙͇̹ͱ̡̻̀
This policy is issued once and upon expiry a new policy shall be ͳ͕ͩ௛௪̡̀͆͵̸͛̀͂̚͡͡௬̙͵̢͙͙ͣ͡Ͳ௪̸̭̼͙̀̓̾̓ͅͱ̴̜̓́͵̜͙͛͡͵͛௛̸̢̻̺̘ͣ͂͡௬̙͵̺͙ʹ̽͢
issued and does not need to be valid for one complete year) ͂Ͼ̻̹̼̠̘̻̓͂̓̾͡ͳ͵̹̘

Premium / Contribution Amount 19.31 - $ ργϘϟ΍ϙ΍έΗηϻ΍Δϣϳϗ

Excess ϝϣΣΗϟ΍ώϠΑϣ

Aljazira Takaful Ta¶awuni Co.: Insurance Joint Stock Co. Operating Saudi Central Bank,
license No. 201312/34, Capital S.R.: 470,664,030 Fully Paid C.R.No.: 4030251980 /
7001791990 ±P.O.Box : 5215 Jeddah 21422, Toll Free.: 8003040400, Web Site
www.ajt.com.sa National Address: Aljazira Takaful Ta¶awuni Co., 7512 Al-Madinah Al-
Munawarah Rd. ±AlHamra Dist., Unit No. 8021, Jeddah, 4516-23324, KSA.
ϱΩϮόδϟ΍ϱΰϛήϤϟ΍ϚϨΒϟ΍ϑ΍ήη·ϭΔΑΎϗήϟΔόοΎΧΔϤϫΎδϣϲϧϭΎόΗϦϴϣ΄ΗΔϛήηˬϲϧϭΎόΗϞϓΎϜΗΓήϳΰΠϟ΍Δϛήη
ϱέΎΠΘϟ΍ϞΠδϟ΍ϢϗέˬϞϣΎϜϟΎΑωϮϓΪϣ୰470,664,030ϝΎϣα΃ήΑ201312/34ϥϡΕϢϗέκϴΧήΘΑ
ϊϗϮϤϟ΍ˬ8003040400ϲϧΎΠϤϟ΍ϒΗΎϬϟ΍±21422ΓΪΟ5215Ώιˬ70017919904030251980
ΓέϮϨϤϟ΍ΔϨϳΪϤϟ΍ϖϳήρ7512ˬϲϧϭΎόΗϞϓΎϜΗΓήϳΰΠϟ΍ΔϛήηϲϨρϮϟ΍ϥ΍ϮϨόϟ΍www.ajt.com.saϲϧϭήΘϜϟϹ΍
ΔϳΩϮόδϟ΍ΔϴΑήόϟ΍ΔϜϠϤϤϟ΍ˬ233244516ˬΓΪΟˬ8021ϢϗέΓΪΣϭˬ˯΍ήϤΤϟ΍±ϲϋήϔϟ΍
 Medical emergencies ΔϳΑρϟ΍Ήέ΍ϭρϠϟ
Customer care centre 920000560 | +966 (0)1 26688877 ˯ϼϣόϟ΍ΔϣΩΧίϛέϣ
Email info@ajt.com.sa ϲϧϭέΗϛϟϻ΍ΩϳέΑϟ΍
Any claims payment made for covered losses under this policy ̸͂௬̙͵̺͙ʹ͚̽̚͢͵̻̗̲̻̺͙͛̓ͩ௛̸̠̞̺̗̓̓͂ͅϾ̯௪̸̻̺͙̜͂௪̴̠̻̺͙̗̺̻̺͙̜̘̯̓̓ͩ̓̾͜͜͡Ͳ௪̳̺̗̻̀̓ͷ͕
will be in Saudi Riyals (SAR). ͷ͡͵̯̠̺͙ͱ̓̀௛̺̗̓ͳ͵̹̘ͮ͵̠

Benefit Limits - ΩϭΩΣϟ΍ ̵̯̼̻̺͙͂

Diagnosis and treatment of emergency cases Up to SAR 100,000 ̺͙̜̺͙͇̮͂ͣ̓ͩ͆̓͜͞ͅ͵̼̯̻͂̀̓
Hospitalization Up to SAR 100,000 ̵̡̓௪̴̠̻̺͙́Ͳ̀͵̼௪̺͙
Emergency dental treatment (*) Up to SR 500  ̺͙͂ͣ̓ͩͅͳ̼̠͙͇̮̓͋͞
Treatment of emergency pregnancy and delivery cases Up to SAR 5,000 ̺͙͂ͣ̓ͩ͛͆͡ͅ͵̺͙͵ͱ̻̜̺͙̜͇̮͆̓͜͞
The treatment of premature babies (**) Up to SAR 100,000  ͳ̀௛̠௪̗̻̺͙ͱ̵͙͇̮̓ͩ͋͞
Emergency Medical Evacuation inside and outside the Kingdom Up to SAR 100,000 ̹͂Ͼ̻̻̺͙̞ͣ̓͞͵ͱ̞͙̺͙̗̺͙͓͇̞ͣ̓ͩ́ͩ͘͡΀͙
Emergency Kidney Dialysis Up to SAR 100,000 ̺͙ͣ̓ͩ͘ͷ͵Ͼ̹̺͙ͱ௬̠̲̺͙
Repatriation of mortal remains to the home country Up to SAR 10,000 ́Ͼ̢͙͋ʹ͡Ͼ̴̗̺̓͗́͵௪̴̻̺͙̮̓ͣ͛̓͗͜͡
Cost of travel and accompanying of one direct family member Up to SAR 5,000 ̜͙͡͵௛̡̗̻̓͛௛̠͕͵̸̴̭̮͙͂௛̻͵௛̵̠
Treatment to injuries resulting from road traffic accidents Up to SAR 100,000 ͂௬̺͍͙̗̹̓͜௛̻̺͙͙͝͡͵̜ͳ̢̮̘̼̺͙̗͂̓̓̓̚͜΀͙͇̮͞
Geographical limits ͂௬̴͙௛̲̺͙̚͡͵̜̺͙͡
the insurance coverage will be effective when the insured ΔϳΩϭόγϟ΍ΔϳΑέόϟ΍ΔϛϠϣϣϟ΍ΩϭΩΣϪϟϥϣ΅ϣϟ΍ϝϭΧΩΩϧϋϲϧϳϣ΄Ηϟ΍˯Ύρϐϟ΍ϱέγϳ
enters the borders of the Kingdom of Saudi Arabia

Covid 19 Coverage COVID-19̸̜̗͆̓͂͜Ͼ̯௪̻̺͙͂௬̼௬̻̔௪̺͙͂௬̲ͩ௪̺͙

Emergence medical cases Up to SAR 650,000 ̺͙͂ͣ̓ͩ͂ͅ௬̗̺͙̜̺͙ͩ͆̓͜

Quarantine Cost SAR 450 per day (maximum of ̗̺͙́ͩͱ௜̯̺͙ͮ௬̺̹̘̓

14 days)

Medical evacuation Actual costs / ͂௬Ͼ̵̯̺͙ͮ௬̺̹̓௪̺͙ ̗̺͙͓͇̞́ͩ΀͙

Return the remains of the deceased to his original home Actual costs / ͂௬Ͼ̵̯̺͙ͮ௬̺̹̓௪̺͙ ́Ͼ̢͙̼͋̿ͩ͵̴̻̺̓͵௪̴̻̺͙̮̓ͣ͛̓͗͜͡

Aljazira Takaful Ta¶awuni Co.: Insurance Joint Stock Co. Operating Saudi Central Bank,
license No. 201312/34, Capital S.R.: 470,664,030 Fully Paid C.R.No.: 4030251980 /
7001791990 ±P.O.Box : 5215 Jeddah 21422, Toll Free.: 8003040400, Web Site
www.ajt.com.sa National Address: Aljazira Takaful Ta¶awuni Co., 7512 Al-Madinah Al-
Munawarah Rd. ±AlHamra Dist., Unit No. 8021, Jeddah, 4516-23324, KSA.
ϱΩϮόδϟ΍ϱΰϛήϤϟ΍ϚϨΒϟ΍ϑ΍ήη·ϭΔΑΎϗήϟΔόοΎΧΔϤϫΎδϣϲϧϭΎόΗϦϴϣ΄ΗΔϛήηˬϲϧϭΎόΗϞϓΎϜΗΓήϳΰΠϟ΍Δϛήη
ϱέΎΠΘϟ΍ϞΠδϟ΍ϢϗέˬϞϣΎϜϟΎΑωϮϓΪϣ୰470,664,030ϝΎϣα΃ήΑ201312/34ϥϡΕϢϗέκϴΧήΘΑ
ϊϗϮϤϟ΍ˬ8003040400ϲϧΎΠϤϟ΍ϒΗΎϬϟ΍±21422ΓΪΟ5215Ώιˬ70017919904030251980
ΓέϮϨϤϟ΍ΔϨϳΪϤϟ΍ϖϳήρ7512ˬϲϧϭΎόΗϞϓΎϜΗΓήϳΰΠϟ΍ΔϛήηϲϨρϮϟ΍ϥ΍ϮϨόϟ΍www.ajt.com.saϲϧϭήΘϜϟϹ΍
ΔϳΩϮόδϟ΍ΔϴΑήόϟ΍ΔϜϠϤϤϟ΍ˬ233244516ˬΓΪΟˬ8021ϢϗέΓΪΣϭˬ˯΍ήϤΤϟ΍±ϲϋήϔϟ΍
 Insurance eligibility criteria ϥϳϣ΄ΗϠϟϥϭϠϫ΅ϣϟ΍
Includes all individuals arriving in the Kingdom of Saudi Γέϳη΄ΗΏΟϭϣΑˬϡϫέγ΃Ω΍έϓ΃ϭΔϳΩϭόγϟ΍ΔϳΑέόϟ΍ΔϛϠϣϣϠϟϥϳϣΩΎϘϟ΍ϊϳϣΟϝϣηϳ
Arabia and their family members, under a legitimate visit
visa (except for pilgrims - Hajj and Umrah)
Special Conditions:
The company¶s prior approval is required for medical expense
to be covered under the policy at the selected provider
network
Compensation will be paid after the company approval of those
expenses that are covered after completing the insurance
application form and submitting it to the company along with the
original detailed bills in additional to any other related documents
such as medical information documents, flight tickets and travelling
documents
Treatment in day care and outpatient clinics shall not be covered
unless it is for emergency
There will be no cover for any illness or injury or physical
weakness or physical disabilities, and the consequences and
symptoms that occur or appear before each trip
This product does not cover pregnancy and delivery cases unless
declared on the porposal from and cover will be limited to
emergency only.
The policyholder and any other person that is listed on the policy
schedule and included in the insurance undertake not to use this
policy to cover any previously known treatment or diagnostic nor
visit the kingdom in order to obtain this treatment within this
coverage.
Signed on behalf of the company
Attorney:
Company Seal
Aljazira Takaful Ta¶awuni Co.: Insurance Joint Stock Co. Operating Saudi Central Bank,
license No. 201312/34, Capital S.R.: 470,664,030 Fully Paid C.R.No.: 4030251980 /
7001791990 ±P.O.Box : 5215 Jeddah 21422, Toll Free.: 8003040400, Web Site
www.ajt.com.sa National Address: Aljazira Takaful Ta¶awuni Co., 7512 Al-Madinah Al-
Munawarah Rd. ±AlHamra Dist., Unit No. 8021, Jeddah, 4516-23324, KSA.
ϥϳέϣΗόϣϟ΍ϭΝΎΟΣϟ΍˯ΎϧΛΗγΎΑΔϳϣΎυϧΓέΎϳί
ΔλΎΧρϭέη
ϥϣοΔϘϳΛϭϟ΍ϕΎυϧϲϓΔϳΑρϑϳέΎλϣϱ΃ΔϳρϐΗϟΔϛέηϟ΍ϥϣΔϘΑγϣϟ΍ΔϘϓ΍ϭϣϟ΍ϰϠϋϝϭλΣϟ΍ΏΟϳ
ΓΩΩΣϣϟ΍ϥϳΩϭίϣϟ΍ΔϛΑη
ΝΫϭϣϧϝΎϣϛΗγ΍ΩόΑ˱Ύϳϧϳϣ΄ΗΓΎρϐϣΕΎϘϔϧϟ΍ϥϭϛϰϠϋΔϛέηϟ΍ΔϘϓ΍ϭϣΩόΑνϳϭόΗϟ΍ΩϳΩγΗϡΗϳϑϭγ
Ε΍ΩϧΗγϣϱ΃ϰϟ·ΔϓΎοϹΎΑΔϠλϔϣϟ΍ΔϳϠλϷ΍έϳΗ΍ϭϔϟ΍ϪόϣϖϓέϣϭΔϛέηϠϟϪϣϳϠγΗϭϥϳϣ΄Ηϟ΍ΏϠρ
έϔγϟ΍Ε΍ΩϧΗγϣϭϥ΍έϳρϟ΍έϛ΍ΫΗϭΔϳΑρϟ΍ΕΎϣϭϠόϣϟ΍Ε΍ΩϧΗγϣϝΛϣΔϠλΕ΍ΫϯέΧ΃
Δ΋έΎρΔϟΎΣϟϥϛϳϡϟΎϣϰρϐϣέϳϏΔϳΟέΎΧϟ΍Ε΍ΩΎϳόϟ΍ϭΩΣ΍ϭϟ΍ϡϭϳϟ΍ίϛ΍έϣϲϓΝϼόϟ΍
ϲΗϟ΍ϭϪϳϠϋΔΑΗέΗϣϟ΍Ξ΋ΎΗϧϟ΍ϭϲϧΩΑίΟϋϭ΃ϱΩγΟϑόοϭ΃ΔΑΎλ·ϭ΃νέϣϱ΃ϲρϐϳϻϥϳϣ΄Ηϟ΍
ˬΝέΎΧϠϟΔϠΣέϝϛϝΑϗΎϬο΍έϋ΃έϬυΗϭ΃ΙΩΣΗ
ϭΏϠρϟ΍ΓέΎϣΗγ·ϲϓϙϟΫϥϋ΢ϳέλΗϟ΍ϡΗ΍Ϋ·ϻ·ΓΩϻϭϟ΍ϭϝϣΣϟ΍ΕϻΎΣϲρϐϳϻΞΗϧϣϟ΍΍Ϋϫ
ρϘϓΉέ΍ϭρϟ΍ΕϻΎΣϰϠϋΔϳρϐΗϟ΍έλΗϘΗγ
ϲϓΝέΩϣϥϳϣ΄ΗϟΎΑϝϭϣηϣιΧηϱ΃ϭΔϘϳΛϭϟ΍ϝϣΎΣΩϬόΗϳΝϼόϟ΍νέϐϟΓέΎϳίϟ΍ϡΩόΑΩϬόΗϟ΍
ϭ΃ϪϳΩϟϡϭϠόϣΝϼϋϱ΃ΔϳρϐΗϟΔϘϳΛϭϟ΍ϩΫϫϡ΍ΩΧΗγ΍ϡΩόΑΔϘϳΛϭϟ΍ϩΫϬΑϪϟϥϣ΅ϣϟ΍ιΎΧηϷ΍ϝϭΩΟ
ΔϳρϐΗϟ΍ΞϣΎϧέΑϥϣοϥϣΝϼόϟ΍΍ΫϫϰϠϋϝϭλΣϟ΍ϑΩϬΑΔϛϠϣϣϟ΍ΓέΎϳίϭΎϘΑγϣιΧηϣ
Δϛέηϟ΍ϥϋΔΑΎϳϧΎϬόϗϭ
ϊϳϗϭΗϟΎΑϝϭΧϣϟ΍
Δϛέηϟ΍ϡΗΧ
ϱΩϮόδϟ΍ϱΰϛήϤϟ΍ϚϨΒϟ΍ϑ΍ήη·ϭΔΑΎϗήϟΔόοΎΧΔϤϫΎδϣϲϧϭΎόΗϦϴϣ΄ΗΔϛήηˬϲϧϭΎόΗϞϓΎϜΗΓήϳΰΠϟ΍Δϛήη
ϱέΎΠΘϟ΍ϞΠδϟ΍ϢϗέˬϞϣΎϜϟΎΑωϮϓΪϣ୰470,664,030ϝΎϣα΃ήΑ201312/34ϥϡΕϢϗέκϴΧήΘΑ
ϊϗϮϤϟ΍ˬ8003040400ϲϧΎΠϤϟ΍ϒΗΎϬϟ΍±21422ΓΪΟ5215Ώιˬ70017919904030251980
ΓέϮϨϤϟ΍ΔϨϳΪϤϟ΍ϖϳήρ7512ˬϲϧϭΎόΗϞϓΎϜΗΓήϳΰΠϟ΍ΔϛήηϲϨρϮϟ΍ϥ΍ϮϨόϟ΍www.ajt.com.saϲϧϭήΘϜϟϹ΍
ΔϳΩϮόδϟ΍ΔϴΑήόϟ΍ΔϜϠϤϤϟ΍ˬ233244516ˬΓΪΟˬ8021ϢϗέΓΪΣϭˬ˯΍ήϤΤϟ΍±ϲϋήϔϟ΍