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Bajaj Allianz General Insurance Company Ltd Regd.Office - GE Plaza, Airport Road, Yerwada, Pune -

Bajaj Allianz General Insurance Company Ltd

Regd.Office - GE Plaza, Airport Road, Yerwada, Pune - 411006 (India)

TRAVELCOMPANION-TRAVELTIMESELITE-NOMEDICAL IDENTIFICATION AND SCHEDULE

Policy No :

OG-12-1101-9910-00005761

Insurance Plan Chosen :

TravelCompanion-TravelTimesEl-

Geographical Coverage :

ExcludingUSAand-

ite-NoMedical

Canada

Proposer Name :

GOPAL KRISHNA SETHI

Partner Id:

39124869

Date Of Birth:

11-MAY-1926

Home Address :

174, GOLF LINKS DELHI

Pincode :

110003

Passport No :

F1295847

Assignee :

Deepali

BENEFITS

Any one Accident Sub limit

Special Conditions for medical expenses benefit

Hospitalization Daily Allowance

Medical Expenses, Evacuation and Repatriation*

Trip Delay

AD & D Common Carrier

Home Burglary Insurance

Personal Liability

Emergency Cash Advance***

Golfer's Hole-in-one

Loss of Passport

Any One Illness Sub limit

Personal Accidental

Delay of checked baggage

Hijack

Loss of checked Baggage ( Per baggage limit of 50% and Per article limit of 10%)

Trip Curtailment

Trip Cancellation

Limits (Max for entire policy period)

DEDUCTIBLE

USD 20000

100

$25 Per day to Max 100

nil

50000

100

$20 per 12 hrs to max $120

12 Hours

1500

nil

Rs. 100,000

nil

100000

nil

500

nil

250

nil

250

25

USD 5000

100

10000

nil

100

12 hrs

$50 per day to max $300

500

200

nil

500

nil

Base Premium (in Rupees) :

7380

Service Tax (in Rupees) :

738

Edu Cess (in Rupees) :

22

Total Premium (in Rupees) :

8140

Date of Purchase of Policy :

18-MAY-2011

Policy Period : From 01-JUN-2011 to 01-JUL-2011

Or Date of return of Insured. [Whichever is earlier]

Claims Assistance Department :

Health Administration Team

24 hours Helpline :

Telephone No +91 20 3030 5858,Fax No: +91 20 3051 2207

Email :

travel@bajajallianz.co.in

Policy Servicing Office :

Bajaj Allianz General Insurance Company Limited,

Ground Floor, Ashoka Plaza, 32/2, Nagar Road, Nr. Weikfield Company, Pune 411014

IMPORTANT : The policy coverages are as per the policy terms and conditions mentioned in the Travel Kit provided with this policy schedule. You may refer the same on our website as well. Always and COMPULSORILY first contact the 24 hours helpline and obtain prior notification num- ber from HELP LINE before incurring any expense. For all claims Please quote the claims notification number and submit claim forms with ori- ginal medical bills. The coverage provided is subject to details and declaration in the proposal form given prior to taking this policy and attached policy wordings.

Extension Process :

In case of any claim, please contact our 24 Hour Call centre at 1800-22-5858, 1800-102-5858 (Toll Free) / 91-020-30305858 (chargeable, add area code before this number in case of mobile call) or email us at 'info@bajajallianz.co.in'. For any claim or policy related queries, please call us at +91 20 3030 5858(chargeable) or Toll Free Nos. mentioned on the travel kit. Alternately you may mail us your query at travel@bajajallianz.co.in.

For & On Behalf of Bajaj Allianz General Insurance Company Ltd.

Stamp Duty Rs. 0.5
Stamp
Duty
Rs. 0.5

Authorized Signatory

Consolidated stamp Duty paid vide Receipt No: .49711 dated

09-MAR-11

Regd Office : GE Plaza,Airport Road, Yerwada Pune-411006 (India)

Agency Code 10003779

Agency Name : KANTI BALLABH PALIWAL

Contact No : 0/9810401923

Email -

ReceiptNo / Collection No / Amt(INR) := By Float No 10003779 (If Premium is paid through cheque the policy is void ab-initio in case of dishonor of chq.)

11290859/-/10003779/-/-

Declaration by the insured : We understand that this policy has been issued based on the information provided by us/our representative and the policy is not valid if any of the information provided is incorrect.We also understand that this policy does not cover pre-existing illnesses or disability or conditions arising there from as per terms and conditions mentioned in the policy wordings.

Policy is valid only if countersigned by the insured in the space above accepting this declaration

Service Tax Reg. No. : AABCB5730G-ST-001

This Policy of Insurance is a Contract between the Company and the Insured Person(s). The Insured Person(s) shall not

Signature of Insured

transfer, assign, alienate or in any way pass the benefits and/or liabilities to any other person, Institution, Hospital, Company or Body Corporate without specific prior approval in writing by a duly authorised officer of the Company. However, if the In- sured Person(s) is permanently incapacitated or deceased, the legal heirs of the Insured may represent him in respect of Claim under the Policy.