This Document is Digitally Signed

Signer: RASHMI RAMAN SINGH

Date: Thu, Nov 10, 2022 08:12:24 IST
Location: NOIDA
Reason: Signing Policy for OICL
OVERSEAS MEDICLAIM POLICY (BUSINESS AND HOLIDAY) POLICY SCHEDULE
UIN: OICTIOP21581V022021

Policy No. : 211200/48/2023/4707 Prev. Policy No. : -

Cover Note No : - Cover Note Date : -

: 166578400 Issue Office code : 211200

Insured's Code
Insured's Name : Kumaresan Ravi (GSTIN: ) Issue Office Name : DO II NEW DELHI (GSTIN:
07AAACT0627R1Z1)

Address : 34/4, MARIYAMMAN KOVIL Address : 16/20, WEA, FIRST FLOOR,NEAR

STREET , ADIRAMPATTINAM SHASTRI PARK,
PADAM SINGH ROAD, KAROL BAGH
NEW DELHI
THANJAVUR TAMIL NADU 614701 NEW DELHI DELHI 110005

Tele/Fax/Email : / / 8111096387 / Tele/Fax/Email : 011-41052050, 41062050, 8851779656 /

ravikumaresan97@gmail.com 011-41052050 /
vkrithika@orientalinsurance.co.in
Agent/Broker Details
Dev.Off.Code :
Agent/Broker : LC0000000660 M/S POLICYBAZAAR INSURANCE BROKERS PRIVATE LIMITED
Address : Plot No. 119, Sector-44, Gurgaon,, Gurgaon, Haryana, 12200,Tel - 1800-258-
5970,GURGAON,HARYANA,122002
Tel/Fax/Email : 1800-258-5970/1800-258-5970//

Period of Insurance : FROM 00:00 ON 06/01/2023 TO MIDNIGHT OF 10/01/2023

Collection No & Dt : CC 2005204283 - 10/11/2022 GST INVOICE NO :0721672570 UIN :0

Gross Premium : 251 GST 45 Stamp Duty : .5 Total : 296

Coinsurance Details : NIL

Channel of Sale Yes/No

1.Online NO

2.Fresh YES

3.Renewal NO

Traveller Details

Name of Person : Kumaresan Ravi

Date of Birth : 10/06/1991
Age : 31
Sex : M
Passport No : W6681606

Occupation : -

Place : NEW DELHI For and on behalf of

Date : 10/11/2022 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post.
General Manager
In case of any query regarding the Policy please call Toll
Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupees Page 1 of 6
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 This Document is Digitally Signed

Signer: RASHMI RAMAN SINGH

Date: Thu, Nov 10, 2022 08:12:24 IST
Location: NOIDA
Reason: Signing Policy for OICL
Attached to and forming part of policy number 211200/48/2023/4707

Travel Details

Plan Type (Plan A Plan B) : PLAN A

Type of Trip (Single or Annual Multi Trip : SINGLE
Sub Plan (Silver or Gold Plan) : GOLD
OMP Serial No : 1

First Day of Insurance : 06/01/2023

No of days outside India : 5
Original copy of physician's report attached : NO
Adverse medical History : NIL
Medical Report attached : NOT-ATTACHED

Place : NEW DELHI For and on behalf of

Date : 10/11/2022 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post.
General Manager
In case of any query regarding the Policy please call Toll
Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupees Page 2 of 6
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 This Document is Digitally Signed

Signer: RASHMI RAMAN SINGH

Date: Thu, Nov 10, 2022 08:12:24 IST
Location: NOIDA
Reason: Signing Policy for OICL
Attached to and forming part of policy number 211200/48/2023/4707

Limits of Indemnity
sno COVERAGES/DEDUCTIBLE SUM INSURED DEDUCTIBLE
1 MEDICAL EXPENSES $ 100000 $100
2 HOSPITAL DAILY ALLOWANCE Mentioned Below 0
3 DENTAL EMERGENCY EXPENSES $ 300 $100
4 ASSISTANCE (MEDICAL,REPATRIATION,EVACUATION AND LEGAL COVERED IN S.NO. 1 ABOVE
5 PERSONAL ACCIDENT $ 30000 0
6 LOSS OF BAGGAGE $ 1000 0
7 DELAY IN BAGGAGE (PER 12 HOURS) $ 100
8 LOSS OF PASSPORT $ 300 $50
9 EMERGENCY MEDICAL EVACUATION COVERED IN S.NO. 1 ABOVE
10 REPATRIATION OF MORTAL REMAINS $ 7500 0
11 HIJACK DISTRESS ALLOWANCE $ 125 PER DAY WITH A MAXIMUM OF $500 0
12 PERSONAL LIABILITY $ 200000 $200
13 FLIGHT DELAY $50 PER 12 HOUR WITH A MAXIMUM OF $200 0
14 AUTOMATIC EXTENSION OF THE POLICY UPTO 7 DAYS
0
15 TRIP CURTAILMENT $ 500 $100
16 TRIP CANCELLATION $ 500 0
17 MISSED CONNECTIONS/MISSED DEPARTURE (PER 3 HOURS) $ 500 0
18 BOUNCED BOOKING OF HOTEL AND AIRLINE $ 500
19 FINANCIAL EMERGENCY ASSISTANCE COVER $ 1000 0

20 HOME BURGLARY INSURANCE INR 1500000 0

21 ACCIDENTAL DEATH / DISMEMBERMENT (ADD) COVERED IN S.NO.5 ABOVE

22 DIFFERENCE IN AIR FARE DUE TO DELAYED/ EARLY RETURN $ 500 0

23 COMPASSIONATE VISIT/ MEDICAL REUNION $ 5000 $100
24 LOSS OF INTERNATIONAL DRIVING LICENCE $ 250 0
25 LAPTOP / TAB COVER $100
$ 1500
26 ADVENTROUS SPORTS COVER COVERED IN S.NO.1 ABOVE

Place : NEW DELHI For and on behalf of

Date : 10/11/2022 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post.
General Manager
In case of any query regarding the Policy please call Toll
Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupees Page 3 of 6
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 This Document is Digitally Signed

Signer: RASHMI RAMAN SINGH

Date: Thu, Nov 10, 2022 08:12:24 IST
Location: NOIDA
Reason: Signing Policy for OICL
Attached to and forming part of policy number 211200/48/2023/4707

COVERAGES/ Plan-A(Worldwide-Excluding USA/CANADA) Plan-B(Worldwide-Including USA/CANADA)

Sections
DEDUCTIBLE Sum Insured Deductible Sum Insured Deductible

HOSPITAL Silver Plan - A daily benifit of $25 Silver Plan - A daily benifit of $25
2 DAILY with a maximum limit of $150 with a maximum limit of $150 Nil
Nil
ALLOWANCE Gold Plan - A daily benifit of $25 Gold Plan - A daily benifit of $25
with a maximum limit of $300 with a maximum limit of $300

Total Premium in words : Indian Rupees Two Hundred Ninety-Six Only

The Insurance under this policy is subject toWarranties & Clauses :

The policy excludes the cover for treatment relating to Mumps, Chicken Pox, Measles, German Measles, Spina Bifida,
Whooping Cough, Diphtheria, Poliomyelitis, Meningitis, and Scarlet Fever and for consequences attributable thereto,
accelerated thereby or arising there from
Cover commences from the time of boarding the aircraft or any other mode of transport from the point of departure.
Subject otherwise to the terms, conditions exceptions, exclusions and limitations of the policy.
In the event of death of Insured Person(s) due to an insured peril all the benefits payable in respect thereof under this insurance,
shall become payable to the assignee declared in the proposal form (incorporated here in the schedule) and assignee's receipt
shall be considered as full final discharge to the company, in respect of all liability under this policy.
It is hereby declared that this policy covers the Air transport expenses for repatriation of mortal remains and Emergency Medical
Evacuation of the insured person from the place of visit as declared to India by Economy Class.
In the event of a claim under the policy exceeding Rs. 1 lac or a claim for refund of premium exceeding Rs. 1 lac,the insured will
comply with the provisions of the AML policy of the Company.The AML policy is available in all our operaing offices as well as
Company's website.

Name of the Assignee : Divya Kumaresan

Relationship with Insured : Spouse

Warranted that in case of dishonour of premium cheque(s) the Company shall not be liable under the policy and the policy shall
be void abinitio (from inception).

Please quote the

OM Policy Number C.O Code Office Code Plan Category Serial Number
OM Policy
Number in all 211200/48/2023/4707 001 211200 - HOLIDAY 1
your Corresponden

Place : NEW DELHI For and on behalf of

Date : 10/11/2022 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post.
General Manager
In case of any query regarding the Policy please call Toll
Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupees Page 4 of 6
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 This Document is Digitally Signed

Signer: RASHMI RAMAN SINGH

Date: Thu, Nov 10, 2022 08:12:24 IST
Location: NOIDA
Reason: Signing Policy for OICL
Attached to and forming part of policy number 211200/48/2023/4707

Location of Centre World Travel World Travel Assist - World Travel Assist Heritage Health Insurance
Assist - USA Europe Singapore TPA Pvt.Ltd. - India

Address W.T.A. TRAVEL W.T.A. TRAVEL W.T.A. TRAVEL Heritage Health Insurance TPA
SERVICES, INC. SERVICES, INC. SERVICES, INC. Pvt.Ltd.
1571 Sawgrass Calle Barcas 2, Planta 75 Kim Yan Road Champion Building, Gr.Flr, 15,
Corporate Pkwy 2, Oficina 302, Regus, Singapore 239372 Parsi Panchayat Road, Andheri
Suite 110 Sunrise, 46002, Valencia. (E), Mumbai - 400069. India.
Fl, 33323-2862, Spain
U.S.A.

Toll Free +1 877 822 7386 +34 900 804 116 +65 3163 2058 1800 22 4004
Number for (Toll Free within India)
Assistance +65 8001302100

Other Telephone +1 305 328 3897 +34 911 881 617 +65 315 80234 +91-22-61273891 (24 hrs)
Numbers +91-22-61273892/ 93

Fax Number(s) +1 877 395 1784 +34 915 932 577 - +91-22-6127 3890

E-Mail ID assistance@wtaby assistance@wtabyhas.c assistance@wtabyhas heritagehealthomp@bajoria.in

has.com om .com

www.wta- www.wta- www.wta- www.wta-heritage.com

Website
heritage.com heritage.com heritage.com

Jurisdiction North, Central & Europe, UK & Ireland, Singapore South & South East Asia,
South America Africa, Pakistan Middle East, Australia &
New Zealand

Place : NEW DELHI For and on behalf of

Date : 10/11/2022 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post.
General Manager
In case of any query regarding the Policy please call Toll
Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupees Page 5 of 6
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 This Document is Digitally Signed

Signer: RASHMI RAMAN SINGH

Date: Thu, Nov 10, 2022 08:12:24 IST
Location: NOIDA
Reason: Signing Policy for OICL
Attached to and forming part of policy number 211200/48/2023/4707

In witness whereof the undersigned being authorised by and on behalf of the company has/have herein to set his/their hands at
DO II NEW DELHI (GSTIN: 07AAACT0627R1Z1) on 10TH DAY OF NOVEMBER 2022

" In case of grievance related to any issue related to this policy the same may be addressed to the office In-Charge or the Grievance
Officer at above policy address. If the grievance remains pending, it may be escalated to Grievance Officer of the concerned Regional
Office 10th FLOOR,HANSALAYA BUILDING,15, BARAKHAMBA ROAD, NEW DELHI,. The next escalation in case grievance remains
unresolved is CSD, Head Office, situated at Oriental House, A-25/27, Asaf Ali Road, New Delhi-110002.
If the insured is not satisfied with the resolution/reply provided by the company, he/she may approach the Office of Insurance
Ombudsman, within his/her jurisdiction. The list of offices of Ombudsman is available on Company's portal."

Entered By : POLBZR_1

Policy Printed By: PRTL IP: For and on behalf of

The Oriental Insurance Company Limited
Policy Printed On: 10-NOV-22 08:12:26 MAC:

General Manager
Authorised Signatory

Place : NEW DELHI For and on behalf of

Date : 10/11/2022 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post.
General Manager
In case of any query regarding the Policy please call Toll
Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupees Page 6 of 6
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in