MIEW96 Travel International Il TUSHAR RAJNIKANT PATEL

VOYAGER GROUP TRAVEL INSURANCE
PART I OF THE POLICY SCHEDULE
(UIN: ICITGBP22095V032122)
Date: 20-Apr-23
To,
Name of Proposer - TUSHAR RAJNIKANT PATEL
Address of Proposer - 11, TRILOK NAGAR SOCIETY, NR PALANPUR, JAKATNAKA, ADAJAN, Surat, Gujarat - 395009, India
Mobile Number - 9099096696
Email ID - glorious.tours.travels@gmail.com
Dear Mr. / Ms. TUSHAR RAJNIKANT PATEL
Sub: Issuance of Policy Certificate no. TITINTLIL4292718 under your application for Group Travel
Insurance Policy dated 20-Apr-23
We would like to thank you for investing your faith in us. Please find enclosed herewith your Policy Certificate, Policy wordings
& Customer Information Sheet based on which your insurance Policy has been issued.
Insured Person Details:

Name of Proposer TUSHAR RAJNIKANT PATEL
Domestic/Overseas/Both Overseas
Geographical Scope of Policy Excluding US & Canada (Including Schengen Countries)
No. of Travel Days 63 days
Countries being visited United kingdom (GB)
Period of Insurance Apr 21, 2023 To Jun 22, 2023
Name of Insured TUSHAR RAJNIKANT PATEL Date of Birth of Insured 10-08-1989

PAN No. of Insured Passport No. of Insured Z4448220
11, TRILOK NAGAR SOCIETY, NR
Relationship of Insured Self Address of the Insured PALANPUR, JAKATNAKA, ADAJAN, Surat,
with Proposer Gujarat - 395009, India
Resident Status Blank Value Country of issue of Blank Value

Passport
Please go through the details as furnished in the format and also as provided in the Policy document and confirm that they are in
order. Should you feel that there are any discrepancies/variations, you are requested to write back to us immediately at
customersupport@icicilombard.com or call at 1800 2666 for necessary changes/rectification. In the absence of any
communication from you within 15 days of receipt of Policy, we would take it that you have accepted the contents and the
coverage to be confirming to your proposal.
Thanking You,
Yours Sincerely,
Authorized Signatory
For ICICI LOMBARD GENERAL INSURANCE CO. LTD.
ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICITGBP22095V032122
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Near Siddhi Vinayak Temple, Prabhadevi, E-mail : Customersupport@icicilombard.com
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
ICICI Lombard General Insurance Company Limited (IRDAI Regn. No. : 115) CIN No. L67200MH2000PLC129408
Master Policy Number – 4168/O-FARES/243858512/00/000 UIN: ICITGBP22095V032122
Voyager Group Travel Insurance

Policy Certificate
On receipt of full premium from the Policyholder as named in this Schedule, Group Travel Insurance master policy number
4168/O-FARES/243858512/00/000 dated 28/03/2022 has been issued at Mumbai, by ICICI Lombard General Insurance
Company Limited to the Policyholder: PITA PARTNERS specified in the Policy, and is governed by, and is subject to, the
terms, conditions & exclusions therein contained or otherwise expressed in the said Policy.
The certificate issued to the customers/employees/members of Client Name under the signature of an authorized signatory
of ICICI Lombard General Insurance Company Limited, represents the availability of the Benefits under the Policy to the
Insured Person named below, subject to the terms, conditions and exclusions expressed in the said Policy, but not exceeding
the Sum Insured as specified below.
(PART I OF THE POLICY SCHEDULE)
POLICY CERTIFICATE NUMBER: TITINTLIL4292718

Master Policy Number: 4168/O-FARES/243858512/00/000
Issued At: Mumbai
Domestic/Overseas/Both: Overseas
Geographical Scope: Excluding US & Canada (Including Schengen Countries)
Trip Details
For Overseas – Round Trip

Type of Trip
Details of Trip* From 21/04/2023

To 22/06/2023 No. of Days 63
Place of Origin Mumbai (BOM) Destination London (LHR)

Common
Carrier/Public Blank Value
Carrier Opted
Adventure
sports
Activities to be NO
undertaken
while on trip
Detailed
Itinerary of the Overseas
Trip*
Proposer/Policyholder Details
Name of the Proposer TUSHAR RAJNIKANT PATEL

Insured Details
Name of the Insured TUSHAR RAJNIKANT PATEL
Gender of the Insured Male
Age as on Policy Start Date 34 years
11, TRILOK NAGAR SOCIETY, NR PALANPUR,
Mailing address/Residential Address of the Insured JAKATNAKA, ADAJAN, Surat, Gujarat - 395009, India
Occupation Others
Mobile Number 9099096696
Email ID glorious.tours.travels@gmail.com
Passport Number Z4448220
Country of Issue of Passport Blank Value
Resident Status Blank Value
PAN Number / National ID No Blank Value
Pre-Existing Disease (if any) Blank Value
Debit/Credit Card Number (if any): Blank Value
For Student Travel policies,
i. Name of Educational Institute in which Insured is enrolled Blank Value
ii. Name of the educational course in which Insured in enrolled
Name of Nominee
Legal Heir
Relationship of Nominee with Insured Legal Heir
Policy Details
Period of Insurance Apr 21, 2023 hours To Jun 22, 2023 hours
Journey Start Date, if different from Policy

Start Date Blank value
No. of Travel Days Overseas– 63 days
Name of Nominee Legal Heir
If Nominee is minor, name of guardian Blank value

Relationship of Nominee with Insured
Legal Heir
Person
Name of Assignee Blank value

COVERAGE TABLE – FOR OVERSEAS POLICY
Deductibles/Franchise/Co-Pay/Cover
Coverage Sum Insured
Specific Condition, if any
Deductible: Nil
Cover Specific Condition:

Below mentioned Trip cancellation cover
triggers will not be applicable for a valid
claim if it is related to or arising out of
COVID-19 pandemic.
Trip Cancellation USD 500 Trigger 5: A Major Travel Event that
prevents You from travelling to one of Your
destination(s) in your itinerary
Trigger 7: Advisory issued by the

government of India not to travel or
prevention of travel by government of India
Trip Interruption or Curtailment USD 500 Deductible: Nil

Repatriation of remains USD 7,500 Deductible: Nil
Medical evacuation USD 250000 Deductible: USD 100
Common Carrier/Public Carrier Deductible: 6 Hours
USD 100
Delay
Loss of checked-in baggage USD 750 Deductible: Nil
Delay of checked-in baggage USD 500 Deductible: 6 Hours
Hospitalization expenses for illness Deductible: USD 100
& injury USD 250000
Outpatient Treatment Expenses for Deductible: USD 100
illness & injury USD 250000
Daily Allowance in case of USD 35 per day up to maximum 7 Deductible: 1 Day
hospitalization days
PREMIUM DETAILS
Net Premium (in Rs.)
CGST: (CGSTN 9 %)
SGST: (SGST 9 %) Paid by PITA Partners
Total Premium (in Rs.)
GSTIN of ICICI Lombard GIC 07AAACI7904G1ZP
HSN/SAC Code 997136 / GENERAL INSURANCE
SERVICES
Servicing Branch: New Delhi
Servicing Branch Address: Fourth Parsavnath Capital Tower Bhai Veer
Singh Marg, New
Delhi New Delhi 110001
The stamp duty of Rs.1 (Rupee One Only) paid vide deface no CSD36420222395 dated 03/Jun/2022

Special Condition
• This Travel Insurance policy is only limited to customers of PITA Partners travelling through Air Mode for
International trips.
• Proposed rates are the per days rates for a round trip policy limited upto 180 days.
• Certificate is only valid to the customers who are travelling from India.
• Pre-existing illness and conditions shall not be covered
• For Outpatient treatment Cash less facility Not Provided
• Any claim arising out of sporting activities, involving either in training and/or participation in competitions,
professional or semi-professional sports, Adventure Sports is not covered.
• Sub-limits shall be applicable as per the define under Policy Wordings (in case of travelling to Schengen
Countries Sub-limits are not applicable)
As per the Circular on Travel insurance Products and operational matters (Ref- IRDAI/HLT/CIR/MISC/174/09/2019)
dated 27th September 2019,
• Premium for Group domestic policies should not be received more than 90 days in advance to the date of commencement
ofthe risk covered or along with purchasing travel ticket, whichever is earlier.
• While offering insurance policies under group mode through an online platform, customers should be specifically provided
with an option to select travel insurance. Further the details of the insurer, premium with the tax breakup and the policy terms
and conditions should be readily available on the online platform. The customer should be clearly conveyed that his/her
participation in the policy is entirely voluntary.
• Where a customer proposes to enroll under the group policy, his/her express consent confirming that he/she has read and
understood all the terms and conditions shall be obtained on the said platforms
• In case the customer who opts for insurance wishes to continue without enrolling under the policy, he/she should also be
provided an option for Opting out or de-selecting the option before concluding the transaction
• In the absence of adherence to the compliance with the above mentioned norms, the master policy will be liable to be
cancelled and will be considered null and void.
• The circular is in force from 1st October 2019 with immediate effect.
IMPORTANT NOTES:
1. Insurance cover will start only on receipt of full premium stated in PART I of the Policy Schedule by ICICI Lombard General
Insurance Company Limited.
2. Insurance cover is subject to the terms and conditions mentioned in the Policy wordings provided to you with this Certificate.
3. The above covers would not be applicable for persons occupied in underground mines, explosives and electrical
installations on high tension lines unless otherwise covered and stated in the Policy Schedule.
4. Major exclusions: Intentional self-injury, suicide or attempted suicide whilst under the influence of intoxicating liquor or
drugs, any loss arising from an act of breach of law with or without criminal intent. Please refer to the Policy wordings for
a complete list of exclusions.
5. For any endorsements such as name correction or change in nominee details, you can contact us at Toll Free Number
1800-2666 or Email us at customersupport@icicilombard.com or visit our nearest branch.
6. For Overseas claims, Contact ICICI Lombard 24hr Help Line number for assistance and registering your claim:
In USA & Canada (Toll Free) +1 844 871 1200; Rest of the World (Call Back Facility) +91 124 449 8778
National Toll Free Number 1800 102 5721; Fax Number +91 124 4006674
Email Address icicilombard@falck.com
OR Login to the e-claim link as provided by the Company details of which will be mentioned in the policy document or
updated on the Website
For Domestic claims, Address for claim notification: IL Health Care, ICICI LOMBARD HEALTHCARE ICICI BANK
TOWER,PLOT NO.12, FINANCIAL DISTRICT, NANAKRAM GUDA, GACHIBOWLI, HYDERABAD, ANDHRA PRADESH
PIN CODE: 500032 or call at 1800 2666
For ICICI Lombard General Insurance Company Limited.
Issuing Office : Mumbai Date: Policy Issuing Date

IRDA Reg No - 115 Misc Code - 168
Authorized Signatory

For ICICI LOMBARD GENERAL INSURANCE CO. LTD.
CUSTOMER INFORMATION SHEET - VOYAGER GROUP TRAVEL INSURANCE

Description is illustrative and not exhaustive
Only those covers that have been opted by You / Group administrator are mentioned in the below document
Cover Name Covers In Brief Some Of Major Exclusions Are -

Medical Expenses for a. Hospitalization Expenses for Illness • Any treatment that is not a part of the treatment
Illness and Accidental and Injury – Reimbursement of for injury or illness sustained during the policy
Injury expenses incurred in case of period
hospitalization due to illness contracted • Routine physical tests/vaccination/inoculations
or any Injury due to an Accident during of any kind
the policy period
b. Outpatient Treatment for Illness and
Injury - Reimbursement of expenses
incurred for Outpatient Treatment due to
illness contracted or any Injury due an
Accident during the policy period
c. Daily Allowance in case of
Hospitalization - Per day payout on
hospitalization due to Illness contracted
or any accidental Injury during the policy
period
Repatriation of Repatriation of Remains- In the
• Death arising from intentional self-injury/suicide/
Remains unfortunate event of the death of the
attempted suicide
insured, reimbursement of expenses
incurred for transporting the remains of
the deceased Insured back to the
Country/Place of Residence or for a local
burial or cremation in the country/place
where death has occurred.
Medical Evacuation Medical Evacuation - Reimbursement
• Any treatment or expense mentioned as an
of expenses for emergency
transportation and evacuation services exclusion under “hospitalization expenses for
necessitated due to any Illness injury” and/or “hospitalization expenses for
contracted or accidental Injury sustained illness and injury”
during the policy period.
Loss of Checked-In Loss of Checked-In Baggage – Pro- • Losses dues to delay, detention, confiscation
Baggage rated payout for pieces of baggage by custom officials or other public authorities
permanently lost whilst under the
custody of common carrier vis-a-vis
pieces of baggage that were checked-in
Delay of Checked-In Delay of Checked-In Baggage- Fixed • Delay resulting from detention/confiscation by
Baggage payout in case the checked-in baggage the common carrier or any authorized agency
is delayed beyond the period specified in
policy certificate
Trip Cancellation Trip Cancellation- Indemnification for • Any change of plans or dis-inclination on the part
financial loss (travel and of the insured resulting in cancellation of the trip
accommodation) incurred on cancellation • In case of “Event cancellation” extension, the
of trip due to unexpected events e.g. event should not include personal family,
sickness, natural calamities, terrorist
political, anti-national or any other event of illegal
attack etc.
nature
Trip Interruption or Trip Interruption or Curtailment- • Any change of plans or disinclination on your
Curtailment Indemnification for the financial loss part which are not results of any unforeseen
incurred in case your trip is interrupted circumstances outside your control
and/or you need to curtail your trip due to • Interruption of the Trip either wholly or in part
unexpected events beyond your control done at the instance of the authority governing
the Common Carrier or the government
Common Carrier/Public Common Carrier/Public Carrier Delay- • For any departure which is delayed as a
Carrier Delay We shall pay a fixed payout in case of result of the insured or any other person
a delay in departure of the scheduled accompanying the Insured on the Trip
Common Carrier/Public Carrier


MIEW96 Travel International Il TUSHAR RAJNIKANT PATEL

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

MIEW96 Travel International Il TUSHAR RAJNIKANT PATEL

Uploaded by

Copyright:

Available Formats

VOYAGER GROUP TRAVEL INSURANCE

PART I OF THE POLICY SCHEDULE

Dear Mr. / Ms. TUSHAR RAJNIKANT PATEL

Insured Person Details:

Period of Insurance Apr 21, 2023 To Jun 22, 2023

Name of Insured TUSHAR RAJNIKANT PATEL Date of Birth of Insured 10-08-1989

Resident Status Blank Value Country of issue of Blank Value

ICICI Lombard General Insurance Company Limited

Master Policy Number – 4168/O-FARES/243858512/00/000 UIN: ICITGBP22095V032122

Voyager Group Travel Insurance

(PART I OF THE POLICY SCHEDULE)

POLICY CERTIFICATE NUMBER: TITINTLIL4292718

For Overseas – Round Trip

Details of Trip* From 21/04/2023

Place of Origin Mumbai (BOM) Destination London (LHR)

ICICI Lombard General Insurance Company Limited

Journey Start Date, if different from Policy

No. of Travel Days Overseas– 63 days

Name of Nominee Legal Heir

If Nominee is minor, name of guardian Blank value

Name of Assignee Blank value

ICICI Lombard General Insurance Company Limited

Cover Specific Condition:

Trigger 7: Advisory issued by the

Trip Interruption or Curtailment USD 500 Deductible: Nil

ICICI Lombard General Insurance Company Limited

For ICICI Lombard General Insurance Company Limited.

Issuing Office : Mumbai Date: Policy Issuing Date

ICICI Lombard General Insurance Company Limited

CUSTOMER INFORMATION SHEET - VOYAGER GROUP TRAVEL INSURANCE

Cover Name Covers In Brief Some Of Major Exclusions Are -

ICICI Lombard General Insurance Company Limited

You might also like