Bajaj Allianz General Insurance Company Ltd.....

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

TRAVELELITESILVER(US$50000) IDENTIFICATION AND SCHEDULE

Policy No : OG-11-2202-9910-00006334 Imdcode : 10002151

Insurance Plan Chosen : TravelEliteSilver(US$50000) Geographical Coverage : Worldwide excluding
USA , Canada
Proposer Name : AVNEESH DUBEY Partner Id: 35668371
Date Of Birth: 07-AUG-1987
Home Address : A SAMARTH NAGAR GOLA KA MANDIR BHIND ROAD GWALIOR - MP . .
Pincode : 0
Passport No : G6910003 Assignee : MR.VEDPRAKASH
DUBEY

BENEFITS Limits (Max for entire policy period) DEDUCTIBLE

Hospital Daily Allowance $25 per day to max $100
Medical Expenses, Evacuation & Repatriation of remains(Max limit for emergency dental USD 50000 USD 100
treatment is US$500(Included in Medical Expenses))
Trip Delay $20 per 12 hrs to max $120 12 Hours
AD & D Common Carrier USD 2500
Home Burglary Insurance Rs. 100000
Personal Liability USD 100000 USD 100
Emergency Cash Advance( would include delivery charges) USD 500
Golfer's Hole-in-one USD 250
Loss Of Passport USD 250 USD 25
Personal Accident USD 15000
Delay Of Checked Baggage USD 100 12 Hours
Hijack $50 per day to max $300
Loss of Checked-in baggage(Per baggage maximum 50% and per item in baggage max- USD 500
imum 10%)
Trip Curtailment USD 200
Trip Cancellation USD 500

Special Condition:
Base Premium (in Rupees) :
Service Tax (in Rupees) :
Edu Cess (in Rupees) :
Total Premium (in Rupees) :
Date of Purchase of Policy :
Policy Period : From 21-OCT-2010 to 24-NOV-2010
This Policy is an extension Of Policy OG-11-2202-9910-00004876 Total Policy Duration of 95days including
this policy. This Policy Excludes for any Claims in respect of any disorder, injury, disease, disability or treat-
ment whether directly or indirectly caused by, or attributable to break period or related to ailment of that break
period / any other ailment or claim existing on or before the extension date.
1045
105
3
1153
20-OCT-2010
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

Authorized Signatory
Consolidated stamp Duty paid vide Receipt No: .12800 dated
29-JUN-10
Regd Office : GE Plaza,Airport Road, Yerwada Pune-411006 (India)

ReceiptNo / Collection No / Amt(INR) := 2202-00679985 / 1/1153 (INR) (If Premium is paid through cheque the policy is void ab-initio in case of dishonor of
chq.)
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 Signature of Insured
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
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.