Bajaj Allianz General Insurance Company Ltd.

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

POLICY IDENTIFICATION AND SCHEDULE
Policy No.: AGAMX011000001026200 Imdcode: 10031022
Insurance Plan Choosen: Travel Prime Individual Silver 50,000 USD Geographical coverage: Excluding USA/Canada
Proposer Name: Mr. Vinay Vaidyanatha Puttappa Bettasogemr Veerabhadrappa Passport Number R3944811
Date of Birth: 02-02-1981 Nominee: Vanitha Vinay
Pincode: 573201 Home Address: INDIA

BENEFITS LIMITS (Max for entire policy period) DEDUCTIBLE

Personal Accident 15,000 USD Nil
Medical Expenses and Evacuation 50,000 USD 100 USD
Emergency Dental Pain Relief included in above limits 500 USD 100 USD
Repatriation 5,000 USD Nil
Loss of Checked Baggage 500 USD Nil
Accidental Death & Disability (Common Carrier) 2,500 USD Nil
Loss of Passport 250 USD 25 USD
Personal Liability 100,000 USD 100 USD
Hijack cover 50 USD per day to max 300 USD Nil
Trip Delay 25 USD per 12 hrs to max 120 USD 12 Hrs
Hospitalization Daily Allowance 20 USD per day to max 100 USD Nil
Golfer’s Hole-in-one 250 USD Nil
Trip Cancellation 500 USD Nil
Trip Curtailment 200 USD Nil
Delay of Checked Baggage 100 USD 12 Hours
Home Burglary Insurance INR 100,000 Nil
Emergency Cash Benefit 500 USD Nil
Missed Connection 100 USD 12 Hours
Difference in Airfare due to delayed or early return 500 USD Nil
Bounced Hotel 500 USD Nil
PA Cover in India INR 50,000 Nil

Please Note: INR indicates Indian National Rupees

* For benefit of Personal Accident- Proposer and earning spouse 100 % of sum assured. For Non earning spouse and every
additional adult 50% of Sum Assured. For Child 25% of Sum Assured
** For benefit of Loss of Baggage- Per Baggage maximum of 50% and per item in the baggage 10%
*** For benefit of Emergency Cash Advance - Cash Advance would include delivery

Charge Base Premium (in Rupees) 545.76

Service Tax (in Rupees) : 98.24

Total Premium (in Rupees) : INR 644.00

Date of Purchase of Policy: 12/24/2017 7:49:40PM
Policy Period: From : 04-01-2018 to 08-01-2018

24-Hours Helpline : Telephone No. +91 124- 4343838

Email : travel@allianz-assistance.in
Policing Servicing Office: 1st Floor, DLF Square,
M-Block, Jacaranda Marg, Phase-II Gurgaon, Haryana - 122002

IMPORTANT: Always and COMPULSORILY first contact the 24 hours helpline and seek prior authorization from HELP LINE before incurring any
expense. For all claims Please quote the claims authorization number and submit claim forms with original medical bills. The coverage provided is
subject to details and declaration in the proposal form and attached policy wordings.

For & on behalf of Bajaj Allianz General Insurance Co. Ltd.

Authorized Signatory Signature of Insured

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.

Regd. Office : GE Plaza, Airport Road, Pune (India) Service Tax Reg. No.: AABCB57530G-ST-001