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Bajaj Allianz General Insurance Company Ltd.....

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


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 Limits (Max for entire policy period) DEDUCTIBLE

Any one Accident Sub limit USD 20000 100
Special Conditions for medical expenses benefit
Hospitalization Daily Allowance $25 Per day to Max 100 nil
Medical Expenses, Evacuation and Repatriation* 50000 100
Trip Delay $20 per 12 hrs to max $120 12 Hours
AD & D Common Carrier 1500 nil
Home Burglary Insurance Rs. 100,000 nil
Personal Liability 100000 nil
Emergency Cash Advance*** 500 nil
Golfer's Hole-in-one 250 nil
Loss of Passport 250 25
Any One Illness Sub limit USD 5000 100
Personal Accidental 10000 nil
Delay of checked baggage 100 12 hrs
Hijack $50 per day to max $300
Loss of checked Baggage ( Per baggage limit of 50% and Per article limit of 10%) 500
Trip Curtailment 200 nil
Trip Cancellation 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 :
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 ''.
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

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

Rs. 0.5

Authorized Signatory
Consolidated stamp Duty paid vide Receipt No: .49711 dated
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.)
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.