Important Notice

Policy Details

Generation Date:

15-Jun-2015

Name of Insured:

SRIHARSHA MITTAPALLI

Address:

flat f-16, block B2,Mahaveer Varna Apartments,kannamangala, opposite 10 downing., Kannamangala,

, PO Area-,
-560067, BANGALORE.

Dear SRIHARSHA MITTAPALLI,

We thank you for utilizing the online services of Bajaj Allianz General Insurance Co. Ltd.This has reference to your policy
number OG-16-9906-9910-00012070 for your Travel Insurance.

Enclosed please find the policy schedule, policy wordings containing detailed terms and conditions of the coverages and the online Proposal
Form cum declaration submitted by you, before buying the policy. We wish to inform you that the premium quoted is based on the information submitted in the proposal forms as well as the acceptance of the terms and conditions online. Request you to kindly go through the
same once again & in case of any disagreement/discrepancy/clarifications please call us on our toll free number 1800-209-0144 or log on to
www.bajajallianz.com or revert back within 15 days of the letter date.

Please note that the information provided by you will be verified at the time of claim & the insurance cover available to you (or other person
or categories of person covered in the policy) shall become void in the event of any untrue or incorrect statement, misrepresentation, non
description or non-disclosure in any form what so ever.

As a valued customer, we would like to provide regular updates on your policy, launch of new products and promotions so that you can take
advantage of the same. However if you do wish not to receive any such updates, we would request you to please register for 'Do Not Call'
registry on our website www.bajajallianz.com .

Assuring you of our best services always and thanking you once again for insuring with us.
With Best Regards,

Mr. Aditya Sharma

Head Direct Marketing, Web Sales, Travel, Retail Health and Home Insurance

Bajaj Allianz General Insurance Co. is now present across many platforms. Join us and stay connected always!
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Bajaj Finserv,1st Floor , Survey # 208/1-B, Behind Weikfield IT-Park, Viman Nagar, Pune-411014

Proposal Form For Travel Policy

Policy Details
Insured Name

SRIHARSHA MITTAPALLI

Telephone No

Address Details

flat f-16, block B2,Mahaveer Varna Apartments,kannamangala, opposite 10 downing.

KannamangalaBangalore

Mobile No

9742647463

Email

[email protected]

Departure Date

29-JUN-15

Return Date

19-JUL-15

No of Journey Days

21

Date of Birth

01-AUG-89

Travel Plan

TRAVELCARE

Premium Excluding Service Tax(INR)

647

Name of Nominee

M V B REDDY

Required Details to Issue Policy

Passport No

G7860245

Family Physician/Doctor Details

Name

Telephone

Address
Terms And Conditions
I Hereby declare & warrant that
1. The reply to the above statements are true and that i have not withheld any information whatsoever
2. I will not be travelling against the advice of a physician
3. I understand that this policy does not cover any pre-existing medical condition/injury/deformity that are declared or undeclared
4. I will not be travelling for the purpose of obtaining medical treatment
5. I consent to Bajaj Allianz General Insurance Company Ltd. seeking medical information from doctor who has anytime attended me, in respect of any matter relating to my physical or mental health and well being and I authorize consent to him giving such information to BAGICL
and / or to its claims administrator or medical advisors.
Are you suffering or have you even suffered from any illness/disease/ailment upto the date of making this proposal or
suffer from physical defect or deformity?

Have you been admitted to any hospital/nursing home/clinic for treatment or observation?

Proposer is already travelled from india and is abroad at the time of proposing for the policy ?

I agree to the terms and conditions

Personal Information
Policy Address
Address Line

flat f-16, block B2,Mahaveer Varna

Apartments,kannamangala, opposite
10 downing.

Street Name

Kannamangala

City

Bangalore

Area

Kannamangala

State

KARNATAKA

Pin code

560067

Mobile

9742647463

Telephone (Res.)

Telephone (Off.)
Where would you like to have the policy delivered
Housing/Building

flat f-16, block B2,Mahaveer Varna

Apartments,kannamangala, opposite
10 downing.

City
State
Time of Availability
Date: 15-Jun-2015

Street Name

Kannamangala

Area
BANGALORE

Pin code

560067

Bajaj Finserv,1st Floor , Survey # 208/1-B, Behind Weikfield IT-Park, Viman Nagar, Pune-411014

Bajaj Finserv,1st Floor

Survey # 208/1-B Behind Weikfield IT-Park Viman Nagar 411014 Pune - 411014 Ph.
No.1800-209-0144

Receipt
Receipt Number:

9906-00584186

Receipt Date:

15-JUN-2015

Business Channel:

WS

Received with Thanks from: SRIHARSHA MITTAPALLI

(Customer ID : 68053486 ) a total sum of Seven hundred thirty-eight rupees only .

Instrument Type

Instrument Date

Amount

ONLINE PAYMENT

15-JUN-15

738

Total Amount Received for this Policy

738

Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General Insurance Company Limited. The insurance cover for
the risk shall be as per the terms and conditions of the Insurance Policy if and when issued.

* Receipt Subject to realisation of cheque(s)

Please note: This is an electronically generated receipt and does not require signature.

Regd Office : GE Plaza, Airport Road, Yerwada, Pune - 411 006

Bajaj Allianz General Insurance Company Ltd.

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

TRAVEL COMPANION IDENTIFICATION AND SCHEDULE

Policy Details
Reference No

Policy No :

OG-16-9906-9910-00012070

Insurance Plan Chosen :

TRAVELCARE
flat f-16, block B2,Mahaveer Varna Apartments,kannamangala, opposite 10 downing. Kannamangala BANGALORE KARNATAKA
560067
Imdcode :
55555557
9906
Telephone No.
68053486
Geographical Coverage
ExcludingUSA

Home Address :
Pincode :
Subcode
Partner Id

BENEFITS
Limits (Max for entire policy period)
Loss Of Passport
USD 250
Personal Accident
USD 10000
loss of checked baggage (Max liability per baggage is 50% of the limit and
USD 250
max liability per item in a baggage is 10% of the limit as mentioned in the
Schedule)
Delay of Checked Baggage
USD 100
Medical Expenses, Evacuation and Repatriation of Remains (Max. limit for
USD 50000
Emergency dental Treatment is USD 500 (included in Medical Expenses))
Emergency Cash Advance
USD 500
Personal Liability
USD 100000
Hijack
$ 50 per day max $300
Base Premium (in Rupees) :
647
Service Tax (in Rupees) :
91
Edu Cess (in Rupees) :
0
Total Premium (in Rupees) :
738
Date of Purchase of Policy :
15-JUN-2015
Policy Period : From 29-JUN-2015 to Or Date of return of Insured, whichever is earlier.
19-JUL-2015
Claims Assistance Department :
24 hours Helpline :
Email :
Policy Servicing Office :

DEDUCTIBLE
USD 15
NIL
NIL

12 hrs
USD 100
NIL
USD 100
NIL

Health Administration Team

Telephone No +91 20 3030 5858,Fax No: +91 20 3051 2207
[email protected]
Bajaj Allianz General Insurance Company Limited, Ground Floor, Ashoka Plaza, 32/2, Nagar Road, Nr. Weikfield Company, Pune
411014

Agency Code : 55555557

Agency Name : WEB SALES

Contact No : 0/0

Email :

IMPORTANT :Policy is not valid for visit to Afghanistan,Chad,Democratic Republic of Congo,Iran,Israel,Nigeria,Pakistan,Somalia and Sudan. 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 number from HELP LINE before incurring any expense. For all claims Please quote the
claims notification number and submit claim forms with original 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 '[email protected]'. 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 [email protected].

For & Behalf of Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory
Bajaj Finserv,1st Floor , Survey # 208/1-B, Behind Weikfield IT-Park, Viman Nagar, Pune-411014
9906-00584186/45502224/738(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
Policy is valid only if countersigned by the insured in the space above
accepting this declaration

Signature of Insured

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 Insured Person(s) is permanently incapacitated or deceased, the legal heirs of the Insured may represent him in respect of Claim under the Policy.