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Important Notice
Policy Details
Generation Date: 18-May-2015
Name of Insured: ANUP NARAIN SRIVASTAVA
Address: Flat-22, DDA-SFS,Pocket 1,Sector 9, Dwarka, Near Siksha
Bharti School,, PO Area-,-110075, NEW DELHI.
Dear ANUP NARAIN SRIVASTAVA,
We thank you for utilizing the online services of Bajaj Allianz
General Insurance Co. Ltd.This has reference to your policynumber
OG-16-9906-9910-00007741 for your Travel Insurance.
Enclosed please find the policy schedule, policy wordings
containing detailed terms and conditions of the coverages and the
online ProposalForm cum declaration submitted by you, before buying
the policy. We wish to inform you that the premium quoted is based
on the informa-tion submitted in the proposal forms as well as the
acceptance of the terms and conditions online. Request you to
kindly go through thesame once again & in case of any
disagreement/discrepancy/clarifications please call us on our toll
free number 1800-209-0144 or log on towww.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 personor categories of person covered in the
policy) shall become void in the event of any untrue or incorrect
statement, misrepresentation, nondescription 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 takeadvantage 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!Visit Our WebsiteLike
UsFollow UsConnect with usDemystify Insurance
Bajaj Finserv,1st Floor , Survey # 208/1-B, Behind Weikfield
IT-Park, Viman Nagar, Pune-411014
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Proposal Form For Travel PolicyPolicy DetailsInsured Name ANUP
NARAIN SRIVASTAVA Address Details Flat-22, DDA-SFS,Pocket 1,Sector
9,
Dwarka Near Siksha Bharti SchoolNew Del-hi
Telephone No Mobile No 9810124587Email
[email protected] Departure Date 17-JUL-15Return Date
18-AUG-15 No of Journey Days 33Date of Birth 13-APR-51Travel Plan
TravelAgeEliteSilver(US$50000) Premium Excluding Ser-
vice Tax(INR)2148
Required Details to Issue PolicyPassport No M8237407 Name of
Nominee Nikhil Srivastava
Family Physician/Doctor DetailsName TelephoneAddress
Terms And Conditions
I Hereby declare & warrant that1. The reply to the above
statements are true and that i have not withheld any information
whatsoever2. I will not be travelling against the advice of a
physician3. I understand that this policy does not cover any
pre-existing medical condition/injury/deformity that are declared
or undeclared4. I will not be travelling for the purpose of
obtaining medical treatment5. I consent to Bajaj Allianz General
Insurance Company Ltd. seeking medical information from doctor who
has anytime attended me, in re-spect of any matter relating to my
physical or mental health and well being and I authorize consent to
him giving such information to BAGICLand / 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
orsuffer from physical defect or deformity?
N
Have you been admitted to any hospital/nursing home/clinic for
treatment or observation? N
Proposer is already travelled from india and is abroad at the
time of proposing for the policy ? N
I agree to the terms and conditions Y
Personal Information
Policy AddressAddress Line Flat-22, DDA-SFS,Pocket 1,Sector
9, DwarkaStreet Name Near Siksha Bharti School
City New Delhi Area DwarkaState DELHI Pin code 110075Mobile
9810124587 Telephone (Res.) 01125072771Telephone (Off.)
01125072771Where would you like to have the policy
deliveredHousing/Building Flat-22, DDA-SFS,Pocket 1,Sector
9, DwarkaStreet Name Near Siksha Bharti School
City AreaState NEW DELHI Pin code 110075Time of Availability
Date: 18-May-2015
Bajaj Finserv,1st Floor , Survey # 208/1-B, Behind Weikfield
IT-Park, Viman Nagar, Pune-411014
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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: 9906-00565300
Receipt Date: 18-MAY-2015
Business Channel: WS
Received with Thanks from: ANUP NARAIN SRIVASTAVA
(Customer ID : 66657919 ) a total sum of Two thousand four
hundred fourteen rupees only .
Instrument Type Instrument Date Amount
CREDIT CARD 18-MAY-15 2414
Total Amount Received for this Policy 2414
Issuance of this receipt does not amount to acceptance of the
risk by Bajaj Allianz General Insurance Company Limited. The
insurance cover forthe 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
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Bajaj Allianz General Insurance Company Ltd.Regd.Office - GE
Plaza, Airport Road, Yerwada, Pune - 411006 (India)
TRAVEL COMPANION IDENTIFICATION AND SCHEDULEPolicy
DetailsReference No YPolicy No : OG-16-9906-9910-00007741 Insurance
Plan Chosen :
TravelAgeEliteSilver(US$50000)Home Address : Flat-22,
DDA-SFS,Pocket 1,Sector 9, Dwarka Near Siksha Bharti School NEW
DELHI DELHIPincode : 110075 Imdcode : 55555557Subcode 9906
Telephone No.Partner Id 66657919 Geographical Coverage
ExcludingUSA
BENEFITS Limits (Max for entire policy period) DEDUCTIBLEMedical
Expenses, Evacuation & Repatriation of Remains (Emergency
dentalpain relief included upto US$500).
USD 50000 USD 100
Personal Accident Death USD 15000AD & D Common Carrier USD
2500Loss of Checked-in baggage(Per baggage maximum 50% and per item
inbaggage maximum 10%)
USD 500
Delay of Checked Baggage USD 100 12 HoursLoss of Passport USD
250 USD25Hijack $50 per day to max $300Trip Delay $20 per 12 hrs to
max $120 12 HoursPersonal Liability USD 100000 USD100Emergency Cash
Advance USD 500Golfer's Hole-in-one USD 250Trip Cancellation USD
500Home Burgulary Insurance Rs. 100000Trip Curtailment USD
200Hospitalization Daily Allowance $25 per day to max $100Base
Premium (in Rupees) : 2148Service Tax (in Rupees) : 258Edu Cess (in
Rupees) : 8Total Premium (in Rupees) : 2414Date of Purchase of
Policy : 18-MAY-2015Policy Period : From 17-JUL-2015
to18-AUG-2015
Or Date of return of Insured, whichever is earlier.
Claims Assistance Department : Health Administration Team24
hours Helpline : Telephone No +91 20 3030 5858,Fax No: +91 20 3051
2207Email : [email protected] Servicing Office :
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 asper 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 andCOMPULSORILY first
contact the 24 hours helpline and obtain prior notification number
from HELP LINE before incurring any expense. For all claims Please
quote theclaims notification number and submit claim forms with
original medical bills. The coverage provided is subject to details
and declaration in the proposal form given priorto 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
codebefore 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) orToll Free Nos.
mentioned on the travel kit. Alternately you may mail us your query
at [email protected] policy excludes for any claims
which are attributable to , arising out of, traceable to or a
complication of any event prior to the policy inception date
mentioned below.Any illness, treatment or symptoms originated
during the period 18-MAY-15 to 17-JUL-15 stand excluded from the
scope of policy.
For & Behalf of Bajaj Allianz General Insurance Company
Ltd.
Authorized SignatoryBajaj Finserv,1st Floor , Survey # 208/1-B,
Behind Weikfield IT-Park, Viman Nagar, Pune-411014
9906-00565300/44646147/2414(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 ifany 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 perterms and conditions mentioned in the policy
Policy is valid only if countersigned by the insured in the
space aboveaccepting this declaration
Signature of Insured
Service Tax Reg. No. : AABCB5730G-ST-001This 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 benefitsand/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, ifthe Insured Person(s) is permanently
incapacitated or deceased, the legal heirs of the Insured may
represent him in respect of Claim under the Policy.
