Bajaj Allianz General Insurance Company Ltd.

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

TRAVEL COMPANION IDENTIFICATION AND SCHEDULE
Reference No :
Policy No :
Insurance Plan Chosen :
Proposer Name :
Date Of Birth:
Home Address :
Pincode :
Passport No :

Y
OG-15-1907-9910-00002079
Imdcode :
Subcode:
TravelEliteGold(US$200000)
MR SAURAV BHAUMIK
Partner Id:
03-SEP-1987
Geographical Coverage :
B-5/16, H/6, PHASE -I, GOVT. HOUSING NOAPARCE, BARASAT, NORTH 24PGS.,
WEST BENGOL.
700125
Telephone Nos :
Z2787968
Assignee :

BENEFITS
Personal Accident
AD & D Common Carrier
Loss of Checked-in baggage(Per baggage maximum 50% and per item in
baggage maximum 10%)
Delay Of Checked Baggage
Loss Of Passport
Hijack
Trip Delay
Personal Liability
Emergency Cash Advance( would include delivery charges)
Golfer's Hole-in-one
Trip Cancellation
Home Burglary Insurance
Trip Curtailment
Hospitalization Daily Allowance
Medical Expenses, Evacuation & Repatriation of remains (Max limit for
emergency dental treatment is US$500(Included in Medical Expenses))
Base Premium (in Rupees) :
Service Tax (in Rupees) :
Edu Cess (in Rupees) :
Total Premium (in Rupees) :
Date of Purchase of Policy :
Policy Period : From 30-JUL-2014 to 19-AUG-2014

10013719
58115279
ExcludingUSA

MR. AMARENDRANATH
BHAUMIK

Limits (Max for entire policy period)

USD 25000
USD 5000
USD 1000

DEDUCTIBLE

USD 100
USD 250
$60 per day to max $360
$30 per 12 hrs to max $180
USD 200000
USD 1000
USD 500
USD 1000
Rs. 200000
USD 300
$25 per day to max $125
USD 200000

12 Hours
USD 25
12 Hours
USD 100

USD 100

859
103
3
965
26-MAY-2014
Or Date of return of Insured.

Claims Assistance Department :

24 hours Helpline :
Email :
Address of Notification of Claims :

Health Administration Team

Telephone No +91 20 3030 5858,Fax No: +91 20 3051 2207
travel@bajajallianz.co.in
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
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 'customercare@bajajallianz.co.in'.
For the extension of the policy seven days prior to the expiry date mentioned above. The payment for the extended period of insurance if granted
would be accepted only through credit card. The policy may or may not be extended and is at the sole discretion of the Company as per
applicable underwriting guidelines prevalent.
For & on behalf of Bajaj Allianz General Insurance Cos. Ltd.

Authorized Signatory
Consolidated Stamp Duty paid towards Insurance Policy Stamps vide Order No. ADJ/CS/42/07/7383/07 Dated 18th April
2007 of General Stamp Office, Mumbai
Regd Office : GE Plaza,Airport Road,Pune(India)
NF/35042910/965(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 any pre-existing
illness or disability or conditions arising therefrom.
Policy is valid only if countersigned by the insured in the space above
accepting this declaration

Service Tax Reg. No. : AABCB5730G-ST-001

" Terms, Conditions and exclusions as per applicable memos and policy clause attached"

Signature of Insured