Royal Sundaram General Insurance Co.

Limited
(Formerly Known as Royal Sundaram Alliance Insurance Company Limited)
"Vishranthi Melaram Towers" No.2/319, Rajiv Gandhi Salai
(OMR), Karapakkam, Chennai - 600097.
Registered Office: 21, Patullos Road, Chennai 600 002.
Toll: 1860-425-0000 Mobile: 94444 48899.
email:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611

November 08, 2019

SHYAM SUNDER PANDEY
HNO 113 GALI NO 4 NEHARPAR GADDA COLONY
MAVAI ROAD 1ST FLR FARIDABAD
FARIDABAD,HARYANA,121002
Dear Customer,

CONFIRMATION OF KEY POINTS ON YOUR POLICY COVERAGE

We thank you for your telephonic acceptance given to us for enrolment in our Personal Accident Insurance plan. You
were fully explained about the contents of the exclusion clauses and the conditions subject to which this policy is being
issued and your acceptance signifies that you have fully understood the terms & conditions of this policy. The names and
details of the persons you indicated for coverage under this plan are given below:

Name of the Insured

Sr.No Date of Birth Sum Insured
Member
1 SHYAM SUNDER PANDEY 15/03/1990 1000000

We request you to note that in case you have opted for the auto debit facility your insurance cover will be renewed
automatically every year so long as your credit card/ Account remains valid and continues to get approval for the
payment of premium, unless we receive your written instructions not to renew the cover. If you do not wish to continue
with your cover or avail of the automatic renewal facility, please write to us with your specific advices, within 15 days
from the receipt of your insurance certificate. In case you have not opted for the auto debit facility, please ensure that you
get in touch with us before your renewal due date to make the renewal premium payment, to ensure continuous coverage.
In case you wish to avail this facility, any time before your renewal date, please call us on the below mentioned contact
number to activate this facility.

We thank you for selecting Royal Sundaram for your Personal Accident Insurance cover and we look forward to a
continuing relationship with you.

Yours sincerely,

Duly Authorized Signatory

________________________________________________________________________________________
Customer Services
Call: 1860 425 0000, Email: customer.services@royalsundaram.in
IRDA/NL-HLT/RSAI/P-P/V.I/180/13-14
 Royal Sundaram General Insurance Co. Limited
(Formerly Known as Royal Sundaram Alliance Insurance Company Limited)
"Vishranthi Melaram Towers" No.2/319, Rajiv Gandhi Salai
(OMR), Karapakkam, Chennai - 600097.
Registered Office: 21, Patullos Road, Chennai 600 002.
Toll: 1860-425-0000 Mobile: 94444 48899.
email:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611

Group Personal Accident Policy(APA002)

Certificate of Insurance

Royal Sundaram General Insurance Co. Limited

D0 : D0-Delhi Regional Office
Address: Rider House, Plot No : 136, Sector 44, Gurgaon
GURGAON - 122001, HARYANA
GSTIN: 06AABCR7106G1ZN

Master Policy No. PASBIG0018 AgencyCode OA500884

Certificate Number PSD0337527000100 - S122 SBI CARDS AND
AgencyName PAYMENT
SERVICES P LTD
Name of Insured SHYAM SUNDER PANDEY ContactNum / -39020202
Person
Date of Birth 15/03/1990
Address HNO 113 GALI NO 4 Period of Insurance
NEHARPAR GADDA From 00:00:00 hrs of 08/11/2019
COLONY To Midnight of 07/11/2020
MAVAI ROAD 1ST FLR GST Invoice Number: PSD033752700000
FARIDABAD Invoice Date: 08/11/2019
FARIDABAD HARYANA
121002
Phone: 8750151220
Place of Supply: HARYANA
State Code:06
Master Policy Holder SBI CARDS AND PAYMENT SERVICES P LTD
Name of Nominee: ANUBHA PANDEY Relationship with SPOUSE
Insured person:
Capital Sum Insured 1,000,000
Benefits Definition Coverage
Section A Accidental Death 100% of Capital Sum Insured
Loss of sight of both eyes, or of the actual loss by physical separation of two entire hands
Section
or two entire feet, or of one entire hand and one entire foot, or such loss of sight of one 100% of Capital Sum Insured
B(a)
eye and such loss of one entire hand or one entire foot
Loss of Use of two hands or two feet or of one hand and one foot, or of such loss of sight
of one eye and such loss of use of one hand or one foot,
Section Loss of sight of one eye, or of the actual loss by physical separation of one entire hand or
50% of Capital Sum Insured
B(b) of one entire foot
Total and irrecoverable loss of use of a hand or a foot without physical separation
Section If such injury shall, as a direct consequence thereof, immediately, permanently totally and
B(c) absolutely, disable the insured person from engaging in any gainful employment or 100% of Capital Sum Insured
occupation of any description, whatsoever

Premium Details
Premium( ) 420
TPA Fees( ) 0.0
SGST ( )9.0 37.8
CGST( )9.0 37.8
Total Premium ( ) 495.6
According code of service :997133
Indication if tax payable under reverse change – No

MasterPolicy is duly stamped

IN WITNESS WHEREOF, this Certificate of Insurance has been signed at CHENNAI on November 08, 2019
Subject otherwise to terms, conditions and exceptions of Group Personal Accident Policy.
Provided that in the case of a policy of general insurance where the remittance made by the proposer or the policyholder is not
realised by the insurer, the policy shall be treated as void ab initio.
If an insured person holds multiple certificates under this group master policy, in case of an admissible claim, the liability of the company is
restricted to only one certificate.
Service Tax No. AABCR7106GST001 PAN Number : AABCR 7106G
For Royal Sundaram General Insurance Co. Limited
Authorised Signatory
This document is digitally signed, hence counter signature / stamp is not required.
538070f53e70f6354e656f6d2c0adb54
 Royal Sundaram General Insurance Co. Limited
(Formerly Known as Royal Sundaram Alliance Insurance Company Limited)
"Vishranthi Melaram Towers" No.2/319, Rajiv Gandhi Salai
(OMR), Karapakkam, Chennai - 600097.
Registered Office: 21, Patullos Road, Chennai 600 002.
Toll: 1860-425-0000 Mobile: 94444 48899.
email:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611

IMPORTANT EXCLUSIONS:
(Refer Master Policy for detailed exclusions)
1. Payment of compensation in respect of death, injury or disablement
• From intentional self injury, suicide or attempted suicide.
• Whilst under the influence of the intoxication of liquor or drugs
• Directly or indirectly caused by venereal diseases, AIDS or insanity
• Arising or resulting from the insured committing any breach of law with criminal intent.
2. Policy shall not cover death resulting directly or indirectly caused by contributed to or aggravated or prolonged by child birth or from
pregnancy of in consequence thereof.
3. Payment of compensation in respect of Death, injury or disablement of the Insured due to or arising out of or directly or indirectly connected
with or traceable to War, Invasion, Act of foreign enemy, Hostilities, (whether war be declared or not) Civil War, Rebellion, Revolution,
Insurrection, Mutiny, Military or Usurped Power, Seizure, Capture, Arrests, Restraints and Detainments of all Kings, Princes and people of
whatsoever nation, condition or quality.

4. Persons whilst engaged in hazardous sports / activities / occupations.

5. Nuclear, Chemical, Biological Terrorism
Renewal:Renewal of the cover shall be available only if Master Policy is renewed & is subject to terms , conditions and rates of such renewed
Master Policy and further subject to condition that the Insured person is an active member of the Group Manager.
Claim Procedure:All claims should be reported through group manager within 30 days from date of accident. Claim can also be reported directly
to Royal Sundaram by writing to customer.service @royalsundaram.in
The original Certificate of Insurance will be a mandatory document in addition to other documents
Death Claim:Duly completed claim form , Death Certificate, Post Mortem Report ,FIR, Inquest Report, Accident Report, Extract of Accident
Register at Hospital, Hospital Records, News paper cuttings if any and any other relevant records Chemical Analysis Report if available, English
Translation of Vernacular documents, Any other documents as required by the Company.
Disablement Claim:Disability Certificate issued by attending physician, Accident Report, FIR/MLC copy, Hospital Records, News paper
cuttings if any and any other relevant records, , English Translation of Vernacular documents, Latest IT return to show Proof of annual income.
Any other documents as required by the Company
Claim Settlement: Claim proceeds shall go to Insured Person in case of Permanent Total Disablement & to nominee in case of Accidental Death.