Sales: 1800-209-0144

Service: 1800-209-5858

Dear YOGESH MIGLANI,

It is our privilege to welcome you to the Bajaj Allianz General Insurance family.
We thank you for choosing Bajaj Allianz for your Insurance needs. We are one of India's leading general insurance companies with iAAA
rating from ICRA for the last ten consecutive years indicating the company's high claims paying ability and fundamentally strong position in the
industry. Please be assured that you have made the right choice by choosing us and we will stand by you in your hour of need.
To provide you with the best customer experience, here are a few important things for you to note:

Policy Details
Policy Number

OG-17-9906-9910-00040509

Policy Type

Travel

Name of Insured

YOGESH MIGLANI

Address

14,NANDWAIN NAGAR SONIPAT SONIPAT

SONIPAT HARYANA 131001

Please find enclosed the policy schedule. We wish to inform you that the policy issued is based on the information submitted in the proposal
form as well as the acceptance of the terms and conditions, and this will be verified at the time of filing of claim. Request you to kindly go
through the same once again and in case of any disagreement, discrepancy or clarifications - let us know within 15 days of the letter date. For
policy wordings containing detailed terms, conditions and exclusions of your insurance coverage, you will receive a hard copy on your
correspondence address.

Once again, we welcome you to the Bajaj Allianz family and look forward to a long association with you.

With Warm Regards,

Sourabh Chatterjee
Senior Vice President, Head-Web Sales

Stay Connected
Toll free no.
1800-209-5858

Email us
customercare@bajajallianz.co.in

Visit our website

Follow us on
www.bajajallianz.com social Media

Proposal Form For Travel Policy

Policy Details
Proposer Name

YOGESH MIGLANI

Telephone No

Address Details

14,NANDWAIN NAGAR SONIPATSONIPAT

Mobile No

9413284204

Email

choudhary.yogesh12@gmail.com

Departure Date

29-NOV-16

Return Date

10-DEC-16

No of Journey Days

12

Date of Birth

13-SEP-91

Travel Plan

TravelPrimeAsiaFlair(US$15000)

Premium Excluding Service Tax(INR)

391

Country Travelling to

Vietnam

Is Self covered

Yes

Name of Nominee

ANJU MIGLANI

Required Details to Issue Policy

Passport No

L1827541

Insured Details
Name
YOGESH MIGLANI

Date Of Birth
13-SEP-1991

Gender
M

Passport No
L1827541

Assignee
ANJU MIGLANI

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.
I/We hereby declare, on my behalf and on behalf of all persons proposed to be insured are in good health, are fit for
travel and are currently in India and are applying for insurance cover.

Yes

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

14,NANDWAIN NAGAR

Street Name

SONIPAT

City

SONIPAT

Area

SONIPAT

State

HARYANA

Pin code

131001

Mobile

9413284204

Telephone (Res.)

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

14,NANDWAIN NAGAR

Street Name

SONIPAT

City

SONIPAT

Area

SONIPAT

State

HARYANA

Pin code

131001

Time of Availability
Date: 26-Nov-2016

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

Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune-411014,Phone No: 1800-209-0144

Receipt
Receipt Number:

9906-01043946

Receipt Date:

26-NOV-2016

Business Channel:

WS

Received with Thanks from: YOGESH MIGLANI

(Customer ID : 87413069 ) a total sum of Four hundred fifty rupees only .

Instrument Type

Instrument Date

Amount

ONLINE PAYMENT

26-NOV-16

450

Total Amount Received for this Policy

450

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 :
Home Address :
Pincode :
Subcode
Partner Id

OG-17-9906-9910-00040509
Insurance Plan Chosen :
14,NANDWAIN NAGAR SONIPAT SONIPAT HARYANA
131001
Imdcode :
9906
Telephone No.
87413069
Geographical Coverage

NAME
YOGESH MIGLANI

DATE OF BIRTH
13-SEP-1991

GENDER
M

PASSPORT NO
L1827541

TravelPrimeAsiaFlair(US$15000)
55555557
ExcludingJapan

ASSIGNEE
ANJU MIGLANI

BENEFITS
Limits (Max for entire policy period)
Personal Accident*
USD 7500
Medical Expenses and Medical Evacuation
USD 15000
Emergency dental pain relief Included in Medical Expenses and Evacuation
USD 500
sum insured
Repatriation
USD 5000
Loss of checked baggage **
USD 200
Accidental Death & Disability (Common Carrier)
USD 2500
Loss of Passport
USD 100
Personal Liability
USD 10000
Hijack cover
USD $ 50 per day to max $ USD 300
Trip Delay
USD $ 20 per 12 hours to max $ USD 120
Delay of Checked Baggage
USD 100
Emergency Cash Benefit***
USD 500
Base Premium (in Rupees) :
391
Service Tax (in Rupees) :
55
Swachh Bharat Cess (in Rupees) :
2
Krishi Kalyan Cess (in Rupees) :
2
Total Premium (in Rupees) :
450
Date of Purchase of Policy :
26-NOV-2016
Policy Period : From 29-NOV-2016
Or Date of return of Insured, whichever is earlier.
00:00 to 10-DEC-2016

DEDUCTIBLE
NIL
USD 100
USD 100
NIL
NIL
NIL
USD 15
USD 100
NIL
NIL
12 hours
NIL

Claims Assistance Department :

24 hours Helpline :
Email :
Policy Servicing Office :

Health Administration Team

Telephone No +91 20 3030 5858,Fax No: +91 20 3051 2207
travel@bajajallianz.co.in
Health Administration Team Overseas Travel Insurance| Bajaj Allianz General Insurance Company Ltd | A -Wing 2nd Floor, Bajaj
Finserv Building, Behind Weikfield IT Park, Off Nagar Road, Viman Nagar | Pune - 411014, Maharashtra
*For benefit of Personal Accident- Proposer and earning spouse 100 % of sum assured. For Non-earning spouse and every additional adult 50% of Sum Assured. For Child
25% of Sum Assured
**For benefit of Loss of Baggage- Per Baggage maximum of 50% and per item in the baggage 10%

Exclusions(If Any )

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 'info@bajajallianz.co.in'. 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 travel@bajajallianz.co.in.

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
(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.