Sales: 1800-209-0144 Service: 1800-209-5858

Dear ROHIT GUPTA,

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-19-9906-9910-00022733

Policy Type Travel

Name of Insured ROHIT GUPTA

Address D-35, Surajmal Vihar, New Delhi Near

Yamuna Sports complex EAST DELHI SURA-

JMAL VIHAR DELHI 110092

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
President-Direct Sales and Marketing, Head-Web Sales

Stay Connected
Toll free no. Email us Visit our website Follow us on
1800-209-5858 customercare@bajajallianz.co.in www.bajajallianz.com social Media
Proposal Form For Travel Policy
Policy Details
Proposer Name ROHIT GUPTA Address Details D-35, Surajmal Vihar, New Delhi Near
Yamuna Sports complexEAST DELHI
Telephone No Mobile No 9871536506
Email gupthrohit@gmail.com Departure Date 10-AUG-18
Return Date 21-AUG-18 No of Journey Days 12
Date of Birth 16-AUG-91
Travel Plan TravelPrimeSilver(US$50000) Premium Excluding Ser- 828
vice Tax(INR)
Country Travelling to Germany Is Self covered Yes
Required Details to Issue Policy
Passport No K3329215 Name of Nominee Rohit Gupta

Insured Details
Name Date Of Birth Gender Passport No Assignee
ROHIT GUPTA 16-AUG-1991 Male K3329215 Rohit Gupta

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 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 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 Yes
travel and are currently in India and are applying for insurance cover.

Proposer is already travelled from india and is abroad at the time of proposing for the policy ? No

I agree to the terms and conditions Yes

Personal Information
Policy Address
Address Line D-35, Surajmal Vihar, New Delhi Street Name Near Yamuna Sports complex
City EAST DELHI Area SURAJMAL VIHAR
State DELHI Pin code 110092
Mobile 9871536506 Telephone (Res.)
Telephone (Off.)
Where would you like to have the policy delivered
Housing/Building D-35, Surajmal Vihar, New Delhi Street Name Near Yamuna Sports complex
City EAST DELHI Area SURAJMAL VIHAR
State DELHI Pin code 110092
Time of Availability
Date: 15-Jul-2018

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: 9906-01904813

Receipt Date: 15-JUL-2018

Business Channel: WS

Received with Thanks from: ROHIT GUPTA

(Customer ID : 123079658 ) a total sum of Nine hundred seventy-seven rupees only .

Instrument Type Instrument Date Amount

ONLINE PAYMENT 15-JUL-18 977

Total Amount Received for this Policy 977

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 Yes
Policy No : OG-19-9906-9910-00022733 Insurance Plan Chosen : TravelPrimeSilver(US$50000)
Home Address : D-35, Surajmal Vihar, New Delhi Near Yamuna Sports complex EAST DELHI DELHI
Pincode : 110092 Imdcode : 55555557
Subcode 9906 Telephone No.
Partner Id 123079658 Geographical Coverage ExcludingUSA
GSTIN / UIN. NA STATE CODE /NAME: 07 - Delhi

NAME DATE OF BIRTH GENDER PASSPORT NO ASSIGNEE

ROHIT GUPTA 16-AUG-1991 Male K3329215 Rohit Gupta

BENEFITS Limits (Max for entire policy period) DEDUCTIBLE

Personal Accident* USD 15000 NIL
Medical Expenses and Evacuation USD 50000 USD 100
Emergency Dental Pain Relief included in above limits USD 500 USD 100
Repatriation USD 5000 NIL
Loss of Checked Baggage** USD 500 NIL
Accidental Death & Disability (Common Carrier) USD 2500 NIL
Loss of Passport USD 250 USD 25
Personal Liability USD 100000 USD 100
Hijack cover USD 50 per day to maximum USD 300 NIL
Trip Delay USD 25 per 12 Hrs to max USD 120 12 Hrs
Hospitalization Daily Allowance USD 20 per day to max USD 100 NIL
Golfer's Hole-in-one USD 250 NIL
Trip Cancellation USD 500 NIL
Trip Curtailment USD 200 NIL
Delay of Checked Baggage USD 100 12 hours
Home Burglary Insurance INR 100000 NIL
Emergency Cash Benefit*** USD 500 NIL
Missed Connection USD 100 12 hours
Difference in Airfare due to delayed or early return USD 500 NIL
Bounced Hotel USD 500 NIL
PA Cover in India INR 50000 NIL

Base Premium (in Rupees) : 828

Integrated GST (18%) (in Rupees) : 149
Total Premium (in Rupees) : 977
Date of Purchase of Policy : 15-JUL-2018
Policy Period : From 10-AUG-2018 Or Date of return of Insured, whichever is earlier.
00:00 to 21-AUG-2018
Claims Assistance Department : Health Administration Team
24 hours Helpline : Telephone No +91 20 3030 5858,Fax No: +91 20 3051 2207
Email : travel@bajajallianz.co.in
Policy issuing office and Correspondence address for communication by Health Administration Team Overseas Travel Insurance| Bajaj Allianz General Insurance
policyholder for claim, service request, notice, summons, etc : 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 'customercare@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 Signature of Insured
declaration

BAGIC GST No : 27AABCB5730G1ZX | Principal Location : GE Plaza, Airport Road, Yerwada, Pune - 411006 PH:66026666 | Services Accounting Code :
997136 - Freight insurance services & Travel insurance services. No reverse charge is payable on these services. | Invoice No. : 100051481/1
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.