VOYAGER GROUP TRAVEL INSURANCE

PART I OF THE POLICY SCHEDULE

(UIN : ICITGBP22095V032122)

Date: 18/Oct/2023
To,

SYSESB00172313744
SUNIL PATIL
1806P 1 Floor Sector 12,, INDIA, SONIPAT, HARYANA - 131001
Mobile Number: 8930200466
Email ID: patilsunil2005@gmail.com

Dear Mr. / Ms. SUNIL PATIL

Sub: Issuance of Policy Certificate no. 4168/CO-IBGNP/311196957/00/000 under your application for Group Travel Insurance
Policy dated 22/Oct/2023.

We would like to thank you for investing your faith in us. Please find enclosed herewith your Policy Certificate, Policy wordings
& Customer Information Sheet based on which your insurance Policy has been issued.

Insured Person Details:

Name of Proposer SUNIL PATIL

Domestic/Overseas Overseas
Geographical Scope of Policy Worldwide (Including Schengen Countries)
No. of Travel Days 15
Countries being visited WORLDWIDE INCLUDING US/CANADA
Period of Insurance Overseas- 22/Oct/2023 hours 12:00 AM
To 05/Nov/2023 hours 11:59 PM
Name of Insured SUNIL PATIL Date of Birth of Insured 01/Jul/1981
PAN No. of Insured Passport No. of Insured Z6002150
Relationship of Insured Self Address of the Insured 1806P 1 Floor Sector 12,, INDIA,
with Proposer SONIPAT, HARYANA - 131001
Resident Status Country of issue of Passport
Politically Exposed Person (PEP)/close relative of PEP: No

Medical expenses due to Covid-19 is covered if contracted during the travel period as per policy terms and
conditions.
1
Please go through the details as furnished in the format and also as provided in the Policy document and confirm that they are
in order. Should you feel that there are any discrepancies/variations, you are requested to write back to us immediately at
customersupport@icicilombard.com or call at 1800 2666 for necessary changes/rectification. In the absence of any
communication from you within 15 days of receipt of Policy, we would take it that you have accepted the contents and the
coverage to be confirming to your proposal.
102/20141021/66

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICITGBP22095V032122
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Marg, Near Siddhi Vinayak Temple, E-mail : Customersupport@icicilombard.com
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
ICICI Lombard General Insurance Company Limited (IRDAI Regn. No. : 115) CIN No. L67200MH2000PLC129408

Master Policy Number - 4168/CO-IBGNP/307049480/00/000 UIN: ICITGBP22095V032122

Voyager Group Travel Insurance

Policy Certificate
On receipt of full premium from the Policyholder as named in this Schedule, Group Travel Insurance
4168/CO-IBGNP/307049480/00/000 dated 01/09/2023 has been issued at Mumbai, by ICICI Lombard General Insurance
Company Limited to the Policyholder, MAT INDIA TECHNOLOGIES PVT LTD as specified in the Policy, and is governed by, and
is subject to, the terms, conditions & exclusions therein contained or otherwise expressed in the said Policy.

The certificate issued to the customers/employees/members of MAT INDIA TECHNOLOGIES PVT LTD under the signature of an
authorized signatory of ICICI Lombard General Insurance Company Limited, represents the availability of the Benefits under the
Policy to the Insured Person named below, subject to the terms, conditions and exclusions expressed in the said Policy, but not
exceeding the Sum Insured as specified below.

(PART I OF THE POLICY SCHEDULE)

POLICY CERTIFICATE NUMBER : 4168/CO-IBGNP/311196957/00/000

Alternate Policy No :
Master Policy Number : 4168/CO-IBGNP/307049480/00/000
Issued At : Mumbai Stamp Duty : 1

GSTIN Number : 06AAGCM1313B1Z8 Invoice No : 1010232111122

Domestic/Overseas : Overseas
Geographical Scope : Worldwide (Including Schengen Countries)
Trip Details
Type of Trip For Overseas- Round Trip
Details of Trip* 1 From 22/Oct/2023 To 05/Nov/2023 No. of Days 15
Place of Origin INDIA Destination WORLDWIDE
INCLUDING
US/CANADA
Common Carrier/Public
Carrier Opted
Adventure sports Activities to
be undertaken while on trip
Detailed Itinerary of the Trip* Overseas -
Proposer/Policyholder Details
Name of the Proposer SUNIL PATIL
Insured Details
Name of the Insured SUNIL PATIL
Gender of the Insured Male
Age as on Policy Start Date 42.0
Mailing address/ Residential Address of the Insured 1806P 1 Floor Sector 12,, INDIA, SONIPAT, HARYANA -
131001
Occupation Others
Mobile Number 8930200466
Email ID patilsunil2005@gmail.com
Passport Number Z6002150
Country of Issue of Passport
Resident Status
PAN Number/ National ID No.
Pre-Existing Disease (if any):
Debit/Credit Card Number (if any):
Name of Nominee Varsha Patil
Relationship of Nominee with Insured Spouse
102/20141021/66

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICITGBP22095V032122
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Marg, Near Siddhi Vinayak Temple, E-mail : Customersupport@icicilombard.com
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
 Policy Details
Period of Insurance Overseas- From 22/Oct/2023 to 05/Nov/2023
Journey Start Date, if different from Policy Start Date
No. of Travel Days Overseas- 15
Name of Nominee Varsha Patil
If Nominee is minor, name of guardian
Relationship of Nominee with Insured Person Spouse
Name of Assignee
COVERAGE TABLE - FOR OVERSEAS POLICY
Overseas
(Coverage Table to be customized in accordance to the Covers & Extensions opted)

Cover-specific
Section and Indemnity/ Deductible, if Franchise, if
Sum Insured Co-Pay, if any Condition, if
Coverage Benefit any any
any
Medical Expenses for Illness & Accidental Injury
Hospitalization USD 5,00,000 Indemnity USD 100 NA NA NA
Expenses for
Illness & Injury
Outpatient USD 5,00,000 Indemnity USD 100 NA NA NA
Treatment for
Illness & Injury
Daily Allowance USD 50 upto Benefit Nil NA NA USD 50 upto
in case of max 10 d max 10 days
Hospitalization
Non Medical Covers
Loss of USD 750 Benefit Nil NA NA NA
Checked-In
Baggage
Delay of USD 200 Benefit 6 Hours NA NA NA
Checked-In
Baggage
Loss of Baggage USD 1,000 Indemnity USD 100 NA NA NA
and Personal
effects
Personal USD 30,000 Benefit Nil NA NA NA
Accident
Accidental Death USD 5,000 Benefit NIL NA NA NA
and
Disablement(Co
mmon
Carrier/Public
Carrier)
Personal Liability USD 2,00,000 Indemnity 5% of actual NA NA NA
Hijack Distress USD 50 upto Benefit 12 Hrs NA NA USD 50 upto
Allowance max 7 da max 7 days
Financial USD 1,000 Benefit Nil NA NA NA
Emergency
Cash Allowance
(lump sum)
Trip Cancellation USD 1,000 Indemnity Nil NA NA NA
Trip Interruption USD 1,000 Indemnity Nil NA NA NA
or Curtailment
Common USD 200 Benefit 12 Hrs NA NA NA
Carrier/Public
Carrier delay
Missed USD 500 Indemnity NIL NA NA NA
Connection (All
Common
102/20141021/66

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICITGBP22095V032122
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Marg, Near Siddhi Vinayak Temple, E-mail : Customersupport@icicilombard.com
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
 Cover-specific
Section and Indemnity/ Deductible, if Franchise, if
Sum Insured Co-Pay, if any Condition, if
Coverage Benefit any any
any
Non Medical Covers
Carrier/Public
Carrier)
Burglary (Home INR 2,00,000 Indemnity NIL NA NA NA
contents)
Compassionate USD 2,000 Indemnity NIL NA NA NA
Visit
Bounced booking USD 1,000 Indemnity USD 250 NA NA NA
of airlines or
hotels
Hotel extension USD 500 Indemnity NIL NA NA NA
due to
contingency
Loss of USD 250 Benefit Nil NA NA NA
Passport /
International
Driving License
Replacement USD 3,000 Indemnity USD 200 NA NA NA
and
Re-Arrangement
of Staff
Other Medical Covers
Repatriation of USD 7,500 Indemnity Nil NA NA NA
Remains
Medical USD 5,00,000 Indemnity USD 100 NA NA NA
Evacuation
Dental USD 500 Indemnity USD 100 NA NA NA
Treatment

PREMIUM DETAILS
Net Premium (in `) ` 1920
IGST: (18 %) ` 345.6
Total Premium (in `) ` 2266
GSTIN of ICICI Lombard GIC 07AAACI7904G1ZP
HSN/SAC Code 997136/ GENERAL INSURANCE SERVICES
Servicing Branch: New Delhi
Servicing Branch Address: Fourth Parsavnath Capital Tower Bhai Veer Singh Marg, New
Delhi New Delhi 110001
We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards i s more than the aggregate turnover notified under
sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.

The stamp duty of `1 paid vide deface no.CSD6920232872 dated 14/Jun/2023.

mat india
SPECIAL CONDITION:
2

Geographical exclusion- Countries sanctioned by United States of America, United Nations, European Union, United Kingdom
are under declined countries.
Special terms
null
As per the Circular on Travel insurance Products and operational matters (Ref- IRDAI/HLT/CIR/MISC/174/09/2019)
dated 27th September 2019,
• Premium for Group domestic policies should not be received more than 90 days in advance to the date of commencement of
the risk covered or along with purchasing travel ticket, whichever is earlier.
102/20141021/66

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICITGBP22095V032122
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Marg, Near Siddhi Vinayak Temple, E-mail : Customersupport@icicilombard.com
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
• While offering insurance policies under group mode through an online platform, customers should be specifically provided
with an option to select travel insurance. Further the details of the insurer, premium with the tax breakup and the policy terms
and conditions should be readily available on the online platform. The customer should be clearly conveyed that his/her
participation in the policy is entirely voluntary.
• Where a customer proposes to enroll under the group policy, his/her express consent confirming that he/she has read and
understood all the terms and conditions shall be obtained on the said platforms
• In case the customer who opts for insurance wishes to continue without enrolling under the policy, he/she should also be
provided an option for Opting out or de-selecting the option before concluding the transaction
• In the absence of adherence to the compliance with the above mentioned norms, the master policy will be liable to be
cancelled and will be considered null and void.
• The circular is in force from 1st October 2019 with immediate effect.
IMPORTANT NOTES:
1. Insurance cover will start only on receipt of full premium stated in PART I of the Policy Schedule by ICICI Lombard General
Insurance Company Limited.
2. Insurance cover is subject to the terms and conditions mentioned in the Policy wordings provided to you with this Certificate.
3. The above covers would not be applicable for persons occupied in underground mines, explosives and electrical installations
on high tension lines unless otherwise covered and stated in the Policy Schedule.
4. Major exclusions: Intentional self-injury, suicide or attempted suicide whilst under the influence of intoxicating liquor or
drugs, any loss arising from an act of breach of law with or without criminal intent. Please refer to the Policy wordings for a
complete list of exclusions.
5. For any endorsements such as name correction or change in nominee details, you can contact us at Toll Free Number
1800-2666 or Email us at customersupport@icicilombard.com or visit our nearest branch.
6. For Overseas claims, Contact ICICI Lombard 24hr Help Line number for assistance and registering your claim:
In USA & Canada (Toll Free) +1 844 871 1200; Rest of the World (Call Back Facility) +91 124 449 8778
National Toll Free Number 1800 102 5721; Fax Number +91 124 4006674
Email Address icicilombard@falck.com
OR Login to the e-claim link as provided by the Company details of which will be mentioned in the policy document or
updated on the Website

For Domestic claims, Address for claim notification: IL Health Care, ICICI LOMBARD HEALTHCARE ICICI BANK TOWER,
PLOT NO.12, FINANCIAL DISTRICT, NANAKRAM GUDA, GACHIBOWLI, HYDERABAD, ANDHRA PRADESH PIN CODE:
500032 or call at 1800 2666
For ICICI Lombard General Insurance Company Limited.

Issuing Office: Mumbai Date : 18/Oct/2023

IRDA Reg No : 115 Misc Code : 168

102/20141021/66

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICITGBP22095V032122
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Marg, Near Siddhi Vinayak Temple, E-mail : Customersupport@icicilombard.com
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
 CUSTOMER INFORMATION SHEET - VOYAGER GROUP TRAVEL INSURANCE
Description is illustrative and not exhaustive

Only those covers that have been opted by You / Group administrator are mentioned in the below document

Cover Name Covers In Brief Some Of Major Exclusions Are -

Medical Hospitalization Expenses for Illness & Injury- * Any treatment that is not a part of the treatment for
Expenses for Reimbursement of expenses incurred in case of injury or illness sustained during the policy period
*
Illness & hospitalization due to illness contracted or any Routine physical tests/vaccination/inoculations of any
Accidental Injury due to an Accident during the policy period kind

Injury Outpatient Treatment for Illness & Injury- * Any treatment that is not a part of the treatment for
Reimbursement of expenses incurred for injury or illness sustained during the policy period
*
Outpatient Treatment due to illness contracted or Routine physical tests/vaccination/inoculations of any
any Injury due an Accident during the policy period kind

Daily Allowance in case of Hospitalization- Per day * Any treatment that is not a part of the treatment for
payout on hospitalization due to Illness contracted injury or illness sustained during the policy period
*
or any accidental Injury during the policy period Routine physical tests/vaccination/inoculations of any
kind

Non Medical Loss of Checked-In Baggage- Pro-rated payout for * Losses dues to delay, detention, confiscation by
Covers pieces of baggage permanently lost whilst under custom officials or other public authorities
the custody of common carrier vis-a-vis pieces of
baggage that were checked-in
Delay of Checked-In Baggage- Fixed payout in * Delay resulting from detention/confiscation by the
case the checked-in baggage is delayed beyond common carrier or any authorized agency
the period specified in policy certificate
Loss of Baggage and Personal effects- * Any loss of partial Contents of the baggage/hand
Reimbursement for loss of insured''s baggage and baggage or cabin baggage except for loss of sports
personal effects due to theft, burglary, larceny, equipment and/or loss of electronic equipment and/or
robbery, hold-up or any such similar events during loss of valuables
the policy period
Personal Accident- Lump sum payout in case of * Death or Disability arising from or resulting directly or
death or permanent total disablement or permanent indirectly from any illness
* Amounts related to
partial disablement of the insured during the policy medical expenses

period
Accidental Death and Disablement(Common * Amounts related to medical expenses
Carrier/Public Carrier)- Lump sum payout in case
of death or disablement of the Insured while
mounting, dismounting or travelling in a Common
Carrier/Public Carrier during the policy period
Personal Liability- Reimbursement of expenses * Liability arising directly/indirectly from, in respect of,
towards payment of legal liability to a third party or due to your wilful, malicious, unlawful and criminal
during the covered trip arising out of accidental acts
death, bodily injury or property damages to third
party
Hijack Distress Allowance- Per day payout payable * If you are in any way involved principally or as an
in the event of an Hijack of the Common accessory in causing or planning the hijack
Carrier/Public Carrier in which the insured is
travelling as a fare paying passenger
Financial Emergency Cash Allowance (lump sum)- * Any loss of money not in personal custody of the
Lump sum payout in case insured is left with no insured
travel funds following an incident of theft, robbery,
larceny etc. during the policy period
Trip Cancellation- Compensation for financial loss * Any change of plans or dis-inclination on the part of
(travel and accommodation) incurred on the insured resulting in cancellation of the trip
* In
cancellation of trip due to unexpected events e.g. case of "Event cancellation" extension, the event should
sickness, natural calamities, terrorist attack etc. not include personal family, political, anti-national or any
other event of illegal nature

Trip Interruption or Curtailment- Compensation for * Any change of plans or disinclination on your part
the financial loss incurred in case insured''s trip is which are not results of any unforeseen circumstances
interrupted and/or insured need to curtail his/her trip outside your control
* Interruption of the Trip either
102/20141021/66

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICITGBP22095V032122
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Marg, Near Siddhi Vinayak Temple, E-mail : Customersupport@icicilombard.com
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
 Cover Name Covers In Brief Some Of Major Exclusions Are -
due to unexpected events beyond his/her control wholly or in part done at the instance of the authority
governing the Common Carrier or the government

Common Carrier/Public Carrier delay- Fixed payout * For any departure which is delayed as a result of the
in case of a delay in departure of the scheduled insured or any other person accompanying the Insured
Common Carrier/Public Carrier on the Trip
Missed Connection (All Common Carrier/Public * For any departure which is delayed as a result of the
Carrier)- Reimbursement for official cancellation insured or any other person accompanying the Insured
charges and additional cost incurred to proceed with on the Trip
insured''s planned trip in case he/she fails to
access a connecting flight or connecting Common
Carrier/Public Carrier due to a delayed arrival of
the previous Common Carrier/Public Carrier
Burglary (Home contents)- Compensation for * Loss or damage directly or indirectly, proximately or
financial loss or damage due to burglary/attempted remotely occasioned by or which arises out of or in
burglary at insured''s residence while insured is on connection with riot and strike, civil commotion, terrorist
a covered trip activities.
Compassionate Visit- Reimbursement of Cost of * Any reason mentioned as exclusion under covers-
visit (travel and accommodation) of a family `Hospitalization Expenses for Injury" and/or
member/friend to the insureds place of `Hospitalization Expenses for Illness and injury".
hospitalization for a specified duration if deemed
necessary by the treating medical practitioner
Bounced booking of airlines or hotels- * Any cancellations due to failure to adhere to the rules
Reimbursement of additional expenses incurred for of the Common Carrier /Public Carrier operator or hotel/
alternative arrangements respectively in the event accommodation provider
of bounced booking of the confirmed Common
Carrier/Public Carrier and/or confirmed pre-paid
accommodation
Hotel extension due to contingency- * Any other reason for extension other than the specific
Reimbursement of expenses towards lodging and contingencies mentioned against this cover
boarding for an extended stay at a pre-booked
hotel/accommodation facility if the insureds
departure is delayed due to unexpected events
beyond control
Loss of Passport / International Driving License- A * Loss of the passport or international driving license
fixed benefit amount shall be given to the Insured due to delay or confiscation or detention by the
if he/she loses or damages their original Passport customs, police or public authorities.
or International Driving License
Replacement and Re-Arrangement of Staff- * Any pregnancy and resulting childbirth, miscarriage or
Reimbursement of expenses for travel and Disease of the female organs of reproduction which
accommodation for a replacement of the insured result in `Replacement and rearrangement of staff"
person arising out of insured persons inability to
continue work due to reason beyond control
Other Medical Repatriation of Remains- In the unfortunate event * Death arising from intentional
Covers of the death of the insured, reimbursement of self-injury/suicide/attempted suicide
expenses incurred for transporting the remains of
the deceased Insured back to the Country/Place of
Residence or for a local burial or cremation in the
country/place where death has occurred
Medical Evacuation- Reimbursement of expenses * Any treatment or expense mentioned as an exclusion
for emergency transportation and evacuation under "hospitalization expenses for injury" and/or
services necessitated due to any Illness "hospitalization expenses for illness and injury"
contracted or accidental Injury sustained during the
policy period.
Dental Treatment- Reimbursement of expenses * Any cost incurred for routine dental treatment and
incurred for emergency dental treatment towards consultation
relief from sudden acute pain and/or due to an
accident during the policy period
102/20141021/66

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICITGBP22095V032122
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Marg, Near Siddhi Vinayak Temple, E-mail : Customersupport@icicilombard.com
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
 Worldwide (Including Schengen C

Name : SUNIL PATIL

Policy No. : 4168/CO-IBGNP/311196957/00/000
Date of Birth : 01/Jul/1981
Valid From : 22/Oct/2023
Valid To : 05/Nov/2023

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2023.10.18 12:29:39 IST
102/20141021/66

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICITGBP22095V032122
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Marg, Near Siddhi Vinayak Temple, E-mail : Customersupport@icicilombard.com
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com