Important Notice

Policy Details

Generation Date: 15-Jun-2015

Name of Insured: SRIHARSHA MITTAPALLI

Address: flat f-16, block B2,Mahaveer Varna Apartments,kannamangala, opposite 10 downing., Kannamangala,

, PO Area-,

-560067, BANGALORE.

Dear SRIHARSHA MITTAPALLI,

We thank you for utilizing the online services of Bajaj Allianz General Insurance Co. Ltd.This has reference to your policy

number OG-16-9906-9910-00012070 for your Travel Insurance.

Enclosed please find the policy schedule, policy wordings containing detailed terms and conditions of the coverages and the online Proposal

Form cum declaration submitted by you, before buying the policy. We wish to inform you that the premium quoted is based on the informa-

tion submitted in the proposal forms as well as the acceptance of the terms and conditions online. Request you to kindly go through the

same once again & in case of any disagreement/discrepancy/clarifications please call us on our toll free number 1800-209-0144 or log on to

www.bajajallianz.com or revert back within 15 days of the letter date.

Please note that the information provided by you will be verified at the time of claim & the insurance cover available to you (or other person

or categories of person covered in the policy) shall become void in the event of any untrue or incorrect statement, misrepresentation, non

description or non-disclosure in any form what so ever.

As a valued customer, we would like to provide regular updates on your policy, launch of new products and promotions so that you can take

advantage of the same. However if you do wish not to receive any such updates, we would request you to please register for 'Do Not Call'

registry on our website www.bajajallianz.com .

Assuring you of our best services always and thanking you once again for insuring with us.

With Best Regards,

Mr. Aditya Sharma

Head Direct Marketing, Web Sales, Travel, Retail Health and Home Insurance

Bajaj Allianz General Insurance Co. is now present across many platforms. Join us and stay connected always!

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

Proposal Form For Travel PolicyPolicy Details

Insured Name SRIHARSHA MITTAPALLI Address Details flat f-16, block B2,Mahaveer Varna Apart-ments,kannamangala, opposite 10 downing.KannamangalaBangalore

Telephone No Mobile No 9742647463

Email sriharsha.m@sjmsom.in Departure Date 29-JUN-15

Return Date 19-JUL-15 No of Journey Days 21

Date of Birth 01-AUG-89

Travel Plan TRAVELCARE Premium Excluding Ser-vice Tax(INR)

647

Required Details to Issue Policy

Passport No G7860245 Name of Nominee M V B REDDY

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 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.

Are you suffering or have you even suffered from any illness/disease/ailment upto the date of making this proposal orsuffer from physical defect or deformity?

N

Have you been admitted to any hospital/nursing home/clinic for treatment or observation? N

Proposer is already travelled from india and is abroad at the time of proposing for the policy ? N

I agree to the terms and conditions Y

Personal Information

Policy Address

Address Line flat f-16, block B2,Mahaveer VarnaApartments,kannamangala, opposite10 downing.

Street Name Kannamangala

City Bangalore Area Kannamangala

State KARNATAKA Pin code 560067

Mobile 9742647463 Telephone (Res.)

Telephone (Off.)

Where would you like to have the policy delivered

Housing/Building flat f-16, block B2,Mahaveer VarnaApartments,kannamangala, opposite10 downing.

Street Name Kannamangala

City Area

State BANGALORE Pin code 560067

Time of Availability

Date: 15-Jun-2015

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

Bajaj Finserv,1st Floor Survey # 208/1-B Behind Weikfield IT-Park Viman Nagar 411014 Pune - 411014 Ph.No.1800-209-0144

Receipt

Receipt Number: 9906-00584186

Receipt Date: 15-JUN-2015

Business Channel: WS

Received with Thanks from: SRIHARSHA MITTAPALLI

(Customer ID : 68053486 ) a total sum of Seven hundred thirty-eight rupees only .

Instrument Type Instrument Date Amount

ONLINE PAYMENT 15-JUN-15 738

Total Amount Received for this Policy 738

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 SCHEDULEPolicy Details

Reference No Y

Policy No : OG-16-9906-9910-00012070 Insurance Plan Chosen :TRAVELCARE

Home Address : flat f-16, block B2,Mahaveer Varna Apartments,kannamangala, opposite 10 downing. Kannamangala BANGALORE KARNATAKAPincode : 560067 Imdcode : 55555557Subcode 9906 Telephone No.Partner Id 68053486 Geographical Coverage ExcludingUSA

BENEFITS Limits (Max for entire policy period) DEDUCTIBLELoss Of Passport USD 250 USD 15

Personal Accident USD 10000 NIL

loss of checked baggage (Max liability per baggage is 50% of the limit andmax liability per item in a baggage is 10% of the limit as mentioned in theSchedule)

USD 250 NIL

Delay of Checked Baggage USD 100 12 hrs

Medical Expenses, Evacuation and Repatriation of Remains (Max. limit forEmergency dental Treatment is USD 500 (included in Medical Expenses))

USD 50000 USD 100

Emergency Cash Advance USD 500 NIL

Personal Liability USD 100000 USD 100

Hijack $ 50 per day max $300 NIL

Base Premium (in Rupees) : 647

Service Tax (in Rupees) : 91

Edu Cess (in Rupees) : 0

Total Premium (in Rupees) : 738

Date of Purchase of Policy : 15-JUN-2015

Policy Period : From 29-JUN-2015 to19-JUL-2015

Or Date of return of Insured, whichever is earlier.

Claims Assistance Department : Health Administration Team24 hours Helpline : Telephone No +91 20 3030 5858,Fax No: +91 20 3051 2207Email : travel@bajajallianz.co.inPolicy Servicing Office : Bajaj Allianz General Insurance Company Limited, Ground Floor, Ashoka Plaza, 32/2, Nagar Road, Nr. Weikfield Company, Pune

411014

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 asper 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 andCOMPULSORILY first contact the 24 hours helpline and obtain prior notification number from HELP LINE before incurring any expense. For all claims Please quote theclaims notification number and submit claim forms with original medical bills. The coverage provided is subject to details and declaration in the proposal form given priorto 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 codebefore 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) orToll 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

9906-00584186/45502224/738(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 ifany 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 perterms and conditions mentioned in the policy

Policy is valid only if countersigned by the insured in the space aboveaccepting this declaration

Signature of Insured

Service Tax Reg. No. : AABCB5730G-ST-001This 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 benefitsand/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, ifthe Insured Person(s) is permanently incapacitated or deceased, the legal heirs of the Insured may represent him in respect of Claim under the Policy.