Schedule of Travel Insurance

IssuedatMumbai

11/02/2015
0009455065-030001

WorldwideExcludingAmericas

Date Issued:
Producer Code:
Applicant Phone No:

Travel Dates:

From: 25/02/2015

Applicant Name:

MrAMITKUMARRAI

Duration:

21Days

Schedule Number:
Insurance Plan:
Zone:

PC793760
TravelGuardSilverPlus
To: 17/03/2015

7382654769

Applicant Address: FLAT NO 103 SAI RAM RESIDENCY FRIENDS COLONY MIYAPUR N HYDERABAD SHANKAR NETRALAYA
500049
PREMIUM
Premium

INR

1013.00

Tax(12.36%)

INR

TOTAL PREMIUM

INR

125.00
1138.00

IMPORTANT:AnyPre-ExistingMedicalcondition/Ailmentsdeclaredor
undeclaredwillbeexcludedfromthepolicy.TheCoverageprovidedis
subjecttothedetailsanddeclarationmadeintheproposaltothe
companyandattachedPolicyWording.
MAXIMUM COVERAGE

BENEFITS
AccidentalDeathandDismembermentBenefit(24hrs)
AccidentalDeathandDismembermentBenefit(CommonCarrier)
Accident&SicknessMedicalExpenseReimbursement
SicknessDentalRelief
EmergencyMedicalEvacuationBenefit
RepatriationofRemains
BaggageDelayBenefit(Afterfirst12hrs.)
CheckedBaggageLossBenefit
LossofPassportBenefit
PersonnalLiabilityBenefit
FlightDelay
Hijack
Automaticextensionofpolicyupto7days
Emergencycashadvance
FraudulentCharges(PaymentCardSecurity)
HomeBurglary(InRs.)
TripCancellation

DEDUCTIBLE

$10,000
$5,000
$100,000
$400

$100
$150

Included*
Included*
$100
$750
$250
$150,000
$100($10per12Hrs)

$30
$200
12Hrs

$500($100perDay)
Available
$750
$500
Rs.100,000
$500

1Day

$50

TripCurtailment
$500
$50
MissedConnection/Misseddeparture
$500
$50
Bouncedhotel/Airlinebooking
$500
$50
NOTES
*IncludedundertheoveralllimitofAccident&ServicesMedicalExpensesReimbursement.
Underannualmulti-trip,entryageisupto70years.Renewalsare applicablebeyond71years andpolicytermsandconditions
shallcommenceonlyincaseofrenewals.
Noticeofamedicalcondition/eventmustbeprovidedtoyourassistancecontact(seebelow)attimeofcareorassoonaspossible
after emergency care; failureto do so may affect benefitsand coverage. For details on sublimitsfor insured 56 years of age
pleaseseethenextpageofthispolicyscheduleorrefertothepolicywordingsscheduleofbenefitPartGsuppliedalongwiththis
schedule.
Insured# InsuredName
1

MrAMITKUMARRAI

PassportNumber
F5919822

DateofBirth
10/08/1981

Assignee
VANDANARAI

#Thebenefitsmentionedinthistableareapplicableforeverysingleinsuredindividuallycoveredunderthispolicy.
Signedfor&onBehalfofTataAIGGeneralInsuranceCompanyLtd.

Agent/BrokerName:Tata

Aig
Agent/BrokerLicenseCode:NA
Agent/BrokerContactNo:18002667780

Declaration:
I/WeherebydeclareandstatethatallstatementsandinformationfurnishedintheProposaltothe
companyandascapturedintheabovescheduleofInsurancearetrueandcomplete.Iffoundthat
thesaidstatementsandinformationfurnished/statedisincorrectoruntrueinanyrespectormanner
whatsoever,IagreeandacknowledgethattheInsurancecompanyshallnotbeliableinanymanner
whatsoeverinrespectoftheinsurancecoverageunderthispolicy.

InsuranceStampDutyPaid:Rs.1/-videreceipt/ChallanNo.MH001559912201314Edated11thFebruary2014

SignatureoftheInsured/Proposer:

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013.
IRDA Regn. No. 108. CIN - U85110MH2000PLC128425
www.tataaiginsurance.in Toll free Helpline 1800-266-7780 Email: customersupport@tata-aig.com

Schedule of Travel Insurance

IssuedatMumbai

11/02/2015
0009455065-030001

WorldwideExcludingAmericas

Date Issued:
Producer Code:
Applicant Phone No:

Travel Dates:

From: 25/02/2015

Applicant Name:

MrAMITKUMARRAI

Duration:

21Days

Schedule Number:
Insurance Plan:
Zone:

PC793760
TravelGuardSilverPlus
To: 17/03/2015

7382654769

Applicant Address: FLAT NO 103 SAI RAM RESIDENCY FRIENDS COLONY MIYAPUR N HYDERABAD SHANKAR NETRALAYA
500049

Address for Claim/US Non Medical

(For Insureds only)

Assistant Contact (For Insureds only)

Claims Department

For excluding the Americas Policies:

Tata AIG General Insurance company Ltd.

Call:+603-8991-2012or+603-8991-2014
(TollWorldwide)
Email(assistance):
TGAP.TATAmedical@travelguard.com

5 th

A-501,
Floor, Building No. 4, Infinity Park,
Gen. A. K. Vaidya Marg, Dindoshi, Malad (E),
Mumbai, India - 400 097.
Visitourwebsite:www.tataaiginsurance.in OR Email
atcustomersupport@tata-aig.com OR Callour24x7
tollfreehelpline1800-266-7780(Accessiblefromall
lines)
OR1800-11-9966(AccessiblefromBSNL/MTNLLines)

For the Americas Policies:

PleaseCall:+1-866-866-2619(TollFreewithinUS&
Canada)+1-817-826-7017(ReverseCharge/Collect
fromotherplaces)
Email:tata.aig@aig.com

US Medical Claims (For Providers Only)

PlanType:
PolicyCertificate#:
Mail Medical Claims to:

Shared Savings

LTA
PC793760

TravelGuard
Attn:TataAIGClaims
POBox8003
StevensPoint,WI54481

Sub-limits :
The following Maximum eligible expenses per Disease/Illness are automatically applicable to Insured Persons aged 56 years
onwards, regardless of the plan/option purchased at the inception/its subsequent renewals if applicable.
Sublimits can be waived off by payment of additional premium. If waived then this will appear in Insurance Plan on Page 1.
The maximum limit would be as mentioned below or upto the Sum insured whichever is lower.
I. Hospital Room Rent, Board and Hospital misc. maximum $1500 per day up to 30 days.
II. Intensive Care Unit-Maximum $3000 per day up to 7 days.
III. Surgical Treatment-Maximum USD $10000
IV. Anesthetist Services-Maximum up to 25% of Surgical treatment
V. Physician's Visit-Maximum $75 per day up to 10 visits.
VI. Diagnostic and Pre-admission testing-Maximum up to $ 500
VII. Ambulance Services-Maximum up to $ 400.

Signedfor&onBehalfofTataAIGGeneralInsuranceCompanyLtd.

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013.
IRDA Regn. No. 108. CIN - U85110MH2000PLC128425
www.tataaiginsurance.in Toll free Helpline 1800-266-7780 Email: customersupport@tata-aig.com