Js 016426

Signedfor&onBehalfofTataAIGGeneralInsuranceCompanyLtd.#Thebenefitsmentionedinthistableareapplicableforeverysingleinsuredindividuallycoveredunderthispolicy.

Declaration:I/WeherebydeclareandstatethatallstatementsandinformationfurnishedintheProposaltothecompanyandascapturedintheabovescheduleofInsurancearetrueandcomplete.Iffoundthatthesaidstatementsandinformationfurnished/statedisincorrectoruntrueinanyrespectormannerwhatsoever,IagreeandacknowledgethattheInsurancecompanyshallnotbeliableinanymannerwhatsoeverinrespectoftheinsurancecoverageunderthispolicy.

Agent/BrokerName:Tata AigAgent/BrokerLicenseCode:NAAgent/BrokerContactNo:18002667780

SignatureoftheInsured/Proposer:InsuranceStampDutyPaid:Rs.1/-videreceipt/ChallanNo.MH001559912201314Edated11thFebruary2014Tata 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

Toll free Helpline 1800-266-7780 Email: customersupport@tata-aig.comwww.tataaiginsurance.in

Schedule of Travel InsuranceIssuedatMumbai

Schedule Number: Date Issued:Insurance Plan: TravelGuardSilver Producer Code:

JS016426 23/03/20150020482001-020001

Applicant Phone No:Zone:Travel Dates: Applicant Name:From: To:

9159535499MrNandagopaalNanjanBhojan

WorldwideExcludingAmericas25/06/2015 21/12/2015

Duration:Applicant Address: G-604purveveneziaapartmentpurvankarayelankabangalorenewtownnearmotherdair560064

180Days

Premium

TOTAL PREMIUM

INRINRINR

PREMIUM

Tax(12.36%)4955.00612.00

5567.00

IMPORTANT:AnyPre-ExistingMedicalcondition/Ailmentsdeclaredorundeclaredwillbeexcludedfromthepolicy.TheCoverageprovidedissubjecttothedetailsanddeclarationmadeintheproposaltothecompanyandattachedPolicyWording.

MAXIMUM COVERAGE DEDUCTIBLEBENEFITSAccidentalDeathandDismembermentBenefit(24hrs) $10,000Accident&SicknessMedicalExpenseReimbursement $50,000 $100SicknessDentalRelief $300 $150EmergencyMedicalEvacuationBenefit Included*RepatriationofRemains Included*BaggageDelayBenefit(Afterfirst12hrs.) $50CheckedBaggageLossBenefit $500LossofPassportBenefit $250 $30PersonnalLiabilityBenefit $100,000 $200Automaticextensionofpolicyupto7days AvailableEmergencycashadvance $500FraudulentCharges(PaymentCardSecurity) $500HomeBurglary(InRs.) Rs.100,000TripCancellation $500 $50TripCurtailment $500 $50MissedConnection/Misseddeparture $500 $50Bouncedhotel/Airlinebooking $500 $50NOTES*IncludedundertheoveralllimitofAccident&ServicesMedicalExpensesReimbursement.Underannualmulti-trip,entryageisupto70years.Renewalsareapplicablebeyond71yearsandpolicytermsandconditionsshallcommenceonlyincaseofrenewals.Noticeofamedicalcondition/eventmustbeprovidedtoyourassistancecontact(seebelow)attimeofcareorassoonaspossibleafteremergencycare; failuretodo somayaffectbenefitsandcoverage. For detailsonsublimitsfor insured56yearsof agepleaseseethenextpageofthispolicyscheduleorrefertothepolicywordingsscheduleofbenefitPartGsuppliedalongwiththisschedule.Insured# InsuredName PassportNumber DateofBirth Assignee

NanjanBhojan.MonishMrNandagopaalNanjanBhojan1 m4739181 06/02/1992

Address for Claim/US Non Medical Assistant Contact

Claims DepartmentTata AIG General Insurance company Ltd.A-501, 5 Floor, Building No. 4, Infinity Park, Gen. A. K. Vaidya Marg, Dindoshi, Malad (E), Mumbai, India - 400 097.

customersupport@tata-aig.com

For excluding the Americas Policies:Call:+603-8991-2012or+603-8991-2014(TollWorldwide)Email(assistance):

Visitourwebsite:www.tataaiginsurance.inTGAP.TATAmedical@travelguard.comFor the Americas Policies: PleaseCall:+1-866-866-2619(TollFreewithinUS&Canada)+1-817-826-7017(ReverseCharge/Collecttollfreehelpline1800-266-7780(Accessiblefromall

(For Insureds only)

lines)

(For Insureds only)

fromotherplaces)Email:tata.aig@aig.com

US Medical Claims (For Providers Only)

PlanType: LTAPolicyCertificate#:

Mail Medical Claims to: TravelGuardAttn:TataAIGClaimsPOBox8003StevensPoint,WI54481Shared Savings

at OR Callour24x7OR Email

th

OR1800-11-9966(AccessiblefromBSNL/MTNLLines)

JS016426

Schedule of Travel InsuranceIssuedatMumbai

Schedule Number: Date Issued:Insurance Plan: TravelGuardSilver Producer Code:

JS016426 23/03/20150020482001-020001

Applicant Phone No:Zone:Travel Dates: Applicant Name:From: To:

9159535499MrNandagopaalNanjanBhojan

WorldwideExcludingAmericas25/06/2015 21/12/2015

Duration:Applicant Address: G-604purveveneziaapartmentpurvankarayelankabangalorenewtownnearmotherdair560064

180Days

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 $ 500VII. Ambulance Services-Maximum up to $ 400.

Signedfor&onBehalfofTataAIGGeneralInsuranceCompanyLtd.

Tata AIG General Insurance Company LimitedRegistered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai - 400013.

IRDA Regn. No. 108. CIN - U85110MH2000PLC128425Toll free Helpline 1800-266-7780 Email: customersupport@tata-aig.comwww.tataaiginsurance.in

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