Aditya Birla Health Insurance Co.

Limited

Group Activ Travel - Certificate of Insurance

Policy Issuing Office Aditya Birla Health Insurance Co. Policy Servicing Office Aditya Birla Health Insurance
Limited, 10th Floor, R-Tech Park, Company Limited, 7th floor, C
Nirlon Compound, Goregaon East, building, Modi Business Centre,
Mumbai – 400063 Kasarvadavali, Mumbai, Thane West -
400615
Policyholder’s Name ANI Technologies Private Limited Policy Number 93-21-00003-00-00
Policyholder’s Address Regent Insignia, 4thBlock, 17th Main, Certificate Number
100 Feet Road Koramangala, GAT-OLA-5423968983
Bengaluru, Karnataka 560034
Product Name Group Activ Travel Intermediary Code NA

Master Policy Start Date 04 May 2021 Master Policy End Date 03 May 2022
Name & Residential Address
of Insured Person umesh, India

Communication Address of India

Group Activ Travel, UIN: ADITGBP21600V032021. Aditya Birla Health Insurance Co. Limited CIN: U66000MH2015PLC263677
the Insured Person
(Please mention if different
than Residential Address)
Geographical Scope Domestic Passport No NA
Unique Identification Coverage Type Individual
5423968983

Date of purchase of policy Insured Person Contact Details

06/07/2021 9588406160

Trip Duration 15 days Trip Type Single

06/07/2021
Period of Insurance: from to 21/07/2021 (both days inclusive)

Assignment: This Policy has been assigned to NA

Insured Person Details

Insured Person Name/
Member ID Date of Birth Gender Nominee Name Relationship
Unique Identifier

GAT-OLA-5423968983 umesh
NA NA Legal Heir Legal Heir

Coverage Details

Construct I - Benefits Payout Basis Deductible Co-pay Sum Insured / Applicability

In-patient Care with Day Care treatment Indemnity Nil Nil 25,000
(For Emergency Care)
(Including Ambulance services max upto Rs 2000)
Repatriation of Mortal Remains Indemnity Nil Nil 10,000

Pre-Existing Disease Details

NA NA

Waiting Period
Benefit Waiting Period
NA NA

Restrictions / Sub-Limits on Medical Expenses

Medical Expenses Sub limits
NA NA
 Premium Details
Particulars Amount (Rs.)
Net Premium 2.12
CGST (9%) -
SGST / UTGST (9%) -
IGST (18%) 0.38
Gross Premium 2.5

GST Registration No: 27AANCA4062G1ZN Category: General Insurance SAC Code:997133

Claim Assistance
Medi Assist Insurance TPA Address for Correspondence Tower D, 4th Floor, IBC Knowledge Park, 4/1 Bannerghatta Road,
Private Limited Bangalore, 560029
Contact Number 1800-425-9449
Email ID [email protected]

Group Activ Travel, UIN: ADITGBP21600V032021. Aditya Birla Health Insurance Co. Limited CIN: U66000MH2015PLC263677
Underwriter Notes

1. Pre existing diseases/ conditions will not be covered under any condition
2. Exclusion for Persons advised
Self Quarantine.
Quarantine/ Isolation Advised by any authorized/ testing centre.
Self Isolation during lockdown.
The Insured and/or Insured Member(s) should have not travelled outside India at least 60 days prior to the inception of the cover as specified in Policy
Schedule / Certificate of Insurance.
Person suffering from any respiratory related symptoms like cough, respiratory distress, breathlessness from last one month.
Persons who are not Immunocompromised. Immunocompromised Persons include Persons who have undergone Hospitalization, surgery or Day Care
procedure(s) within 90 days immediately preceding the Certificate Period Start Date.
Co-habitation: No claim shall be payable where the Insured Person was living with and sharing the same address as that of person(s) who were Diagnosed
with COVID-19 or Quarantined at the time of Proposal.

Stamp Duty :-
The stamp duty of INR 1.00 /- paid vide MH007558193202021E dated 01/12/2020 & MH007641812202021E dated 02/12/2020, received from Stamp Duty
Authorities vide Receipt No./GRASS DEFACE NO 0003866897202021 dated 16/12/2020 & 0003866967202021 dated 16/12/2020, payment h as been made
vide Letter of Authorisation No.CSD/197/2020/3052 dated 21/12/2020 from Main Stamp Duty Office.

Grievance Redressal

In case of a grievance, the Insured Person/ Policyholder can contact Us with the details through our website: www.adityabirlacapital.com, Email:
[email protected] or Toll Free: 1800 270 7000. Address: Any of Our Branch office or Corporate office.
For senior citizens, please contact respective branch office of the Company or call at 1800 270 7000 or write an e- mail at
[email protected] The Insured Person can also walk-in and approach the grievance cell at any of Our branches. If in
case the Insured Person is not satisfied with the response, then they can contact Our Head of Customer Service at the following email
[email protected]. If the Insured Person is still not satisfied with Our redressal, he/she may approach the nearest
Insurance Ombudsman. The contact details of the Ombudsman offices are provided on Our website and in the Policy.

Note: This certificate must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation of Po licy or any alteration in
the insurance affecting the premium.

Important –
1) In case of payment by cheque, in the event of dishonour of cheque for any reason whatsoever, insurance provided under this document automatically
stands cancelled from the inception irrespective of whether a separate communication is sent or not
2) Insurance cover is subject to the terms and conditions mentioned in the Policy wordings provided to you with this Certificate of Insurance. For
complete set of benefits, terms, conditions & exclusions please refer policy wordings.
3) The assignment of Benefits under the Policy shall be allowed subject to applicable law.

Master Policy Number: 93-21-00003-00-00 Certificate Number: GAT-OLA-5423968983

Date: 06/07/2021 Place: Mumbai

*This is a computer generated statement doesn’t need any signature