Digitally signed by Reliance General

Insurance
Company Limited
Date: 2024.06.26 13:17:24 IST

RELIANCE TRAVEL CARE POLICY - FOR TOURIST

POLICY SCHEDULE ura

PolicyIssuing Office : PolicyServicing Office Code 1316
RELIANCE GENERAL INSURANCE COMPANY LIMITED 6TH FLOOR, F-17, UG FLOOR, UNIT 1/2, PREET VIHAR, DELHI INDIA
OBEROI
COMMERZ, INTERNATIONAL BUSINESS PARK, OBEROI GARDEN CITY,
OFF
WESTERN EXPRESS HIGHWAY, GOREGAON (EAST), MUMBAI – 400 063
PolicyNo : 1642011540321587881
Tax Invoice No. & Date : R18441585735 & 15/05/2024 IntermediaryCode : 11BRG429

Proposer Details :

Communication Address & Place

Name of the Proposer Date of Birth Occupation Contact No.
of
Supply
MR. SHIBA RAJ JAISHI 18-04-1993 Others AKELGHURUWA, 06
PRATAPPUR, KAILALI 9896213455

GSTIN / UIN of the Proposer :

Details of the Insured Person :

Insured Pre-Existing
Name of the Insured Person Date of h Passport Suffering Since Under Medication
Relationship wit illness/ injury/
Birth N
the proposer condition if any
MR. SHIBA RAJ JAISHI 18-Apr-1993 Self 08274474 No NA No

Nominee Details

Nominee Name Date of Birth Nominee Relationship with

proposer
KHIMA JAISHI MOTHER

Address of the Insured : AKELGHURUWA, 06 PRATAPPUR, KAILALI Mobile No :

9896213455
Email-ID : Telephone No :
Geographical Coverage : Excluding USA and Canada
Group corp ID :
Name of Countries to be visited :
PolicyPeriod : From 00:00 Hrs. on 07-Jul-2024 To 06-Jul-2025 midnight or Date of return of Insured whichever is earlier
Name of the Plan Opted : Standard
Trip Type: Single
Coverage Sum Insured (In Deductible (In
USD) USD)
Medical Expenses Including Transportation Evacuation And 50000 50
Repatriation Of Mortal Remains
Dental Treatment 500 50
Loss of Passport 100 25
Total loss of checked Baggage 1000 100
Personal Accident 25000 NA
Accidental Death Common Carrier 2500 NA
Personal Liability 100000 200
Bail Bond 500 50
Study Interruption 10000 NA
Sponsor Protection 10000 NA
Compassionate Visit 7500 NA

nce General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
 gistered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off Western Express ghway, Goregaon
(East), Mumbai – 400 063
GI/MCOM/CO/Trave/PS/VER.1.0/010218 Corporate Identity No. U66603MH2000PLC128300. UIN: RELTIOP08002V010708
de Logo displayed above belongs to Anil Dhirubhai Ambani Ventures PrivateLimited and used by Reliance General Insurance Company Limited under License.

arranties/Conditions:

1 Warranted that insured is a citizen of India and has a permanent place of residence in India and is not a NRI or OCI or
foreign national and was within the territory of India at the time of issuance of the policy and before the commencement of
the trip.
2 Warranted that maximum amount payable per checked-in baggage in case more than one bag has been checked in, is 50%
(100% for only one checked-in baggage) of applicable Sum Insured and per item in baggage max 10%.
3 Warranted that the trip is for the purpose of Study not for any other purpose including employment.
4 Warranted that any claim arising out of sporting activities in so far as they involve the training or participation in
competitions of professional or semiprofessional sports persons is excluded
5 Medical/Hospitalization expenses due to COVID 19 Infection is covered if contracted during the travel as per policy terms
and conditions.

iance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
gistered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off Western Express ghway, Goregaon
(East), Mumbai – 400 063
GI/MCOM/CO/Trave/PS/VER.1.0/010218 Corporate Identity No. U66603MH2000PLC128300. UIN: RELTIOP08002V010708
ade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures PrivateLimited and used by Reliance General Insurance Company Limited under License.

et Premium ` 1,411.00 IGST (@ 18% ) ` 253.98

otal Premium : ` 1,665.00
STIN : 07AABCR6747B1ZI , HSN :997142
escription of Services : Freight insurance services & Travel insurance services

tegory-General Insurance Business Service 00440005

te : In the event of dishonor of the cheque, this policy document automatically stands cancelled from inception, irrespective of whether a separate communication is sent or not. witness whereof this
policy has been signed at Mumbai on policy tax invoice date in lieu of Proposal No. as mentioned in the policy.
is document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services TaxRules 2017. The policy
rding with detailed terms, conditions and exclusions are available on our website www.reliancegeneral.co.in

licy wordings link : https://www.reliancegeneral.co.in/Insurance/About-Us/Downloads.aspx)

u can also write to us at [email protected] or call us on 1800 3009 (toll free)/ 022 4890 3009 (Paid) to avail the policy wording.
case of a renewal, the benefits provided under the policy and/or terms and conditions of the policy including premium rate may be subject to change

rievance Clause : For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 1800 3009 or may write an
email at [email protected]. In case the insured is not satisfied with the response of the office, insured may contact the Nodal Grievance
Officer of the Company at [email protected]. In the event of unsatisfactory response from the Nodal Grievance Officer, insured may
email to Head Grievance Officer at [email protected]. In the event of unsatisfactory response from the Head Grievance
Officer, he/she may, subject to vested jurisdiction, approach the Insurance Ombudsman for the redressal of grievance. Details of the offices of
the Insurance Ombudsman are available at IRDAI website www.irda.gov.in or on company website www.reliancegeneral.co.in or on
www.gbic.co.in. The insured may also contact the following office of the Insurance Ombudsman within whose territorial jurisdiction the branch or office of
the Company is located.
Smt. Sandhya Baliga Office of the Insurance Ombudsman,2/2 A,Universal Insurance Building,Asaf Ali Road,New Delhi – 110 002. Tel.: 011 -
23239633 / 23237532 Fax: 011 - 23230858 Email: [email protected]

For and on behalf of Reliance General Insurance Company Limited

Authorised Signatory

e policy has been issued based on the information provided by you / your representative and the policy is not valid if any of the information provided is incorrect or incomplete. bject otherwise
to the terms, conditions and exclusions of the Reliance Travel Care Policy Medical Assistance & Emergency Services are implemented by our rvice Providers-
EUROP ASSISTANCE INDIA PVT LTD.
7th Floor, Star Hub, Bldg No. 2,
Near ITC Maratha Hotel, Sahar,
Andheri East, Mumbai – 400 059, INDIA.
Are at your disposal for 24 hours during 365 days/year
case of any requirement for emergency assistance whilst abroad, please contact the International Toll Free helpline numbers given below:
A – 18337426673,Greece – 86002038017,Australia – 0011-80099441111,Canada -011-80099441111,Singapore and Thailand – 001-80099441111, pan – 001-010-
80099441111 and 010-80099441111,Hong Kong – 001-80099441111 and 006-80099441111,
ael – 00-80099441111 and 014-80099441111,Argentina, Austria, Belgium, China, Czech Republic, Denmark, France, Germany, Hungary, Italy, Malaysia, therlands,
w Zealand, Norway, Philippines, Poland, Portugal, South Africa, Spain, Sweden, Switzerland, Taiwan & United Kingdom – 00-80099441111

Dedicated National Toll Free Help Line : 1800 209 5522 Land Line Numbers: +91 22 67347843 & +91 22 67347844
E-mail: [email protected] Fax Number: +91 22 67347888
ebsite: www.europ-assistance.com
nsolidated Stamp duty Paid vide Letter of Authorization “NO.LOA/CSD/151/2021/(Validity Period Dt.15/10/2021 to 30/03/2022)/4163” date 12 Oct 2021 at General Stamp
fice, Mumbai.** Not Applicable for the State of Jammu & Kashmir

EASE NOTE:
ttached with this Policy Schedule are the Policy Terms and Conditions, and Annexures. Please ensure that the Policyholder has received, read and understood all these cuments. If the
Policyholder has not received any of these, pleaseemail/write to the Company at [email protected] or contact us on 1 800 3009(toll free) .The nefits which are mentioned in this
Schedule shall only be available under the Policy.

termediary Name & Code HEARTBEAT INSURANCE BROKERS PVT LTD 11BRG429
termediary Contact No.: 8802188888

iance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
gistered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off Western Express ghway, Goregaon
(East), Mumbai – 400 063
GI/MCOM/CO/Trave/PS/VER.1.0/010218 Corporate Identity No. U66603MH2000PLC128300. UIN: RELTIOP08002V010708
ade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures PrivateLimited and used by Reliance General Insurance Company Limited under License.
 Reliance Travel Care Policy- Online Proposal Form with Proposal No R18441546201
Please find attached herewith Policy No. 164201154032165025 which has been issued based on the details furnished to us by Proposer / Insured Person:- MR. SHIBA RAJ JAISHI

Proposer Details :
Communication Address & Place
Name of the Proposer Date of Birth Occupation Contact No.
of
Supply
MR. SHIBA RAJ JAISHI 18-04-1993 Others AKELGHURUWA, 06
PRATAPPUR, KAILALI 9896213455

GSTIN / UIN of the Proposer :

Details of the Insured Person :

Pre-Existing
Name Date of Relationship with Passport Sufferin Under Professional
Birth proposer No illness/ injury Since Medicatio Sportsperson
condition if any
MR. SHIBA RAJ JAISHI 18-Apr-1993 Self 08274474 No NA No No

Nominee Details

Nominee Name Date of Nominee Relationship with proposer

Birth
KHIMA JAISHI MOTHER

Whether Resident of India : No

Mailing Address : AKELGHURUWA, 06 PRATAPPUR, KAILALI

Address of residential property :
Insuredelephone No. :
MobileNo. 9896213455
-mail id :
Visa Type : NA Geographical :Excluding USA & CANADA
Policy Period : From: 07-Jul-2024 To: 06-Jul-2025 Coverage
Name of Plan Opted : Standard
Trip Type : Single
Purpose of Visit : Business

Please go through the details as furnished above and also as provided in the Policy Schedule and confirm that they are in discrepancies /
variations, you are requested to write back to us immediately at [email protected] for necessary written communication from you
within 7 days or commencement of Policy Period whichever is earlier , it is hereby agreed answ and particulars are complete, correct and true
in all respects and are the basis on which this Policy is being granted and found the above statements, answers or particulars are incorrect or
untrue in any respect, the policy will be considered Null have no liab under the policy
Declaration & Warranty on Behalf of All Persons Proposed to be Insured
I Policy has been issued basis Insured Person(s)
1) Is / are not travelling against advice of Medical Practitioner
2) Is / are not on Waiting list for any Medical treatment
3) Is / are not travelling for the purpose of obtaining Medical treatment
4) Have not received a terminal prognosis for a medical condition before Journey
5) Being in India before taking cover and commencement of Trip
6) Warranted that the Insured / Insured Person(s) has no past history of any illness / hospitalization.
7) Being Indian Citizen
8) Purpose of visit "Study" Only

tered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off Western Express
ay, Goregaon (East), Mumbai – 400 063
 GI/MCOM/CO/Trave/PS/VER.1.0/010218 Corporate Identity No. U66603MH2000PLC128300. UIN: RELTIOP08002V010708
ade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures PrivateLimited and used by Reliance General Insurance Company Limited under License.

have read and understood the brochure, prospectus, sales literature & Policy wordings and confirm to abide by the same.
I understand that the information provided byme will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurance company andat he policy
will come into force only after full receipt of the premium chargeable.
I/We further declare that I/We will notify in writing any change occurring in the occupation or general health of the life to be insured / proposer after the proposal has been
bmitted but before communication of the risk acceptance by the Company.
/We declare and consent to the Company seeking medical information from any Doctor or from a hospital who at anytime has attended on the life to be insured / proposer from any past or
present employer concerning anything which affects the physical or mental health of the life to be assured / proposer and seeking information from any urance company to which an
application for insurance on the life to be assured / proposer has been made for the purpose of underwriting the proposal and / or claim ttlement.
I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or claims ttlement and with
any Governmental and / or Regulatory Authority.
. Receipt of the Proposal form by the Company shall not be construed as acceptance of proposal. I hereby agree that the insurance coverage shall commence only on alization of full premium
and on receipt of complete medical reports (wherever applicable) and subject to individual underwriting by the Company. The Company at its sole cretion reserves the right to accept or reject
or load any proposal without assigning any reason thereof.
I. I understand that the Policy shall become void at the Company's option, in the event of any untrue or incorrect statement, misrepresentation, non-description or ndisclosure of any material
fact in the Proposal form/personal statement, declaration and connected documents or any material information having been withheld by me or yone acting on my behalf.
I hereby declare that the person(s) proposed to be insured would submit to medical examinations, before the nominated doctors of the Company, or undergo diagnostic or her medical tests,
as suggested by the Company for its underwriting.
X. I consent to provide a valid age proof and identity proof at the time of claims or any other time when required by the Company.
XI. I/We consent to receive information from the Company through physical, electronic or telecommunication means from time to time.
XII. I hereby declare on my behalf & on behalf of all persons proposed to be insured that the above statements, answers and/or particulars given by me in this proposal form are e and complete
in all respects to the best of my knowledge and that I/We am/are authorized to propose on behalf of these other persons. XIII. I further declare that the premium is ing paid from my credit/debit
card/internet bank account.

1.

The insurance company has right to cancel the insurance contract in case I am/ have been found guilty by any competent court of law under any of the statutes,
2.
3.

IMPORTANT:
The information that you give to Reliance General Insurance Company Ltd in this online form will be treated as the proposal form and details in any supplemental information form or documentation supplied
The questions in this online form are indicative rather than exhaustive. You must provide us with all information relative to the risk to be insured, even if it is not the subject of a question in this online form. If

been paid.

•
No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property, in India, a

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
gistered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off Western Express ghway, Goregaon
(East), Mumbai – 400 063
GI/MCOM/CO/Trave/PS/VER.1.0/010218 Corporate Identity No. U66603MH2000PLC128300. UIN: RELTIOP08002V010708
ade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures PrivateLimited and used by Reliance General Insurance Company Limited under License.