SERBIA VISA
APPLICATION
FILE NO. 2025/0104
PASSPORT NO
A00033407
NAME
SHAMAL BALA
Username - shamalbala@[Link]
Password - Gola@123#
COMPREHENSIVE TRAVEL PROTECTION
TRAVEL PROTECTION CARD
NAME : SHAMAL BALA ASSIST NO.
6500985006594
ADDRESS : Vipul Tech Square, Tower C, 3rd Floor,Golf Course START DATE END DATE
Road, Gurgaon Sector 43 27/05/2025 23/11/2025
STYLE PRO
Assist Fees : 7637( Incl GST @ 18%)
You can now enjoy exclusive travel assistance including insurance benefits on your trip. Kindly
ensure to carry this document for a pleasant travel experience.
Travel hassle-free with...
TRAVEL ASSISTANCE TRAVEL INSURANCE
24x7 Medical Lifestyle Domestic Roadside Arranged with an IRDAI authorised underwriter - ICICI
Assistance Assistance Assistance Lombard General Insurance Company Ltd.
Travel Support Services
Emergency Assistance Expert Intensive Care & Consultation 24/7 Customer Helpline
Ask for help
Note: Assistance provided by ASEGO TRAVEL LLP,
24x7 helpline: +91 22 67872 037
Insurance underwritten by ICICI Lombard General
Assistance: customercare@[Link] Insurance Company Ltd.
Claims: claims@[Link] Customer will bear any cost or expenses arising
Whatsapp message only for claims: +91 86478 34444 from availing the assistance services through a
third party service provider.
[Link]
Keep travelling, because the world is waiting for you and we are always by your side.
BON VOYAGE!
Click here or scan the QR code for detailed information about our assistance services.
ICICI LOMBARD GENERAL INSURANCE COMPANY LTD.
ICICI Lombard House, 414, Veer Savarkar Marg, Prabhadevi,Mumbai – 400025 IRDAI
Registration No: 115 Telephone: 1800 2666 Certificate Of Insurance
Customer Details:
Insured Name :SHAMAL BALA Date of Birth :07/01/1983 Passport Number:A00033407
Address Vipul Tech Square, Tower C, 3rd Floor,Golf Course Road, Gurgaon Sector 43
Travel Assure - Group Overseas Travel Insurance Mobile no 8544698821 Landline no 01125665584
E Mail :TRAVELWITHWORLD@[Link] CR no :SERBIA
Issue Date :16/04/2025
Certificate No : SX101186594
Intermediary Code :IM-1335344
Travel Assure - Group Overseas Travel Insurance Intermediary Name : ASEGO INSURANCE LLP
This Group Travel Insurance policy 4198/O/320154890/00/000 dated 16-04-2025 has been issued at Mumbai by ICICI Lombard General Insurance Company Ltd. to the
master policy holder, ASEGO TRAVEL LLP. and governed by the terms, conditions and exclusions therein contained or otherwise expressed in the said certificate, but not
exceeding the Sum Insured as specified in the Schedule. This Certificate, issued under the facsimile signature of ICICI Lombard General Insurance Company Ltd. represents
the availability of benefit to the above mentioned Insured Person. Through the master policy holder ICICI Lombard General Insurance Company Ltd. has received an amount
of Rs. 2852.90 (Incl GST @ 18%) towards covering the risk benefits, on behalf of the above mentioned insured.
Insurance Details :
Commencement Date:From:27/05/2025 End Date: mid-night on:23/11/2025 No. of Days:180
Plan Name :IC Single Trip STP - 2 75000 Geographical Coverage :Excluding USA and CANADA
Assignee :LEGAL HEIR Relation :Legal Heir
Exclusions :
Coverages Sum Insured Deductibles Coverages Sum Insured Deductibles
Emergency Medical Expenses Emergency
Medical Evacuation Repatriation of Mortal USD 75000 NA Dental Treatment Expenses USD 1000 NA
remains
USD 50 per
Daily Allowance in case of Hospitalization day upto 7 NA Compassionate Visit USD 5000 NA
days
Personal Accident Accidental Death -Common Carrier
Accidental Death Permanent Total Disability-Common Carrier
USD 25000 NA USD 5000 NA
Permanent Total Disability(PTD) Permanent partial Disability -Common
Permanent Partial Disability(PPD) Carrier
USD 100 per
Hijack Distress Allowance day upto 4 12 HRS Child Escort USD 1000 NA
days
Total Loss of checked in Baggage USD 1500 NA Delay of Checked-in Baggage USD 250 12 HRS
USD 750 per
Loss of Passport and documents USD 750 NA Mugging Benefits day upto 1 NA
day
Trip Cancellation and/or Interruption USD 1500 NA Missed connection USD 1000 3 HRS
USD 100 per
Trip Delay day upto 1 3 HRS Flight Delay(Airlines) USD 500 3 HRS
days
Over Booked-Common Carrier USD 1500 6 HRS Bounced Hotel Booking USD 1000 NA
Travel Inconvenience USD 1000 NA Overseas Travel Service Supplier Insolvency USD 1000 NA
Loss of International Driving License USD 1000 NA Car Rental Excess Insurance USD 1000 NA
Personal Liability USD 200000 NA Legal expenses USD 1500 NA
INR As per INR As per
erst while fire
Home Burglary Insurance (Contents) INR 300000 erst while fire Home fire Insurance (Contents) INR 300000
tariff
tariff
NA
Financial Emergency Assistance USD 1000 NA Bail Bond USD 5000
NA
Golf Equipment Cover USD 2000 NA Pet Care (in INR) INR 15000
Loss of Gadgets USD 1000 -
This policy covers adventure sports upto the limits specified under 'Other Terms & Conditions' and will be a part of Emergency Medical Expenses sum
insured
Emergency Assistance Details :
For claims, Contact ICICI Lombard 24hr Help Line number for assistance and registering your claim:
In USA & Canada (Toll Free) +1 844 871 1200;
Rest of the World (Call Back Facility) +91 124 449 8778
National Toll Free Number 1800 102 5721;
Fax Number +91 124 4006674
Email Address : icicilombard@[Link]
OR Login to the e-claim link [Link]
Other Terms & Conditions :
• This policy covers Emergency Medical Expenses incurred due to sudden and unexpected injury or any acute Sickness including COVID-19, arising when insured
is outside the 'Republic of India' up to the limits as mentioned in the policy schedule.
• This Travel Insurance policy is only limited to customers of ASEGO TRAVEL LLP.
• This policy covers the insured if travelling to any Schengen & its associate countries to a minimum of Euro 30000 minus deductibles (if any).
• This policy consist of following coverage’s which will be treated as benefit covers i.e. Personal Accident- Accidental Death Permanent Total Disability (PTD)
Permanent Partial Disability (PPD), Accidental Death—Common Carrier, Permanent Total Disability - Common ,Permanent Partial Disability - Common carrier,
Daily Allowance in case of Hospitalization, and Hijack Distress Allowance subject to policy terms and conditions applicable to these sections. All others
coverage’s will be treated as indemnity.
• Sum insured for Emergency Medical Evacuation and Repatriation of mortal remains will be sublimited to sum insured specified in Emergency Medical Expenses.
Pre-existing condition(s) are excluded from the policy including but not limited to life threatening conditions to save the Insured/Insured person’s life. This
exclusion will apply to the following sections: Emergency Medical Expenses, Emergency Medical Evacuation, Dental Treatment Expenses, Daily Allowance in case
of Hospitalization, Permanent Total Disability (PTD), Permanent Partial Disability (PPD). This exclusion has been waived to the extent of USD 20000 per policy or
upto 15% Sum Insured whichever is lesser & limited to section as indicated in the Policy Certificate for mentioned section for the age of upto 80 Years and USD
3000 for the above 80 Years
• Any claim arising out of sporting activities in so far as they involve the training or participation in competitions of professional or semi-professional sports
persons, Adventure Sports is not covered This exclusion has been waived to the extent of USD 20000 per policy if specifically opted or mentioned above.
• Sanctions Limitation and Exclusion Clause: Not applicable for sanctioned countries listed in certificate of insurance.
• No (re)insurer shall be deemed to provide cover and no (re)insurer shall be liable to pay any claim or provide any benefit hereunder to the extent that the
prevision of such cover, payment or such claim or provision of such benefit would expose that (re)insurer to any sanction, prohibition or restriction under United
Nations resolutions or the trade or economic sanction, laws or regulations of the European Union, United Kingdom or United States of America. Excluding
from/to and or countries places prohibited by GOI & also Specifically Excluding Iran I Iraq/Syria/ Sudan/ North Korea/Cuba/Crimea.
• Below Sublimit is applicable from the age 61 Years up to the age of 80 years for Emergency Medical Expenses.
Sublimit Applicable- from 61 Years- 80 Years
Room Rent including Boarding lodging $1750/day up to 30 days
Intensive Care unit $3250/day up to 7 days
Operation Theatre charges (Inclusive surgeon charges)” Maximum Up to USD 15000
Anesthetist services Up to 25% of Surgical Treatment
Physician Visit Max $ 100/day up to 10 visits
Diagnostic and Radiology services Max up to USD 1000
Ambulance Services Max up to $ 500
Hospital Miscellaneous Expenses Maximum of USD 1000
• Above mentioned sub limits are not applicable for Emergency medical Expenses section if sublimit waiver has been opted by insured & clearly mentioned on
above coverage section
• Sublimit applicable for age group above 80 years upto the age of 90 years & only limited to Emergency Medical Expenses is restricted to USD 5000 per illness &
Injury.
• Subject to the terms, conditions and exclusions of the ICICI Lombard General Insurance Company Ltd.
Authorised Signatory
(ICICI Lombard General
Insurance Company Ltd.)
The certificate 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, subject otherwise to the Terms, Conditions and Exclusions mentioned in the policy.
Certificate is only valid to the customers who are travelling from India.
•• Treatment abroad if that is the sole reason or one of the reasons for the Insured/Insured person's temporary stay
abroad• Any claim if the Insured Person 1. Is travelling against the advice of a Medical Practitioner;2. Is receiving, or is
on a waiting list to receive, specified medical treatment declared in the Medical Practitioner’s report or certificate;
• Has received terminaIprognosis for a medical condition; Is taking part in a navaI, military or air force Operation.•
1 General Exclusions Congenital external diseases, delects or anomalies • Diseases, illness and accidents that are results of war and warlike
occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, insurrection, civil commotion assuming
the proportions of or amounting to an uprising, military or usurped power, active participation in riots, confiscation or
nationalization or requisition of or destruction of or damage to property by or under the order of any government or
local authority.
For any claim related query, intimation of claim and submission of claim related documents you may contact our
Emergency Assistance Service Provider.
In case of a claim, you may reach us at 844-691-8883 (For Canada), 844-691-8885 (For USA) or +91 11 42221403 (For
2 Notice of Claim other parts of the world) or email us at customersupport@[Link]
Alternatively you can contact us through: Toll Free -1800 2666
Email -customersupport@[Link] Post/courier to Company - ICICI Lombard General Insurance Company Ltd.,
ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda,Gachibowli, Hyderabad-500032
Claims Procedure
1. In the event of an accident or sudden illness which is likely to give rise to a claim under this Policy, the Insured Person
shall immediately contact the Emergency Assistance Service Provider giving details of the Policy issued to him/her. The
details of phone numbers and Help Line are given in the Notice of claim section.
2. All necessary claim documents should be furnished to the Company/ Emergency Assistance Service Provider by the
policy holder/insured to make a claim. However, claims filed even beyond such period should be considered if there are
valid reasons of any delay.
3 Claim Procedure & Documentation Claim Service Guarantee: The Company shall settle the claim within 30 days from the date of receipt of last necessary
document in accordance with the provision of regulation 27 of IRDAI (Health Insurance) Regulations, [Link] the case of
delay in the payment of a claim, the Company shall be liable to pay interest from the date of receipt of last necessary
document to the date of payment of claim at a rate 2% above the bank rate
Claims Documentation-
• Duly filled in and signed claim form• Certificate of Insurance •Any additional document relevant to claim and specified
in the Policy wordings This is only a summary of the product features. The actual benefits available are as described in
the policy wordings and will be subject to the policy terms, conditions and exclusions.
For Detailed Terms & Conditions of your Travel Insurance Policy Kindly Click here
or paste the link "[Link] on your browser.
Website: [Link]; IRDAI Registration No: 115, Email:customersupport@[Link]
ICICI Lombard General Insurance Company Ltd.,, ICICI Lombard House, 414, Veer Savarkar Marg, Prabhadevi,Mumbai – 400025
UIN: ICITGOP22203V022122, CIN:L67200MH2000PLC129408
GOVERNMENT OF THE PEOPLE'S REPUBLIC OF
BANGLADESH
Dhaka Police Station
Dhaka
Ref No. 16ATGAO Dated: 16-APR-2025
POLICE CLEARANCE CERTIFICATE
The character and antecedents of Mr. SHAMAL BALA Son of Mr.
SREEDAM BALA Village/ Area: MUNSHIGANJ, P/O: MUNSHIGANJ,
Post Code:1550, P/S: DHAKA, District: MUNSHIGANJ holder of
Bangladesh International Passport No. A00033407 Issued at DHAKA on
16-APR-25 have been verified and there is no adverse information against
him/her on record
This certificate is issued in pursuance of Ministry of Home Affairs Memo
No. Nirdesh-2/75-Pt. 2152-Bohi(1), dated the 19th May, 1977.
Superintendent of Police Officer-in-Charge. Dhaka
Seal.
District Special Branch Dhaka Police Station.
This is a digital copy of the unsigned certificate issued by Bangladesh Police Online Police Clearance Management System.
The printed original must contain seal and signature of the designated officials.
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