CERTIFICATE OF INSURANCE AFTER ENROLLMENT UNDER

Globetrotter - Overseas Group Travel Insurance

Policy Certificate No.: 4110/O-PRUWAY/7053/00/000

Invoice No. :
ICICI Lombard Globetrotter Overseas Group Travel Insurance has been issued at Mumbai by ICICI Lombard General insurance Company Limited to the
customers of Pruway Direct enrolling under the DL-4110/O/4233087 policy as specified in the Policy and is governed by the terms, conditions and exclusions
there in contained or otherwise expressed in the said policy. This cover is subject to the terms, conditions and exclusions contained or otherwise expressed in
the said policy to the extent of sum insured mentioned as maximum liability, but not exceeding the sum insured as specified below.

Please Note: Any claim due to or arising out of pre-existing medical condition/ailment whether declared or undeclared is not covered under the Policy.

Policy Details (Part I of the Policy - Schedule)

Period of Insurance From: 04 Jun 2022 To: 12 Jun 2022(midnight)

Geographical Scope Excluding USA/Canada

Details of the Insured

Name DHRUV GUPTA Date Of Birth 17-Jun-1994

Mailing Address 176 BINDRA COLONY CHHINDWARA 480001, Chhindwara, Madhya Pradesh

Telephone No. Purpose of Trip Personal

Passport Number V2663200 Nominee name NARENDRA GUPTA

IL ID

GSTIN Number of Insured GSTIN Number of [Group Admin] 23AAKCP0629H1ZK

Insured Age

Reference No: PRUWAYGLOBAL50X

Benefits Sum Insured Deductible

Medical Expenses (Includes Medical Evacuation cost) USD 50,000 100

Repatriation of Remains USD 7,500 NIL

Dental Treatment USD 250 100

Personal Accident USD 10,000 Nil

Loss of Checked-In Baggage USD 300 NIL

Delay of Checked in baggage USD 100 8 Hours

Passport Loss USD 250 Nil

Trip Cancellation and Interruption USD 750 100

Trip Delay USD 300 8 hours

Missed Flight Connection USD 500 3 Hours

Financial Emergency assistance USD 750 NIL

Burglary INR 1,00,000 NIL

USD 125 per day upto Max 7

Hijack Distress Allowance 24 hours
days

Personal Liability USD 1,00,000 NIL

Special Terms and Conditions:

Note 1: Insurance benefit shall become voidable at the option of the Company, in the event of any untrue or incorrect statement, misrepresentation, non-
description or nondisclosure of material particulars in the Proposal Form/ personal statement, declaration and connected documents, or any material
information has been withheld by beneficiary or anyone acting on beneficiary's behalf to obtain insurance.

Note 2: Sublimits are not applicable for this policy.

Medical expenses due to Covid-19 is covered if contracted during the travel period as per policy terms and conditions.
 IGST (@18.00% on Premium) UTGST (@0.00% on Premium) CGST (@0.00% on Premium) SGST (@0.00% on Premium) Total Premium including GST
Start Date End Date Premium (INR)
(INR) (INR) (INR) (INR) (INR)

04 Jun 2022 12 Jun 2022 99.15 17.85 0.0000 0.0000 0.0000 117

GST IN Number of ICICI LOMBARD

HSN / SAC CODE SERVICING BRANCH SERVICING BRANCH ADDRESS
GIC

414, ICICI LOMBARD HOUSE,

VEER SAVARKAR MARG, NEAR
00440005 GENERAL INSURANCE
27AAACI7904G1ZN Mumbai SIDDHI VINAYAK TEMPLE MAIN
SERVICES
GATE, PRABHADEVI, MUMBAI,
400025, MAHARASHTRA

For ICICI LOMBARD GENERAL INSURANCE CO. LTD.

Date of Issue: 03 Jun 2022
Place of Issuance:Mumbai
Authorised Signatory

The stamp duty of Rs 1.(Rupee One only) paid vide deface no. CSD2602018523718 dated 04 Dec 2018
This certificate has to be read in conjunction with the Terms and Conditions, coverages and exclusions mentioned in policy schedule. Please refer to Part II and III of the policy schedule for detailed
terms and conditions of the covers described above.
FOR CLAIMS : Please contact our 24x7 toll free helpline for assistance and registering your claim(For cashless or reimbursement):
From USA and Canada + 1 844 871 1200 (toll free), From rest of the world + 91 124 4498778 (Call back facility)
In India 1800 102 5721, Fax Number + 91 124 4006674 and
[email protected]
Website:www.falck.com
Failure to send immediate notice on the happening of a loss resulting in a claim may prejudice the Insured's claim under the Policy. The documents required in support of the claim shall be forwarded
to the Company at the address mentioned below immediately upon return to India. Customer to send documents to IL at:-
CLAIMS DEPARTMENT
ICICI LOMBARD
C/O Falck India Pvt Ltd
Upper Floor
The Peach Tree, Block - C
SushantLok - I, Sector 43,Gurgaon,
Haryana - 122015 (India)

In cases of any product related query, please call us at 1800 2666 (Toll Free and accessible in India only). Policy extension is valid only if all claims that are put up/that will be put up by the insured on
return back to Republic of India, for the original policy duration have been informed as soon as they occur and well in advance to the extension request.

In case of any grievance related to policy/claim kindly approach our grievance redressal channel available on company website.
Note: In case you find any variation between the information provided by you and the details as mentioned in the policy certificate, kindly contact us immediately. Disclaimer: Insurance is subject matter
of solicitation. Please refer to policy wordings for terms and conditions, coverage and exclusions.

ICICI Lombard General Insurance Company Limited IRDA Reg.No.115, Misc 110
ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025
UIN No.: ICITIDP08003V030708 Product Code/Product Name: 4110O/Group Travel Overseas CIN no.: L67200MH2000PLC129408 www.icicilombard.com

Name : DHRUV GUPTA

Policy No. : 4110/O-PRUWAY/7053/00/000
Date of Birth : Jun 17, 1994
Vaild From : Jun 04, 2022
Valid To : Jun 12, 2022
 KEY INFORMATION SHEET (KIS)
S.No. Title Description (Description is illustrative and not exhaustive) Refer to Clause

1 Product Name Globetrotter- Overseas Group Travel Insurance

Hospitalisation expenses for Injury/illness during the trip

Expenses incurred for injury/illness to natural tooth or teeth during the trip
Cost of transportation of mortal remains in the event of death during the trip
Transportation expenses for medical evacuation with prior approval
Accidental injury leading to Death/PTD during the trip
Value of Checked-In Baggage lost whilst in custody of common carrier
What am I covered
2 Allowance for the Delay of Checked-In Baggage whilst on trip Part II of the Schedule
for
Loss of Passport whilst on Trip abroad
Sub limits are not applicable for this policy

(Note: The above mentioned is an illustrative listing of the policy coverages which may be
applicable under your policy. Please refer to the policy certificate for the exact coverages
applicable to you. For details on coverages, please refer policy wordings).

Pre-existing Disease or illness except in Life saving unforeseen emergency and/or acute painful
conditions provided the same has been opted for under the master policy.
l Cosmetic treatment or Plastic surgery in any form or manner
Rehabilitation and/or physiotherapy or the costs of prostheses/prosthetics(artificial limbs)etc
Mental or psychiatric disorders; HIV/AIDS.
Part II of the Schedule
Self inflicted injuries; Drug or alcohol abuse
General Exclusion Coverages and Exclusions
3 Partial loss of items in the checked in Baggage
Conditions Applicable of respective
Loss of Valuables and money
benefits
Theft of passport unless reported to police within 24 hours
Any claim arising out of sporting or adventurous activities/aircraft operation.

(Note: The above mentioned is a partial listing of the policy exclusions. Please refer to the
policy wordings for the full listing).

Lodge your claim by calling at following numbers for Overseas Policies

In USA & Canada +1 844 871 1200 (Toll Free)
From the rest of the World +91 124 4498778 (Call Back Facility)
In India 1800 102 5721 (Toll Free & Accessible in India Only)
Fax +91 124 4006674
Claims Contact Claims Procedure in Part II of
4 E-mail - [email protected]
and procedure the Schedule
For Domestic policies, please call 1800 2666 or e-mail [email protected]
Promptly give the Company any and all information and documentation concerning the claim or
the Company's liability for it
Any other document as required by the Company or Company's TPA to investigate the Claim or
Our obligation to make payment for it

This policy would be cancelled in below conditions

We may cancel this Policy on grounds of misrepresentation, fraud, non disclosure of material
facts or non cooperation of Insured/Policy Holder by sending 15 days written notice by
registered post to your last known address, and then we shall refund a pro-rata premium for the Cancellation Clause under
5 Cancellations
unexpired Policy Period. Part III of the Schedule
You may cancel this Policy any time before date of expiry of insurance by giving us 15 days
written notice and in such case We shall refund premium on short term basis for the unexpired
Policy Period provided no claim has been reported on your behalf under the Policy

General Conditions under

6 Extension l If applicable under your policy, kindly approach the nearest branch for the extension of policy.
Part II of the Schedule

(LEGAL DISCLAIMER) NOTE: The information must be read in conjunction with the product brochure and policy certificate. In case of any conflict between the KIS
and the policy certificate, the terms and conditions mentioned in the policy certificate shall prevail.

Note: Description of covers provided in policy wordings (Part II of the Schedule) will be applicable only to the covers mentioned on your policy certificate. Insurance
is the subject matter of the solicitation. IRDA Reg. No. 115. Misc 110