COMPREHENSIVE TRAVEL PROTECTION

TRAVEL PROTECTION CARD

NAME : SANTOSH KUMAR
A S S I S T N O.
1100101667314/EN1
ADDRESS : FLAT NO D-401, PLOT-79, VIDISHA, CGHS
PATPARGANJ IP EXTENSION DELHI-110092 S TA RT D AT E E N D D AT E
15/04/2025 28/04/2025
Assist Fees : 1434
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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

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24x7 helpline: +91 8448582205 Note: Assistance provided by Asego Global
Assistance Private Limited, Insurance underwritten
Assistance: [email protected] by ICICI Lombard General Insurance Company Ltd.
Claims: [email protected] Customer will bear any cost or expenses arising
from availing the assistance services through a
Whatsapp message only for claims: +91 86478 34444 third par ty service provider.

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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 :SANTOSH KUMAR Date of Birth:15/11/1982 Age:42
Address :FLAT NO D-401, PLOT-79, VIDISHA, CGHS PATPARGANJ IP EXTENSION . Delhi-110092
Travel Assure - Group Overseas Travel Insurance Mobile no : Landline no :
E Mail :Na CR no :
Passport Number:C0883555 Issue Date :08/04/2025

Occupation Income per annum

CKYC/Driving Gender:
CKYC no. License/Aadhaar/Election
Card/Passport/MNREGA Card No.:
Certificate No : SX101667314 Intermediary Code :IM-2235173
Travel Assure - Group Overseas Travel Insurance Intermediary Name : ASEGO INSURANCE LLP
Th is Grou p Travel I n su ra nce p olicy 4 1 9 8 /O/3 8 2 0 5 4 1 8 9 /0 0 /0 0 0 d ated 0 1 - 0 3 - 2 0 2 5 h a s b een issu ed at Mu m b a i by I C I C I Lom b a rd Gen era l I n su ra n ce C om p a ny Ltd . to t h e m a ster
p olicy h old er, Asego Glob a l Assista n ce Pr ivate Lim ited . a n d gover n ed by t h e ter m s, con d it ion s a n d exclu sion s t h erein conta in ed or ot h er wise exp ressed in t h e sa id cer t ificate,
b u t n ot exceed in g t h e Su m I n su red a s sp ecified in t h e Sch ed u le. Th is C er t ificate, issu ed u n d er t h e fa csim ile sig n at u re of I C I C I Lom b a rd Gen era l I n su ra n ce C om p a ny Ltd .
rep resent s t h e ava ila b ilit y of b en efit to t h e a b ove m ent ion ed I n su red Person . Th rou g h t h e m a ster p olicy h old er I C I C I Lom b a rd Gen era l I n su ra n ce C om p a ny Ltd . h a s received a n
a m ou nt of Rs. 3 8 2 . 0 0 (I n cl GST @ 1 8 %) towa rd s cover in g t h e r isk b en efit s, on b eh a lf of t h e a b ove m ent ion ed in su red .

Insurance Details :
Commencement Date:From: 15/04/2025 End Date: mid-night on: :28/04/2025 No. of Days:14
Policy Name :IC Single Trip : SP Lite 2 150000 Geographical Coverage :Excluding USA and CANADA
Assignee :PRITI SHAH Relation :Wife
Pre-existing Illness Yes/No:No Exclusions :

Politically Exposed Person (PEP)/close relative of PEP: No

Coverages Sum Insured Deductibles Coverages Sum Insured Deductibles

Emergency Medical Expenses Emergency
Medical Evacuation Repatriation of Mortal USD 150000 USD 100 Dental Treatment Expenses USD 500 USD 100
remains
USD 35 per
Daily Allowance in case of Hospitalization day upto 5 2 days Compassionate Visit USD 1500 NA
days
Personal Accident,Accidental Accidental Death -Common Carrier
Death,Permanent Total Permanent Total Disability-Common Carrier
USD 15000 NA USD 2500 NA
Disability(PTD),Permanent Partial Permanent partial Disability -Common
Disability(PPD) Carrier
USD 50 per
Hijack Distress Allowance day upto 4 12 Hrs Total Loss of checked in Baggage USD 1000 NA
days
Mugging Benefit USD 500 NA Trip Cancellation and/or Interruption USD 1000 USD 100
Missed connection USD 500 3 Hrs Flight Delay (Airlines) USD 500 3 Hrs
Over Booked-Common Carrier USD 500 6 Hrs Bounced Hotel Booking USD 500 USD 100
Personal Liability USD 200000 USD 100 Legal Expenses USD 1000 USD 100
INR As per INR As per
Home Burglary Insurance (Contents) INR 100000 erst while fire Home Fire Insurance (Contents) INR 100000 erst while fire
tariff tariff
USD It ’s a
part of
Automatic Extensions NA Travel Inconvenience USD 500 USD 100
medical cover
upto 7 days
Trip Delay USD 100 3 Hrs Loss of Passport and Documents USD 300 USD 25
Emergency Financial Assistance USD 500 NA Delay of Checked-in Baggage USD 100 12 Hrs

Nominee Details :
Nominee Name 1. PRITI SHAH 2. 3. 4.
Gender
Relationship with Nominee Wife
Date of birth of nominee
Percentage of nomination 100%
Mobile no. of nominee
Email id of nominee
Present and permanent address of nominee

Appointee Details: (If nominee is minor)

Appointee Name 1. 2. 3. 4.
Gender
Relationship with Appointee
Date of birth of Appointee
Percentage of Appointee
Mobile no. of Appointee
Email id of Appointee
Present and permanent address of Appointee

PAST INSURANCE DETAILS

Sr no. Policy Period Insurance Company Product name Date of issuance of first policy Premium Paid Claims

Bank Details of insured

Insurer Nominee Appointee
Beneficiary name
Bank Name:
Branch:
Bank Account Number
MICR Number
IFSC Code

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 : [email protected]
OR Login to the e-claim link https://fgaindia.com/FalckMLink/Register.aspx

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 Global Assistance Private Limited.
• 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 10000 per policy or
upto 10% 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
1500 for the above 81-85 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
• 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 A pplica ble- from 6 1 Yea rs- 8 0 Yea rs
Room Rent in clu d in g B oa rd in g lod g in g $ 1 5 0 0 /d ay u p to 3 0 d ays
I nten sive C a re u n it $ 3 0 0 0 /d ay u p to 7 d ays
Op erat ion Th eat re ch a rges (I n clu sive su rgeon ch a rges)” Maxim u m Up to USD 1 0 0 0 0
An est h et ist ser vices Up to 2 5 % of Su rg ica l Treat m ent
Physicia n V isit Max $ 7 5 /d ay u p to 1 0 visit s
Dia g n ost ic a n d Ra d iolog y ser vices Max u p to USD 1 0 0 0
Am b u la n ce Ser vices Max u p to $ 5 0 0
Hosp ita l Miscella n eou s Exp en ses Maxim u m of USD 1 0 0 0
• 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.

Au t h or ised Sig n ator y

Sca n t h e cod e of a u t h ent icate (I C I C I Lom b a rd Gen era l
p olicy I n su ra n ce C om p a ny 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.
•• Treat m ent a b roa d if t h at is t h e sole rea son or on e of t h e rea son s for t h e I n su red /I n su red p erson ' s tem p ora r y stay
a b roa d • Any cla im if t h e I n su red Person 1 . I s t ravellin g a ga in st t h e a d vice of a Med ica l Pra ct it ion er ; 2 . I s receivin g , or is
on a wa it in g list to receive, sp ecified m ed ica l t reat m ent d ecla red in t h e Med ica l Pra ct it ion er ’s rep or t or cer t ificate;

• Ha s received ter m in a I p rog n osis for a m ed ica l con d it ion ; I s ta k in g p a r t in a n ava I , m ilita r y or a ir force Op erat ion . •
1 Gen era l Exclu sion s
C on gen ita l ex ter n a l d isea ses, d elect s or a n om a lies • Disea ses, illn ess a n d a ccid ent s t h at a re resu lt s of wa r a n d wa r like
occu r ren ce or inva sion , a ct s of foreig n en em ies, h ost ilit ies, civil wa r, reb ellion , in su r rect ion , civil com m ot ion a ssu m in g
t h e p rop or t ion s of or a m ou nt in g to a n u p r isin g , m ilita r y or u su r p ed p ower, a ct ive p a r t icip at ion in r iot s, confiscat ion or
n at ion a lizat ion or req u isit ion of or d est r u ct ion of or d a m a ge to p rop er t y by or u n d er t h e ord er of a ny gover n m ent or
loca l a u t h or it y.
For a ny cla im related q u er y, int im at ion of cla im a n d su b m ission of cla im related d ocu m ent s you m ay conta ct ou r
Em ergen cy Assista n ce Ser vice Provid er.
I n ca se of a cla im , you m ay rea ch u s at 8 4 4 - 6 9 1 - 8 8 8 3 (For C a n a d a ), 8 4 4 - 6 9 1 - 8 8 8 5 (For USA) or +9 1 1 1 4 2 2 2 1 4 0 3 (For
2 N ot ice of C la im ot h er p a r t s of t h e wor ld ) or em a il u s at cu stom ersu p p or t @icicilom b a rd . com
Alter n at ively you ca n conta ct u s t h rou g h : Toll Free - 1 8 0 0 2 6 6 6
Em a il - cu stom ersu p p or t @icicilom b a rd . com Post /cou r ier to C om p a ny - I C I C I Lom b a rd Gen era l I n su ra n ce C om p a ny Ltd . ,
I C I C I B a n k Tower, Plot N o. 1 2 , Fin a n cia l Dist r ict , N a n a k ra m Gu d a , Ga ch ib owli, Hyd era b a d - 5 0 0 0 3 2
Cla ims Proc edure
C la im s (if a p p roved ) sh a ll b e p a id t h rou g h C a sh less fa cilit y or Reim b u rsem ent of b en efit s, u p to a n a m ou nt a s sp ecified
for sa id cover.
Tu r n Arou n d Tim e(TAT) for cla im sett lem ent s-
C a sh less C la im s: N ot if y u s t h rou g h ou r Assista n ce Ser vice Provid er wit h in 2 4 h ou rs of em ergen cy h osp ita lizat ion to ava il
3 Cla im Proc edure & Docu m entat ion ca sh less fa cilit y. I f You n ot if y p re a u t h or izat ion req u est for ca sh less fa cilit y t h rou g h ou r Assista n ce Ser vice Provid er
a lon g wit h com p lete set of d ocu m ent s & infor m at ion , We will d ecid e wit h in 1 h ou r of t h e a ct u a l receipt of su ch p re
a u t h or izat ion req u est . Fu r t h er, we sh a ll g ra nt fin a l a u t h or izat ion wit h in t h ree h ou rs of t h e receipt of d isch a rge
a u t h or izat ion req u est from t h e h osp ita l.
Reim b u rsem ent C la im s: C la im s will b e p rocessed wit h in 1 5 d ays from receipt of cla im a lon g wit h cla im for m a n d
d ocu m ent s. Rea son s for rej ect ion s (if a ny ) will b e p rovid ed .
For Deta iled Ter m s & C on d it ion s of you r Travel I n su ra n ce Policy Kin d ly C lick h ere
or p a ste t h e lin k htt ps: //a sego. co/a segot ravel/n ew/Travel- Assu re- OV R- p olicy- word in g s. p d f on you r b rowser.

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I C I C I Lom b a rd Website: w w w. icicilom b a rd . com ; I RDAI Reg ist rat ion N o: 1 1 5 , Em a il: cu stom ersu p p or t @icicilom b a rd . com
I C I C I Lom b a rd Gen era l I n su ra n ce C om p a ny Ltd . , , I C I C I Lom b a rd Hou se, 4 1 4 , Veer Sava r ka r Ma rg , Pra b h a d evi, Mu m b a i – 4 0 0 0 2 5
UI N : I C I TGOP2 2 2 0 3 V 0 2 2 1 2 2 , C I N : L6 7 2 0 0 MH2 0 0 0 PLC 1 2 9 4 0 8