Group Activ Travel - Certificate of Insurance

Aditya Birla Health Insurance Co. Limited, 10th Aditya Birla Health Insurance Company Limited, 7th floor,
Policy Servicing
Policy Issuing Office Floor, R-Tech Park, Nirlon Compound, C building, Modi Business Centre, Kasarvadavali,
Office
Goregaon East, Mumbai- 400063 Mumbai, Thane West - 400615

Policyholder's Name ANI Technologies Private Limited. Policy Number 63-20-00002-00-00

Regent Insignia, 4thBlock, 17th Main, 100 Feet

Certificate
Policyholder's Address Road Koramangala, Bengaluru, Karnataka GAT-OLA-4912047988
Number
560034

Product Name Group Activ Travel Intermediary Code NA

Policy start date 10 Sep 2020 Policy end date 09 Sep 2021

Name & Residential Address of Insured

Abhinay Anand ,India
Person

Communication Address of the Insured

Person (Please mention if different than India
Residential Address)

Geographical Scope Domestic Passport No NA

Unique Identification 4912047988 Coverage Type Individual

Insured Person
Date of purchase of policy 17 Sep 2020 9953820071
Contact Details

Trip Duration 15 Days Trip Type Single

Period of Insurance: From 00:00 hrs on 17 Sep 2020 To 23:59 hrs on 01 Oct 2020 (both days inclusive)

Insured Person Details

Member ID Insured Person Name Date of Birth Gender Nominee Name Relationship

GAT-OLA-4912047988 Abhinay Anand - - Legal Heir Others

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

Medical Cover In-patient Care with Day Care treatment(For Emergency Care) Indemnity Nil Nil 25000

Waiting Periods
Initial Waiting Period NA

Pre-Existing Disease Details

NA NA

Restrictions / Sub-Limits on Medical Expenses

Medical Expenses Sub limits

NA NA

Premium Details
Particulars Amount (Rs.)

Net Premium 5

CGST (9%) -

SGST / UTGST (9%) -

IGST (18%) 1

Gross Premium 6

GST Registration No.: AANCA4062G Category: General Insurance SAC Code: 997133

Claim Assistance
Address for Correspondence Tower D, 4th Floor, IBC Knowledge Park, 4/1 Bannerghatta Road, Bangalore, 560029

Contact Number 1800-425-9449

 Fax Number

Email ID info@mediassist.in

Underwriter Notes

Pre-existing diseases/ conditions will not be covered under any condition

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 MH002366280202021M dated 20/07/2020, received from Stamp Duty Authorities vide Receipt No./GRASS DEFACE NO
0001461475202021 dated 17/08/2020, payment has been made vide Letter of Authorisation No. CSD/75/2020/180 3/2020 dated 07/09/2020 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:
care.healthinsurance@adityabirlacapital.com 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 seniorcitizen.healthinsurance@adityabirlacapital.com 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 carehead.healthinsurance@adityabirlacapital.com. 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 Policy 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: 63-20-00002-00-00

Date: 23 Oct 2020 Place: Mumbai

***** This is a computer generated certificate and does not require any signature *****

Group Assure COVID-19