HUHUNJINJIN

1. Risk Assumption Letter
Dear Sir / Madam,
We thank you for placing this Insurance business with us.
Please find attached herewith Policy No.:4129/107759001/00/000, which has been issued
based on the details furnished to us by insured:
1. Name of the Insured : Ms. Mukta Mehta
2. Mailing Address : Apt. 903, Building 10, Close North|Nirvana Country, Sector
50||Gurgaon, Gurgaon, Haryana-122002, India
3. Telephone No. : NA
4. Mobile No. : 8130972200
5.E-mail Id : tigertrailsolutions@gmail.com
6. Date of Birth : 29-Dec-1941
7. Passport No. : L4399836
8. Nominee Name : Mala Baveja
9. Visa Type : Non Immigrant
10. Period of Insurance/Trip Particulars : From 25-Oct-2015 to 22-Jan-2016 Days 90
11. Geographical Scope : SCHENGEN COUNTRIES
12. Plan Type : SeniorCitizen-S
Please go through the details as furnished in the format and also as provided in the policy document and confirm that
they are in order. Should you feel that there are any discrepancies/variations, you are requested to write back to us
immediately at customersupport@icicilombard.com or call at 1800 2 666 for necessary changes/rectification. In the
absence of any communication from you with in 15 days or before the risk inception date of the policy in this
connection, we would take it that you have accepted the contents and the coverage to be confirming to your proposal.
P l e a s e N o t e : A n y c l a i m d u e t o o r a r i s i n g o u t o f p r e-e x i s t i n g m e d i c a l c o n d i t i o n / a i l m e n t w h e t h e r
d e c l a r e d o r u n d e c l a r e d i s n o t c o v e r e d u n d e r t h e P o l i c y .
It brings us pleasure in announcing that our operations function has been ISO 9001:2000 certified with
effect from 7th September 2004. The certifying agency was Det Norske Veritas (DNV). This would
mean that we would meet the service related promises that we make to our customers.
Thanking you,
Authorised Signatory
ICICI Lombard General Insurance Company Limited.
Corporate Address: Mailing Address
ICICI Lombard General Insurance Company LTD, ICICI Lombard General Insurance Company

2. IRDA Regn. No. 115. LTD.,IRDA Regn. No. 115
ICICI LOMBARD HOUSE , 414, Veer Savarkar 401­402, Interface Bldg; No.11
Marg, Link Road, Malad (West),
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai Mumbai - 400064
400 025
www.icicilombard.com

3. PART 1 OF THE SCHEDULE - INTERNATIONAL TRAVEL INSURANCE
POLICY DETAILS
Policy No.: 4129/107759001/00/000
Period of Insurance/Trip Particulars : From 25-Oct-2015 To 22-
Jan-2016
Midnight (Single Trip) or actual date of arrival whichever is earlier
Insured no of travel days : 90 days
Geographical Scope : SCHENGEN COUNTRIES
P l e a s e N o t e : A n y c l a i m d u e t o o r a r i s i n g o u t o f p r e-e x i s t i n g m e d i c a l c o n d i t i o n / a i l m e n t w h e t h e r
d e c l a r e d o r u n d e c l a r e d i s n o t c o v e r e d u n d e r t h e P o l i c y .
DETAILS OF THE INSURED
Name Ms. Mukta Mehta
Mailing Apt. 903, Building 10, Close
Address North|Nirvana Country, Sector
50||Gurgaon, Gurgaon, Haryana-
122002, India
Plan Name : SeniorCitizen-S
B e n e f i t s
S u m
D e d u c t i b l e s
I n s u r e d
Delay Of Checked-In
USD 100 6 hours
Baggage
USD
Personal Liability 5% of Actuals
100,000
Emergency Cash
USD 1000 NA
Advance
HijackDistress
USD 125
per day for 12 hours
Allowance
max 7 days
Personal Accident USD 2500 NA
Loss Of Passport USD 300 USD 50
Pin Code
Telephone No
Mobile No.
E-mail Id
Date Of Birth
Passport No.
Nominee
Name
IL ID
122002
NA
8130972200
tigertrailsolutions@gmail.com
29-Dec-1941
L4399836
Mala Baveja
985879116
Medical Expenses- US$ 100 (Total amount
(SublimitsAre Not applicable for Medical
ApplicableFor USD 50,000 Expenses alongwith the
Schengen Countries applicable extensions
Upto 85 Years Of Age) under Medical Expenses)
Total LossOf Checked-
USD 500 NA
In Baggage
Trip CancellationAnd
USD 500 NA
Interruption
Missed Flight
USD 500 3 hours
Connection
Trip Delay USD 500 6 hours
Repatriation Of
Remains(Included In USD 7500 NA
Medical Expenses)
Political RiskAnd
Catastrophe USD 7500 NA
Evacuation
Special terms and conditions:
NA
Add on covers: (if any)
The above records details given by the insured pursuant to Clause 4 (4) of the IRDA (Policyholder's
interest) Regulations, 2002. If the information shown above is found to be either incomplete or
incorrect at the time of claim, the same shall be construed as non disclosure of material information.

4. Premium Details in Rs. (for persons)
Service Education
Higher
Start Date End Date Premium Education Net Premium (Rs.)Tax (Rs.) Cess (Rs.)
Cess (Rs.)
Original 25-Oct- 22-Jan-
Rs. 22749.65
Rs.
Rs. .00 Rs. .00 Rs. 26,450.07
Details 2015 2016 3700.42
Details of the member/s insured under the policy:
S. No Name
Relationship with Date of Birth
Passport No. Nominee Name Sum Insured (USD)
primary insured (dd/mm/yy)
1 Mukta Mehta Mother 2 9-Dec-1941 L4399836 Mala Baveja 50,000
F o r I C I C I L O M B A R D G E N E R A L I N S U R A N C E C O . L T D , I R D A R e g n . N o . 1 1 5
Authorised Signatory
Date of Issue: 12-Oct-2015
Time of Issue: 00:00
Place of issuance: MUMBAI
Service Tax Registration No. : GIS/MUMBAI-I/1528/2001
Service Tax Code Number : AAACI7904GST001
Category: General Insurance Business Services 00440005.
The stamp duty of Rs 1.00 paid in cash or by demand draft or by payorder,vide Receipt/Challan no. 3182900 dated 27-Aug-2015

5. KEY INFORMATION SHEET (KIS)
TITLE
1 Product Name
2 What is covered under the policy
What are the major exclusions in
3
the policy
4 Limit Of Covered expenses
DESCRIPTION
REFERENCE
TO POLICY
International Travel Insurance -
 Hospitalisation expenses for Injury/illness during the Part II of
trip schedule
 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
 Allowance for the Delay of Checked-In Baggage
whilst on trip
 Loss of Passport whilst on Trip abroad (Note: This
is an indicative list. The list of benefits applicable
as per your plan is mentioned in Part 1 of the
schedule. Please refer to policy wordings for
details of applicable benefits)
 Any claim due to or arising out of pre-existing
medical condition/ailment is not covered under
the Policy
 Cosmetic treatment or Plastic surgery in any form or
manner
 Cosmetic treatment or Plastic surgery in any form or
manner
Part II of
 Rehabilitation and/or physiotherapy or the costs of
schedule
prostheses/prosthetics(artificial limbs)etc
 Mental or psychiatric disorders; HIV/AIDS
Exclusions to
 Self inflicted injuries; Drug or alcohol abuse
respective
 Partial loss of items in the checked in Baggage
benefits
 Loss of Valuables and money
 Theft of passport unless reported to police within 24
hours
 Any claim arising out of sporting or adventurous
activities/aircraft Operation unless specifically covered
under the policy
S u b l i m i t s a r e n o t a p p l i c a b l e f o r S c h e n g e n
c o u n t r i e s u p t o 8 5 y e a r s
 For policies with sum insured over US$ 100,000, the
benefit of medical expenses is restricted to US$
100,000 per sickness or accident leading to one or
more hospitalizations
 For persons aged 51 years and above, maximum
Part II of
eligible medical expenses are as follows:
schedule
 Hospital Room and boarding,- US$ 1,800
per day up to max of 30 days
Benefit 1- ICU – max US$ 3,250 per day up to max of
7 days Medical
Expenses
 Surgery -Max. upto US$ 15,000

6.  Anesthetist services -max up to
25% of surgical treatment
 Medical Practitioners visit fees - max
US$ 100 per day per visit up to 10 visits
 Diagnostic and radiology services -
Max. US$ 1000
 Ambulance services - Max upto US$ 500
 Misc Expenses - Max upto US $ 2000
-For planned hospitalization cases, you are required to
notify the company at least 5 business days before
admission and for emergency hospitalization, within
business day or as soon as possible before discharge.
 In USA & Canada +1 844 871 1200 (Toll
Free)
5 Claims Contact  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
 E-mail - icicilombard@falck.com
- Special
Conditions
Part II of
schedule
Claims
Information
You can extend the policy online by logging at our
6 Extension Condition website -
www.icicilombard.com
After the journey begins, this policy would be cancelled
Part II of
only if you return to the place of origin 30 days before the
7 Cancellation
schedule
policy end date. No refund will be processed if Claim General
filed on the policy. In case of multitrip , the company will Condition-7
retain premium on short period scales.
An annual cover valid in respect of trips undertaken Part I of
8 subject to the duration of any one trip not exceeding
schedule
Multi Trip 'Maximum Trip Duration'
(LEGAL DISCLAIMER) NOTE: The information must be read in conjunction w ith the product brochure and policy document.
In case of any conflict betw een the CIS and the policy document the terms and Conditions mentioned in the policy document
shall prevail.

7. N a m e : M u k t a M e h t a
P o l i c y N o . : 4 1 2 9 / 1 0 7 7 5 9 0 0 1 / 0 0 / 0 0 0
D a t e O f B i r t h : D e c e m b e r 2 9 , 1 9 4 1
V a l i d F r o m : O c t o b e r 2 5 , 2 0 1 5
V a l i d T o : J a n u a r y 2 2 , 2 0 1 6