GROUP DOMESTIC TRAVEL ASSURE

Certificate Of Insurance
Intermediary/ Broker Name: REHANA SULTANA
Intermediary/Broker License Number: 2777175
Intermediary/Broker Contact No.: 9566068546
Insured Person Name & Correspondence Address: Dhakshinamurthy Jaganathan
Old no 2 new no 5 flat no 4 navarthna flat krishnamachari street radha nagar
Chrompet
CHENNAI
TAMIL NADU
600044
Insured Person E-mail id: [email protected]
Insured Person Date of Birth: 05-08-2003
Insured Person Contact No: 8122491044
Policyholder name & Correspondence Address: TRAVEL ASSURE
1ST FLOOR, OLD NO 20, NEW NO 35 VEERABADRAN STREE
NUNGAMBAKKAM CHENNAI, TAMIL NADU
CHENNAI
TAMIL NADU
600034
Place of Supply: TAMIL NADU
State Code: 31
Issuing Office : CHENNAI
Servicing Office : CHENNAI

Policy Number : 0239760012

Certificate Number : 50000005
Proposal Number : PR/24/7200667285
Partner Application number :
For policy details, Please
scan the QR code

Age : 20
Description of the Insured : 841567144898
Relationship Type : Non Employer Employee
Purpose Of Trip: Business
Nature of Trip: One way trip
City/State/Zone: INDIA
Number of Travel days : 3
Round Trip : 3
AMT :
Place Of Origin : Chennai
Place of Destination : Trichy
Policy Issue Date : 12-04-2024
Certificate Issue Date : 10-05-2024
Policy Period Start Date From: 12-04-2024 Policy Period End Date To : 11-04-2025
Cover Period From: 10-05-2024 Cover Period To : 12-05-2024
Premium Details
Particulars Amount (Rs.)
Net Premium 1,525.42
GST as Applicable 274.58
Gross Premium 1,800.00
Insured Person Details
S.No NAME GENDER DOB NOMINEE
1 Dhakshinamurthy Jaganathan Male 05-08-2003 Jaganathan
2 Mallieswari Mallieswari Female 17-07-1954 Subramaniyan V
3 Sasikala Sasikala Male 20-12-1957 Sreedhar Balakrishnan
4 Rajeswari B Female 18-05-1965 Paritosh
5 Naveen Ravikumar Male 23-06-2002 Ravikumar
6 Achuthan Balasubramaniyan Male 11-08-2007 Balasubramaniyan
7 Parvathi Shanmuga Sundaram Female 18-11-1958 E Shanmugasundaram
8 K Sundari Male 28-02-1963 R Srinivasan

TATA AIG General Insurance Company Limited

Registered office : Peninsula Business Park, Tower A,15th Floor, G.K Marg,Lower Parel, Mumbai-400013
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen) Fax : 022 6693 8170 Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No : 108 CIN : U85110MH2000PLC128425 PAN : AABCT3518Q UIN : TATTGDP23099V022223
Group Domestic Travel Assure
Page 1 of 5
 9 D R Harindranath Male 22-01-1959 Paritosh
10 Azhagu Lekshmi M Female 12-10-1956 M Kokila
11 Kalyani K Female 24-07-1968 Rajesh CK
12 Krishnakumari B Female 07-08-1963 Dhanasekaran B
13 Hariharan Srinivasan Male 30-10-1967 H Shrayanthi
14 Lakshmi Ramamorthy Female 29-04-1970 H Shrayanthi
15 Gomathi S Female 15-04-1965 K Selvaraj
16 Chitra Ravindran Female 05-06-1961 Raman Bharath
17 Ravindran Ravindran Male 05-07-1958 Raman Bharath
18 Aishwarya K Female 01-10-1993 Vijay Lakshmanan
19 R Brindha Female 21-04-1967 K T Dasarathy
20 Kalyanasundaram J Male 09-08-1956 Nagajothi
21 Tamilselvi K Female 06-09-1959 Nagajothi
22 Muthulakshmi Munuswamy Female 26-07-1966 Rekha
23 Latha T Female 22-01-1966 Jayalakshmi
24 G Parthasarathy Male 20-01-1962 Vidhyavadhi
Nominee Details
Name Gender DOB Relationship with Address
Insured Person
Jaganathan Male 01-01-1990 Father Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Subramaniyan V Male 01-01-1990 Spouse Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Sreedhar Balakrishnan Male 01-01-1990 Son Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Paritosh Male 01-01-1990 Paritosh Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Ravikumar Male 01-01-1990 Father Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Balasubramaniyan Male 01-01-1990 Father Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
E Shanmugasundaram Male 01-01-1990 Spouse Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
R Srinivasan Male 01-01-1990 Spouse Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Paritosh Male 01-01-1990 Son Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
M Kokila Female 01-01-1990 Daughter Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Rajesh CK Male 01-01-1990 Son Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Dhanasekaran B Male 01-01-1990 Son Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
H Shrayanthi Female 01-01-1990 Daughter Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
H Shrayanthi Female 01-01-1990 Daughter Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
K Selvaraj Female 01-01-1990 Spouse Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Raman Bharath Male 01-01-1990 Spouse Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Raman Bharath Male 01-01-1990 Spouse Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Vijay Lakshmanan Male 01-01-1990 Spouse Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
K T Dasarathy Female 01-01-1990 Spouse Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Nagajothi Female 01-01-1990 Daughter Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Nagajothi Female 01-01-1990 Daughter Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Rekha Female 01-01-1990 Daughter Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044

TATA AIG General Insurance Company Limited

Registered office : Peninsula Business Park, Tower A,15th Floor, G.K Marg,Lower Parel, Mumbai-400013
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen) Fax : 022 6693 8170 Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No : 108 CIN : U85110MH2000PLC128425 PAN : AABCT3518Q UIN : TATTGDP23099V022223
Group Domestic Travel Assure
Page 2 of 5
 Jayalakshmi Female 01-01-1990 Daughter Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Vidhyavadhi Female 01-01-1990 Spouse Old no 2 new no 5 flat no 4 navarthna flat
krishnamachari street radha nagar chrompet 600044
Plan Name:Travel Assure-20
Coverage Details
Sr. No. Coverage Sum Insured Aggregate Limit Deductible Co-pay Sub limits Conditions
1 Add on-Loss of Checked-in 10,000.00 0 0 0
Baggage
2 Add on-Replacement and 5,000.00 0 100 0
Rearrangement - Business Trip
Only
3 Base Cover-Accidental Death(24 10,00,000.00 5000000 0 0
Hours)
4 Add on-Adventure Sports Cover 0.00 0 500 0 Included
Medical
Expenses -
Accident only
5 Add on-Hijack Daily Allowance 2,000.00 0 0 0 Deductible 1
day
6 Add on-Accommodation 10,000.00 0 100 0
cancellation
7 Base Cover-Hospital Daily Cash- 1,000.00 0 5 0 Deductible in 5
Accident only days
8 Add on-Common Carrier Delay 7,500.00 0 0 0 Flight delay
only Deductible
5 hours
9 Add on-Delay of Checked-in 2,500.00 0 0 0 Deductible 5
baggage hours
10 Add on-Compassionate Visit 20,000.00 0 100 0
Travel
11 Add on-Trip Cancellation 10,000.00 0 1000 0
12 Base Cover-Medical Expenses - 5,00,000.00 0 500 0
Accident Only
13 Add on-Electronic Equipment 10,000.00 0 0 0
Cover
14 Add on-Loss of Baggage and 10,000.00 0 100 0
Personal Effects
15 Add on-Personal Liability 1,00,000.00 0 100 0
16 Extension-Permanent Partial 10,000.00 0 0 0
Disability
17 Extension-Permanent Total 1,00,000.00 0 0 0
Disability
18 Add on-Home Content Burglary 1,00,000.00 0 1000 0
19 Add on-Trip Interruption 10,000.00 0 100 0
20 Extension-Outpatient Expenses- 50,000.00 0 500 0
Accident only
21 Add on-Missed Flight / Cruise 2,500.00 0 0 0
Conditions (if any):
ADD ON LOSS OF CHECKED IN BAGGAGE PER ARTICLE PER BAG LIMIT 10 PERCENT TO 50 PERCENT MAXIMUM TRIP DURATION PER
PERSON PER TRIP 180 DAYS AGGREGATE LIMIT INR PER INCIDENT FOR ACCIDENTAL DEATH IS 5000000
Insurance is the subject matter of solicitation. For complete details please refer to the Policy.
"For complete benefits, terms & conditions please refer the below link."
https://www.tataaig.com/s3/Group_Domestic_Travel_Assure_Base_Policy_wordings_8dd796ee58.pdf
The Certificate of Insurance has to read in conjunction with the Policy Wordings. Only the benefits/covers opted and mentioned in this Certificate of
Insurance will be applicable.
Claims Administrators Details
Address for Reimbursement Claim (For Insured only)
Claims Department
Tata AIG General Insurance Company Ltd 7th and 8th Floor, Romell Tech Park, Cama Industrial Estate, Western Express Highway, Goregaon(E),
Mumbai, Maharashtra 400063 Visit our website :www.tataaig.com OR Email at [email protected]. OR Call our 24x7 toll free helpline
1800-266-7780 (Accessible from all lines) OR 1800-22-9966 (Accessible from BSNL/MTNL Lines)

TATA AIG General Insurance Company Limited

Registered office : Peninsula Business Park, Tower A,15th Floor, G.K Marg,Lower Parel, Mumbai-400013
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen) Fax : 022 6693 8170 Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No : 108 CIN : U85110MH2000PLC128425 PAN : AABCT3518Q UIN : TATTGDP23099V022223
Group Domestic Travel Assure
Page 3 of 5
 Policy Servicing/Grievances/Complaints:
The Company is committed to extend the best possible services to its customers. However, if you are not satisfied with our services and wish to
lodge a complaint / claim, please feel free to call our 24X7 Toll free number 1800-266-7780/022-66939500 (tolled) or you may email to the customer
service desk at [email protected].. Senior citizens can call our dedicated line at 1800 22 9966. Please refer The Company’s website for
the detailed grievance redressal policy.
Prohibition of Rebates – Section 41 of Insurance Act, 1938 as amended by Insurance Laws I Amendment) Act, 2015.
No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an
insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any
rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except
such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer.
Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.

docit-digital-sign
Digitally Signed by: Malpa Devi Maharana
Date: 10-05-2024
Location: Mumbai

For Tata AIG General Insurance Company Limited

Place : CHENNAI
Consolidated Stamp Duty has been paid to the State Exchequer

Policy Servicing Office

2ND FLOOR ,SAMSON TOWERS, 403 L PANTHEON ROAD, EAGMORE,CHENNAI,
CHENNAI-600008 Tel No: 4466841050

Table of Losses - A

Permanent Total Disability

Type of Permanent Total Disability - % of Sum Insured (as specified in Policy Schedule /
Certificate of Insurance)
Actual Loss by physical separation or Functional Loss of both Hands or Both Feet 100%
Actual Loss by physical separation or Functional Loss of sight of Both Eyes 100%
Actual Loss by physical separation or Functional Loss of one Hand and One Foot 100%
Actual Loss by physical separation or Functional Loss of either Hand or Foot and Sight 100%
of One Eye
Loss of Speech and Hearing in Both Ears 100%
Actual Loss by physical separation or Functional Loss of either Hand or Foot 50%
Loss of Sight of One Eye 50%
Loss of Speech 50%
Loss of Hearing in Both Ears 50%
Actual Loss by physical separation or Functional Loss of Thumb and Index Finger of 25%
Same Hand
Quadriplegia 100%
Paraplegia 100%
Hemiplegia 100%
Uniplegia 50%

Table of Losses - B

Permanent partial disability

1. Loss of toes – all 20%
2. Loss of Great Toe 5%
3. Other than great toe, if more than one toe lost, each 1%
4. Loss of Hearing – both ears 50%
5. Loss of hearing – one ear 25%
6. Loss of four fingers and thumb of one hand 40%
7. Loss of four fingers 25%
8. Loss of thumb 15%
9. Loss of index finger 10%
10. Loss of middle finger 6%
11. Loss of ring finger 5%
12. Loss of little finger 4%

TATA AIG General Insurance Company Limited

Registered office : Peninsula Business Park, Tower A,15th Floor, G.K Marg,Lower Parel, Mumbai-400013
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen) Fax : 022 6693 8170 Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No : 108 CIN : U85110MH2000PLC128425 PAN : AABCT3518Q UIN : TATTGDP23099V022223
Group Domestic Travel Assure
Page 4 of 5
 RECEIPT

Receipt No. : 202400003330946 Receipt Date : 10/05/2024

Policy No : 0239760012 50000005

Received with thanks from Dhakshinamurthy Jaganathan a sum of 1,800.00 ( Rupees One Thousand Eight Hundred only) vide instaPolicy,
towards

Sr.No Policy Number Total Premium ₹ Utilized from the receipt for policy ₹ Balance ₹
1 50000005 1,800.00 1,800.00 0.00

Note:
1. This is a computer generated receipt and does not require a signature.
2. Upon issuance of this Receipt, all previously issued temporary receipts, if any, related to this Policy shall be considered null and void.
3. Amounts received by cheque shall be subject to realization.
4. Any amount received in excess of the Premium is being/shall be refunded by the Company.

GSTIN : 33AABCT3518Q1Z3-TAMIL NADU Service Accounting Code : 99713

TATA AIG General Insurance Company Limited

Registered office : Peninsula Business Park, Tower A,15th Floor, G.K Marg,Lower Parel, Mumbai-400013
24x7 Toll Free No: 1800 266 7780 or 1800 22 9966 (Senior Citizen) Fax : 022 6693 8170 Email: [email protected] Website: www.tataaig.com
IRDA of India Registration No : 108 CIN : U85110MH2000PLC128425 PAN : AABCT3518Q UIN : TATTGDP23099V022223
Group Domestic Travel Assure
Page 5 of 5