Important Notice

Policy Details

Generation Date: Name of Insured: Address:

25-Oct-2012 MADHURI SHEKHAR CHAVAN 117/6, Umergaon Building Dr. B. A. Road, Mumbai, MAHARASHTRA - 400012.

Dear MADHURI SHEKHAR CHAVAN,

We thank you for utilizing the online services of Bajaj Allianz General Insurance Co. Ltd.This has reference to your policy

number OG-13-9906-9910-00009982 for your Travel Insurance.

Enclosed please find the policy schedule, policy wordings containing detailed terms and conditions of the coverages and the online Proposal Form cum declaration submitted by you, before buying the policy. We wish to inform you that the premium quoted is based on the information submitted in the proposal forms as well as the acceptance of the terms and conditions online. Request you to kindly go through the same once again & in case of any disagreement/discrepancy/clarifications please call us on our toll free number 1800-233-3355 or log on to www.bajajallianz.com or revert back within 15 days of the letter date.

Please note that the information provided by you will be verified at the time of claim & the insurance cover available to you (or other person or categories of person covered in the policy) shall become void in the event of any untrue or incorrect statement, misrepresentation, non description or non-disclosure in any form what so ever.

As a valued customer, we would like to provide regular updates on your policy, launch of new products and promotions so that you can take advantage of the same. However if you do wish not to receive any such updates, we would request you to please register for 'Do Not Call' registry on our website www.bajajallianz.com .

Assuring you of our best services always and thanking you once again for insuring with us. With Best Regards,

Ms Anamika Rashtrawar

Head - Corporate & Direct marketing

Bajaj Finserv,1st Floor , Survey # 208/1-B, Behind Weikfield IT-Park, Viman Nagar, Pune-411014

Proposal Form For Travel Policy

Policy Details Insured Name Telephone No Email Return Date Date of Birth Travel Plan MADHURI SHEKHAR CHAVAN 9820974304 info@cosmeticagroup.net 12-NOV-12 23-APR-76 TravelEliteGold(US$200000) Premium Excluding Service Tax(INR) 859 Address Details Mobile No Departure Date No of Journey Days 37, Jehangir Building, Jehangir Merwanji Street, Mumbai 9820056498 27-OCT-12 17

Required Details to Issue Policy Passport No F3356797 Name of Nominee Shekhar Ramrao Chavan

Family Physician/Doctor Details Name Address Terms And Conditions I Hereby declare & warrant that 1. The reply to the above statements are true and that i have not withheld any information whatsoever 2. I will not be travelling against the advice of a physician 3. I understand that this policy does not cover any pre-existing medical condition/injury/deformity that are declared or undeclared 4. I will not be travelling for the purpose of obtaining medical treatment 5. I consent to Bajaj Allianz General Insurance Company Ltd. seeking medical information from doctor who has anytime attended me, in respect of any matter relating to my physical or mental health and well being and I authorize consent to him giving such information to BAGICL and / or to its claims administrator or medical advisors. Are you suffering or have you even suffered from any illness/disease/ailment upto the date of making this proposal or suffer from physical defect or deformity? Have you been admitted to any hospital/nursing home/clinic for treatment or observation? Proposer is already travelled from india and is abroad at the time of proposing for the policy ? I agree to the terms and conditions Personal Information Policy Address Address Line City State Mobile Telephone (Off.) 37, Jehangir Building, Mumbai MAHARASHTRA 9820056498 24144859 Street Name Area Pin code Telephone (Res.) Jehangir Merwanji Street, Parel 400012 24142644 N N N Y DR NIRAV P SHAH Telephone 27657562

Shree Ganesh Clinic, Abhimanyu Co-op Hsg. Society, Sector 29, Vashi, Navi Mumbai 400705

Where would you like to have the policy delivered Housing/Building City State Time of Availability Date: 25-Oct-2012 117/6, Umergaon Building Mumbai MAHARASHTRA Street Name Area Pin code Dr. B. A. Road, Parel 400012

Bajaj Finserv,1st Floor , Survey # 208/1-B, Behind Weikfield IT-Park, Viman Nagar, Pune-411014

Bajaj Allianz General Insurance Company Ltd. Bajaj Finserv,1st Floor Survey # 208/1-B Behind Weikfield IT-Park Viman Nagar 411014 Pune - 411014 Ph. No.020-66495000

Receipt
Receipt Number: 9906-00125333 Receipt Date: 25-OCT-2012 Business Channel: WS

Received with Thanks from: MADHURI SHEKHAR CHAVAN (Customer ID : 46926830 ) a total sum of Nine hundred sixty-five rupees only .

Instrument Type CREDIT CARD Total Amount Received for this Policy

Instrument Date 25-OCT-12

Amount 965 965

Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General Insurance Company Limited. The insurance cover for the risk shall be as per the terms and conditions of the Insurance Policy if and when issued. * Receipt Subject to realisation of cheque(s) Please note: This is an electronically generated receipt and does not require signature.

Regd Office : GE Plaza, Airport Road, Yerwada, Pune - 411 006

Bajaj Allianz General Insurance Company Ltd.

Regd.Office - GE Plaza, Airport Road, Yerwada, Pune - 411006 (India)

TRAVEL COMPANION IDENTIFICATION AND SCHEDULE

Policy Details Reference No
Policy No : Home Address : Pincode : Subcode Partner Id

Y
OG-13-9906-9910-00009982 Insurance Plan Chosen : TravelEliteGold(US$200000) 55555557 ExcludingUSA

37, JEHANGIR BUILDING, JEHANGIR MERWANJI STREET, MUMBAI 400012 Imdcode : 9906 Telephone No. 46926830 Geographical Coverage

BENEFITS Limits (Max for entire policy period) Personal Accident USD 25000 AD & D Common Carrier USD 5000 Loss of Checked-in baggage(Per baggage maximum 50% and per item in USD 1000 baggage maximum 10%) Delay Of Checked Baggage USD 100 Loss Of Passport USD 250 Hijack $60 per day to max $360 Trip Delay $30 per 12 hrs to max $180 Personal Liability USD 200000 Emergency Cash Advance( would include delivery charges) USD 1000 Golfer's Hole-in-one USD 500 Trip Cancellation USD 1000 Home Burglary Insurance Rs. 200000 Trip Curtailment USD 300 Hospitalization Daily Allowance $25 per day to max $125 Medical Expenses, Evacuation & Repatriation of remains (Max limit for USD 200000 emergency dental treatment is US$500(Included in Medical Expenses)) Base Premium (in Rupees) : 859 Service Tax (in Rupees) : 103 Edu Cess (in Rupees) : 3 Total Premium (in Rupees) : 965 Date of Purchase of Policy : 25-OCT-2012 Policy Period : From 27-OCT-2012 to Or Date of return of Insured, whichever is earlier. 12-NOV-2012 Claims Assistance Department : 24 hours Helpline : Email : Policy Servicing Office :

DEDUCTIBLE

12 Hours USD 25 12 Hours USD 100

USD 100

Health Administration Team Telephone No +91 20 3030 5858,Fax No: +91 20 3051 2207 travel@bajajallianz.co.in Bajaj Allianz General Insurance Company Limited, Ground Floor, Ashoka Plaza, 32/2, Nagar Road, Nr. Weikfield Company, Pune 411014 IMPORTANT :Policy is not valid for visit to Afghanistan,Chad,Democratic Republic of Congo,Iran,Israel,Nigeria,Pakistan,Somalia and Sudan. The policy coverages are as per the policy terms and conditions mentioned in the Travel Kit provided with this policy schedule. You may refer the same on our website as well. Always and COMPULSORILY first contact the 24 hours helpline and obtain prior notification number from HELP LINE before incurring any expense. For all claims Please quote the claims notification number and submit claim forms with original medical bills. The coverage provided is subject to details and declaration in the proposal form given prior to taking this policy and attached policy wordings. Extension Process : In case of any claim, please contact our 24 Hour Call centre at 1800-22-5858, 1800-102-5858 (Toll Free) / 91-020-30305858 (chargeable, add area code before this number in case of mobile call) or email us at 'info@bajajallianz.co.in'. For any claim or policy related queries, please call us at +91 20 3030 5858(chargeable) or Toll Free Nos. mentioned on the travel kit. Alternately you may mail us your query at travel@bajajallianz.co.in.

For & Behalf of Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory

QC signed and verified Bajaj Finserv,1st Floor , Survey # 208/1-B, Behind Weikfield IT-Park, Viman Nagar, Pune-411014

Agency Code : Contact No :

Agency Name : Email :

9906-00125333/21439071/965(INR) (If Premium is paid through cheque the policy is void ab-initio in case of dishonor of chq.) Declaration by the insured : We understand that this policy has been issued based on the information provided by us/our representative and the policy is not valid if any of the information provided is incorrect.We also understand that this policy does not cover pre-existing illnesses or disability or conditions arising there from as per terms and conditions mentioned in the policy Policy is valid only if countersigned by the insured in the space above accepting this declaration Signature of Insured

Service Tax Reg. No. : AABCB5730G-ST-001

This Policy of Insurance is a Contract between the Company and the Insured Person(s). The Insured Person(s) shall not transfer, assign, alienate or in any way pass the benefits and/or liabilities to any other person, Institution, Hospital, Company or Body Corporate without specific prior approval in writing by a duly authorised officer of the Company. However, if the Insured Person(s) is permanently incapacitated or deceased, the legal heirs of the Insured may represent him in respect of Claim under the Policy.