STAR STUDENT TRAVEL PROTECT

Policy Schedule
Unique Identification No.IRDA/NL-HLT/SHAI/P-T/V.I/142/13-14
Corporate Office, No. 1, New Tank Street, Valluvar Kottam High Road,, Nungambakkam,, Chennai - 600 034., 600034, INDIA
The Proposal and Declaration and Annexure thereto together with any statement, report or other document leading to the issue of this Policy shall
form the basis of this policy and are deemed to be incorporated herein. In consideration of the payment of the required premium the Company agrees
subject to the terms, conditions and deductibles provided under this Policy to pay the sum insured or the appropriate benefit to the Insured Person
named in the Schedule or his/her legal representatives.

Provided the insurance hereunder is only with respect to such benefits as are indicated by specific amount set against each benefit mentioned in the
Schedule. The Policy, Schedule, attached proposal forms, endosements, procedures and riders shall be read together.
Policy No. : P/171216/03/2019/000117 Date Issued : 22/02/2019
Customer's Code/Name : AA0008330089 - MALAVIYA AVAKASH CHATURBHAI

Proposer's Code : 10795337 Proposer Name : MALAVIYA AVAKASH CHATURBHAI

Address : 44,JAI BAJRANG CO-OP SOCIETY,B/H Fulfiller Code : SH10627
MALEK SABAN STADIUM, :
Issue Office Code 171216
BAPUNAGAR, Issue Office Name : Branch Office - Naroda
AHMEDABAD
Ahmadabad (M Corp.+OG) GSTIN : 24AAJCS4517L1Z4
(Part),Ahmadabad,Gujarat-380024 SAC : 997136/Freight Insurance Services &
Tel /Mobile : NA/7874625743/
Travel Insurance Services
E-mail Id : Address : B/5,Sardar Patel Mall,Diamond Mill
iamavakash@gmail.com
Mobile No-in Overseas Nicol Gam Road,Naroda
: NA/7874625743/
Ahmedabad-382350
--
Tel/Mobile : 079 - 22706070-80-90 / /
naroda.ahmedabad@starhealth.in
Cover Note No. :
--
Cover Note Date :
Receipt No/Date. :
1261007339 - 22/02/2019
Proposer GSTIN : - Place of Supply : -

Intermediary Code/Name : BA0000039979/JIGARKUMAR PATEL

Intermediary Tel/Mobile : 07922706080/9727770935
Intermediary Email : care.suvidha@yahoo.com
Insured/Travel Details
Name of the Insured : MALAVIYA AVAKASH
Plan : GOLD
CHATURBHAI
Sex : MALE Sum Insured : 100000

Date of Birth : 22/09/1994 Medical Report attached : NO

Age - Yrs : 24 Does your trip include USA . :
NO
Passport Number : N0872705 Date of Commencement : 01/03/2019
Date of Expiry : 08/07/2025 Cover Valid not beyond : 29/05/2019 both days inclusive
Place of Issue : AHMEDABAD Days of Travel : 90
Visa Type : STUDENT Purpose of Travel : STUDY
Special Exclusions*** : NIL Country of Visit : France
Name of the Sponsor : -- Address in country of Study : 1,RUE BOUGAIBVILLE-757007 PARIS,

Address of the Sponsor : -- Name of the Institution : ECOLE SUPERIEURE LIBRE DES
SCIENCE COMMERCIALES
APPLIQUEES
Relationship with the : -- I-20 No : --
Sponsor
Coverage and Deductibles: Gross Premium : 1,439
Benefits Sum Insured in Deductible / Excess per
USD claim in USD
Emergency Medical Expenses M1,Emergency Medical 1,00,000 100 Stamp Duty : 1 /-
Transportation Expenses M2,Repatriation Of Mortal
Total : 1,699 /-
Remains M3
Dental Emergency Assistance M4 250 30 CGST @9% : 130 /-
Personal Accident A1 5,000 0
Loss of Checked-In Baggage T1 400 0 SGST / UGST @9% : 130 /-
Loss of Passport T2 150 15
Total pemium : 1,699 /-
Personal Liability L1 10,000 0
Bail Bond L2 5,000 0
Compassionate Visit Two Way S1 5,000 0
Study Interruption S2 5,000 0
Sponsor Protection S3 5,000 0

Signed for on and behalf of

IRDAI Regn. No 129 Star Health and Allied Insurance Company Limited
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in
Authorised Signatory
Please see overleaf
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 Important:
1. The benefit under this Policy is not applicable for Indian citizens going abroad for the purpose of any employment including but not limited to persons holding
Emigrant Visa(s).
2. It is mandatory to contact first the 24 hr Alarm Centre / Claims Assistance Company's Nos. stated below and take prior authorisation from the Claims
Assistance Company before incurring any expense.Warranted that in case of dishonour of premium cheque(s) the Company shall not be liable under the
policy and the policy shall be void abinitio (from inception).
General Condition No. 11 regarding delay in payment of claim shall read as follows and not as stated in policy wordings:
"The Company shall pay interest as per Insurance Regulatory and Development Authority of India (Protection of Policyholders' Interests)
Regulations, 2017, in case of delay in payment of an admitted claim under the Policy"
Sector Classification :
Urban

Please check whether the details given by you about the Insured persons in the Proposal Form and the Medical report findings, if any ,are
incorporated correctly in the Policy.If you find any discrepancy , please inform us within 7 days from the date of receipt of the policy, failing which the
details relating to the Insured persons given in the Policy are deemed to have been accepted by you.
The Contact details of the Overseas Assistance Company is given in the sheet enclosed.

List of Overseas Assistance Company Centres

Location of WTA Travel Services, WTA Travel Services, WTA Travel Services, Heritage Health Insurance
Centre Inc.- USA Inc.- Europe Inc.-Singapore TPA Pvt.Ltd. - India

Heritage Health Insurance

WTA Travel Services, WTA Travel Services, WTA Travel Services, TPA Pvt.Ltd.
Inc Inc Inc Champion Building,
Address 2893 Executive Park C/ Covarrubias 22. 2ºIzda 75 Kim Yan Road Ground Floor,
Drive, 28010 Madrid. Singapore 239372 15, Parsi Panchayat Road,
Suite 201, Weston, Florida Spain Andheri (East),
33331, U.S.A. Mumbai - 400069.. India

Toll - Free
Number for +1800 2541032 +34 900838022 8001302100 1800 22 4004
Assistance (Toll Free within India)

Other +91-22-61273891
Telephone +1 954 2710202 +34 911 881 617 +65 315 80234 (24hrs)
Numbers +91-22-61273892/ 93

Fax Number(s) +1 877 395 1784 +34 915 932 577 - +91-22-6127 3890

E-Mail ID assistance@wt-assist.com assistance@wt-assist.com assistance@wt- travelservices-

assist.com hhtpl@bajoria.in

Website www.wta-heritage.com www.wta-heritage.com www.wta-heritage.com www.wta-heritage.com

North,central & South Continental Europe, UK Singapore South & South East Asia,
Jurisdiction America & Ireland, Africa, Middle East, Australia
Pakistan & New Zealand

The Name, Address / Contact Details of the Service Provider / Overseas Assistance Company mentioned in other places of the policy / Annexure shall read as
above only and not as originally stated therein.
"Consolidated stamp duty paid vide order No. GHM-2018-103-M-STP-122018-1725-H-1 of revenue dept Sachivalay,
Gandhinagar Dt.20/Aug/2018"
In witness whereof the undersigned being authorised by and on behalf of the company has / have herein to set his/ their hands at Branch Office - Naroda on22nd
Day of February 2019

Signed for on and behalf of

Star Health and Allied Insurance Company Limited

Authorised Signatory
Please see overleaf
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TAX Invoice

Invoice No. : 24K261Y19P000501 Customer ID : AA0008330089

Invoice Date : 22/02/19 Policy No : P/171216/03/2019/000117
Recipient Supplier

GSTIN : - GSTIN : 24AAJCS4517L1Z4

Customer's : MALAVIYA AVAKASH NAME : Star Health and Allied Insurance Co Ltd
Code/Name CHATURBHAI - Branch Office - Naroda
Address : 44,JAI BAJRANG CO-OP Address : B/5,Sardar Patel Mall,Diamond Mill
SOCIETY,B/H MALEK SABAN Nicol Gam Road,Naroda
STADIUM, Ahmedabad-382350
BAPUNAGAR,
AHMEDABAD
City : Ahmadabad (M Corp.+OG) City : NARODA
(Part),Ahmadabad,Gujarat-380024
State : Gujarat State : Gujarat
Pincode : 380024 Pincode : 382350
Client Category : IND Place of Supply : 24 - Gujarat

HSN / Description of Total Discount TaxableValue IGST @ 18% CGST @9% UT/SGST@9% Total Invoice Value
SAC Service(s)
A B C=A-B D = C * IGST E=C F=C H = C + D + E+
Code
*CGST *UTGST or F
SGST
997136 Insurance Services 1439 0 1439 130 130 Rs. 1699
Total Invoice Value (in Figures) : Rs. 1699
Total Invoice Value (in Words) : Rupees: One thousand six hundred
ninety-nine only
Amount of Tax Subject to reverse Charge : No

Important Note:

The invoice is issued as per Section 31 of the CGST Act

In case no GSTIN or incorrect GSTIN is provided by the Proposer at Proposal stage, Star Health and Allied Insurance Co Ltd shall not be
responsible for any Input Tax Credit losses and no subsequent revision of invoice will be undertaken.

E. & O.E
This is a digitally signed document and hence no physical signature is required

IRDAI Regn. No 129 Corporate Identity Number U66010TN2005PLC056649 Email ID : stargst@starhealth.in

Signed for on and behalf of

Star Health and Allied Insurance Company Limited

Authorised Signatory
Please see overleaf
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