IFFCO-TOKIO GENERAL INSURANCE CO .LTD.

Regd. Office : IFFCO Sadan, C1 Distt. Centre, Saket, New Delhi 110017
Servicing Office: 5th Floor, SONA Complex, Opp. M Ward Office, 1st Road, Chembur, Mumbai 400071
CIN U74899DL2000PLC107621, IRDA Licence No. 106

SCHEDULE - CUM - TAX INVOICE

PRAVASI BHARTIYA BIMA YOJANA POLICY 2017
Policy / Invoice No.: 32163887

Details of the Insured:

First Name : SHAMBHU KUMAR Last Name : GUPTA
Address : VILLAGE SUPAULI Date of Birth : 10/05/1990
POST ITWA

SIWAN - 841241 State : BIHAR - 10

Mobile No. : +91-8709893050
Passport No. : M3393181 Validity of Passport : 17/11/2024
Nominee's Name : BHAVNATH SAH Nominee's Relation : Father

Period : 2 YEARS ; 00:00 Hrs on 10/01/2020 To Midnight of 09/01/2022

POLICY COVERAGE
Benefits Sum Insured

I) Personal Accident Covering Death & Permanent Total Disability Rs.10,00,000/-

II) Transportation and Airfare for Attendant Actual Ecomony Class Return Airfare for Attendant &
Actual Transportation cost of Mortal Remains
III) Hospitalization Expenses covering Injuries/Diseases Rs.1,00,000/- (upto Rs.50,000/- Per Hospitalization)
IV) Maternity Expenses Rs.35,000/- Normal, Rs.50,000/- Caesarean
V) Hospitalization Expenses of Insured's Family in India Rs.50,000/-
VI) Employment Contingencies Actual Economy Class Airfare
VII) Repatriation Expenses On Medical Grounds Actual Economy Class Airfare
VIII) Legal Costs Rs.45,000/-

Premium Details in Rs.

Basic Premium : 275.00 IGST - 18% : 50.00 Total Invoice Value : 325.00

G.S.T. Regn. No. : 27AAACI7573H1ZC SAC - 00440005, Description of Services - General Insurance Services

Special Condition :

* This Policy is valid for all emigrants who solicit the policy under provision of PBBY Notification 2017, irrespective of the passport category.
* This Policy has been issued based on the information provided by you and the policy will not be valid if any information provided is incorrect.
* The Insurance Cover is subject to the terms, conditions and exclusions of Pravasi Bharatiya Bima Yojana 2017.
* The intimation of accident/physical injury is to be sent to the insurer within 30 days from the date of accident.
* The documents for the claim are to be submitted to the insurer within 90 days from the date of death/permanent disability.

For And on Behalf of IFFCO-TOKIO GENERAL INSURANCE CO .LTD.

Subrata Mondal

Date/Time of Issue : 10/01/2020 19:11:10 Authorised signatory

Consolidated Stamp Duty deposited as per the order of Government of National Capital Territory of Delhi
In case of any clarifications, Please call +91 022 25225902/25223217/25226208 or Write to IFFCO-TOKIO GENERAL INSURANCE CO.LTD.
Off. 5th Floor, SONA Complex, Opp. M Ward Office, 1st Road, Chembur, Mumbai 400071
Authenticity of this policy can be verified at http://pbby.iffcotokio.co.in (Policy query mode)