GROUP PERSONAL ACCIDENT INSURANCE POLICY (for Members / Customers of M/s. Srei Sahaj e-Village Ltd)
CERTIFICATE OF INSURANCE Master Policy Number
PASAHAJ001
Certificate Number
PASAHAJ001 - 00013655
Name of the Insured Person
Date of Birth
MD RAJIQUL ISLA SONARDI HAJI PARA SUJAPUR CHAMAGRAM MALDA WEST BENGAL 732206 05/05/1979
Gender
M
Address
Period of Insurance
190026126
From 00.01 hrs. on 06/10/2012 To: Midnight of 05/10/2013
Coverage Accidental Death
Gross Premium
Affinity No
Sum Insured 100000/-
Name of Nominee
Relationship with Insured person
MUKREMA BIBI
WIFE
Rs. 49 /-
Service Tax
Rs. 6 /-
Total Premium
Rs. 55 /-
th
IN WITNESS WHEREOF this Certificate has been signed at Chennai on 17 Oct 2012. Subject otherwise to terms, conditions and exceptions of Group Personal Accident Insurance Policy No. PASAHAJ001.
For Royal Sundaram Alliance Insurance Company Limited
Authorised Signatory CLAIM PROCEDURE: All claims must be notified to M/s. Royal Sundaram Alliance Insurance Company Limited through M/s. Srei Sahaj e-Village Ltd, within 30 days from date of accident along with the filled claim form and the following documents and any other documents as required by M/s. Royal Sundaram.
Death Claim: Original Certificate of Insurance, Death Certificate, Copies of Post Mortem Report, FIR / Panchanama / Accident Report, Admission / Discharge / Death Summary issued by hospital authority, authority, wherever applicable and / or legal heir certificate/succession certificate/succession certificate. certificate. Disability Claim: Original Certificate of Insurance, Disability Certificate, Self Declaration, FIR / Panchanama / Accident Report, Discharge Summary issued by hospital authority, wherever applicable. And any other documents as required by M/s. Royal Sundaram. All documents in regional languages are to be translated to English . Settlement of Claim Any Settlement of admissible claims will be made to the nominee above mentioned / the l egal heir of the insured person, in case of death claims and to the insured person in case of disabil ity and related claims.
IMPORTANT EXCLUSIONS: (Refer Master Policy for detailed exclusions) 1. Whilst crossing the railway track. 2. Any claim relating to accidents occurring before the commencement of the cover or otherwise outside the Period of Insurance. 3. As a result of, or which is contributed to by, the Insured person suffering from any pre-existing condition or pre-existing physical or mental defect or infirmity. 4. Intentional self-injury, suicide or attempted suicide. 5. Whilst under the influence of intoxicating liquor or drugs. 6. Arising or resulting from the Insured person committing any breach of law with or without criminal intent. 7. Participation in Hazardous Sport / Hazardous Activities including speed racing 8. Claims related to pregnancy or maternity or its consequence. 9. Nuclear, Chemical, Biological Terrorism
All documents in regional languages are to be translated to English.
Address for correspondence regarding clams: - M/s. Royal Sundaram Alliance Insurance Co. Ltd., 3rd Floor , Deshbandhu Plaza, 47, Whites Road, Royapettah, Chennai 600 014.
