21/11/2023 01:30:20 (hour of New Delhi)

FRENCH REPUBLIC
LONG-STAY VISA APPLICATION FORM
IDENTITY
This application form is free
PHOTOGRAPH

EMBASSY OR CONSULATE STAMP BOX FOR VISA NUMBER STICKER

1. Surname (Family name)

For official use only
KAHLON

2. Former surname(s)
Application date :

3. First name(s)
Jugal Singh
5. Place of birth 7. Current nationality Application number :
4. Date of birth
(day-month-year) MIRA ROAD, THANE, Indian FRA1NE20237054853
03/10/1998 MAHARASHTRA
6. Country of birth Processing officer(s) :
Nationality at birth, if different :
India

8. Sex 9. Marital status

X Male  Female X Single  Married  Separated  Divorced  Widow(er)
 Other (please specify)
Marginal entries
10. For minors : Surname, first name, address (if different from applicant's) and nationality of parental authority / legal
guardian

11. National identity number, where applicable :

12. Type of travel document  Diplomatic passport  Service passport
 Official passport  Special passport
X Ordinary passport
  Other travel document (please specify) :
.....…........…...…............…..........................…..........….
13. Number of travel document 14. Date of issue 15. Valid until 16. Issued by
R3600292 (DD/MM/YY) (DD/MM/YY) India
28/07/2017 27/07/2027
17. Applicant's home address (no., street, city, postcode, country)
104, SAI PRASAD, PLOT NO. 2, SECTOR-20, KHARGHAR
410210 NAVI MUMBAI
India

18. Email address 19. Telephone number(s)

pgdmib23jugal_s@mdi.ac.in

20. If you are resident in a country other than the country of current nationality, please state :
Number of residence permit Date of issue Valid until OFFICIAL DECISION

21. Current occupation Date :

Student, trainee
22. Employer (employer's address, email and telephone number) - For students, name and address of educational
institution  GRANTED
MANAGEMENT DEVELOPMENT INSTITUTE, GURGAON
MEHRAULI RD, BLOCK C, SUKHRALI, SECTOR 17  REFUSED
122007 GURUGRAM
India
mdiwebsite@mdi.ac.in
+91-124-4560000

23. I request a visa for the following purpose :

 Employment X Studies  Training period/education  Marriage  Medical reasons
 Family stay  Private stay/Visitor  Re-entry visa
 Official taking up of duties  Other (please specify) : .........…..............…....…..…..........….….........….......

1/3

*FRA1NE20237054853*
21/11/2023 01:30:20 (hour of New Delhi)
24. Name, address, email address and telephone number in France of inviting employer / host institution / family member, etc.

25. What will be your address in France during your stay ?

AUSTIN'S SAINT LAZARE HOTEL
26 RUE D'AMSTERDAM, OPERA
75009 PARIS
France

26. Intended date of entry into France or the Schengen Area

29/12/2023
27. Intended duration of stay on the territory of France
 Between 3 and 6 months X From 6 months to one year  More than one year
28. If you intend to stay in France with members of your family, please state :
Date of birth
Family relationship Surname(s), first name(s) (DD/MM/YY) Nationality

29. What will be your means of support in France ?

All expenses covered during stay

Will you be granted a scholarship ?  YES X NO


If yes, write the name, address, email address and telephone number of the institution and the amount of the scholarship :

2/3
21/11/2023 01:30:20 (hour of New Delhi)

30. Will you be supported by one or several person(s) in France ? X YES

  NO
If yes, state their name, nationality, occupation, email address and telephone number :

BANK LOAN

31. Are members of your family resident in France ?  YES X NO


If yes, state their name, nationality, relationship with you, address, email address and telephone number :

32. Have you been resident in France for more than three consecutive months ?  YES X NO

If yes, specify at which date(s) and for what purpose

At which address(es) ?

I am aware of and consent to the following : the collection of the data required by this application form and the taking of my photograph and, if applicable, the taking of fingerprints, are mandatory for the
examination of the visa application; and any personal data concerning me which appear on the visa application form, as well as my fingerprints and my photograph will be supplied to the relevant French authorities
and processed by those authorities, for the purposes of a decision on my visa application.
Such data as well as data concerning the decision taken on my application or a decision whether to annul or revoke a visa issued will be entered into, and stored in the French VISABIO biometric database for a
maximum period of five years, during which it will be accessible to the visa authorities and the authorities competent for carrying out checks on visas at borders, national immigration and asylum authorities for the
purposes of verifying whether the conditions for the legal entry into, stay and residence on the territory of France are fulfilled, and of identifying persons who do not or who no longer fulfil these conditions. Under
certain conditions the data will also be available to designated French authorities and to Europol for the purpose of the prevention, detection and investigation of terrorist offences and of other serious criminal
offences. The French authority responsible for processing the data is : Commission nationale de l'Informatique et des Libertés (CNIL)- 3 place de Fontenoy- TSA 80715 - 75334 PARIS CEDEX 07.
Pursuant to Act No 78-17 of 6 January 1978 on Data Processing, Files and Individual Liberties, I am aware that I have the right to obtain from the French government the communication of the data relating to me
recorded in the VISABIO database and the right to request that such data which are inaccurate be corrected or possibly deleted only if processed unlawfully. This right of access to and possible correction of such data
shall be exercised by applying to the head of mission or consular post. It may be possible to refer to the National Commission on Data Processing and Liberties (CNIL) if I choose to question the conditions under
which the personal data relating to me are protected.
I am aware that any incomplete application will increase the risk of my visa application being refused by the consular authority and that the said authority may have to retain my passport while my application is being
processed.
I declare that to the best of my knowledge all particulars supplied by me are correct and complete. I am aware that any false statements will lead to my application being rejected or to the annulment of a visa already
granted and may also render me liable to prosecution under French law.
I have been informed that if over two months have elapsed with no reply since I submitted my request and received a receipt as proof, this implicitly means that my request has been denied. This decision can be
contested through the Commission des recours contre les décisions de refus de visa (Appeals Commission for denied visas) , BP 83.609, 44036 Nantes CEDEX 1, France, within two months of the implicit decision
I undertake to leave the French territory before the expiry of the visa, if granted, and if I have been refused the right to stay in France after the expiry of the visa.
I have been informed that the informative booklet “Venir vivre en France” (“Living in France”) is available on the following websites : www.immigration.interieur.gouv.fr and www.ofii.fr

Place and date Signature (for minors, signature of the parental authority / legal guardian)

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21/11/2023 01:30:58 (hour of New Delhi) 1/2

France-Visas
The official website for visa application to France

Registration receipt

On 20/11/2023, your information has been recorded by the France-Visas system.

Reference of the application : FRA1NE20237054853

Last name/s : KAHLON

First name/s: Jugal Singh

*FRA1NE20237054853*
Birth date (DD/MM/YYYY): 03/10/1998

REQUIRED SUPPORTING DOCUMENTS TO SUBMIT YOUR APPLICATION

The day of your appointment, thank you for coming with originals and copy of all documents listed below, translated into French /
English or Spanish (if accepted by the visa center)*.
If you are a student and have scanned all your supporting documents, please bring the originals of the documents listed below only.

FORMS

Signed and dated application form

Receipt France-Visas

PRE-REQUISITES

A travel document, issued less than 10 years ago, containing at least two blank pages, with a period of
validity at least 3 months longer than the date on which you intend to leave the Schengen Area or, in the
case of a long stay, at least three months longer than the expiry date of the visa requested. Be sure to
transmit (scan) ALL PAGES of your travel document containing visas, entry and exit stamps or any other
inscription.

ID photograph.

If you are not a national of your country of residence: proof that you are legally resident in that country (e.g.
residence permit).

If you have an official travel document, a note verbale is required.

PURPOSE OF TRAVEL/STAY

Country following the EEF-Etudes en France procedure : Certificate of pre-registration generated by the
EEF-Pastel application, stating the EEF ID number. Country outside of the EEF-Etudes en France
procedure : Certificate of pre-registration (or registration) in an establishment of higher education or
training.

Last completed degree (countries out of procedure EEF-Etudes en France).

21/11/2023 01:30:58 (hour of New Delhi) 2/2

FUNDS

Proof of a minimum monthly income of €615 : certificate of scholarship or bank statement showing a
deposit in a French bank account, or bank statement of permanent and irrevocable transfer (or blocked
account), or an undertaking to accept financial liability from a guarantor who must provide proof of
adequate, reliable and regular income, as well as a copy of their ID document.

ACCOMMODATION

Proof of accommodation : hotel reservation, rental agreement, sworn statement/undertaking from the host
(establishment/institution or private individual) or explanatory letter from the student detailing how the
accommodation is planned.

APPLICABLE VISA FEE

On the day of your appointment, you will have to pay the application fee of : 50 €**,or about 4 382 INDIAN RUPEE.
What currency is accepted? What are the payment method types? Please read the Fees section after choosing the pages specific
to your local. You will find information on the fees and, more generally, the most accurate information for your visa application. In
the case where the submission of your application is made with a service provider, service fees will be collected.
* Please note : if any documents are missing, this may lead to the non-issuance of the visa you have applied for. The visa center
reserves the right to ask for further documentation and information.
** This amount is for informational purposes only. Certain individual cases may give rise to different prices, in accordance with
applicable regulations.
 3

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 Appointment Confirmation
Group URN - FRB15828539744

Appointment Date Appointment Time Visa Application Center

27 Nov 2023 02:45 pm France Visa Application Centre, New
Delhi

Number of Customer/s Visa Category

1 Student Long Stay

Appointment Details

L
APS Certificate
Applicant Name Passport Number Appointment Time Visa Category Reference Number
number

BA
JUGAL SINGH FRA1NE2023705
R3xxxxxx92 02:45 pm Student Long Stay
KAHLON 4853
FRB15828539744/1

Your appointment has been confirmed for the date and time reflecting against your name and reference number. Please be available at
the following address not more than 15 minutes before the appointed time.
LO
Email ID : info.francein@vfshelpline.com
Helpline Number : 022-67866014
“Please note that additional charges is applicable for Premium Lounge services ” For more information with regards to this service kindly
visit VFS Global website.
G

Also, applicants needs to bring all the documents in A4 size only.

Note: Biometric is exempted for children below 12 years, hence Children below the age of 12 years need not visit the Visa Application
Centre to submit their applications or to enroll Biometrics. Parents/Legal Guardian can submit their application on behalf of the children.
For Parking:
While the Shivaji Stadium Metro Station does not allow parking of vehicles at the station itself due to Security Protocols mandated by
DMRC, ample paid parking is available in close vicinity of the Metro Station premises as detailed below:
FS

Multi-Level Car Park in DLF Capitol Point Building – Approx. 5 Minutes’ walk to the Metro Station. Basement Level Parking behind Rajiv
Gandhi Handicrafts Bhavan (Diagonally Opposite the Metro Station)- Approx. 5 Minutes’ walk to the Metro Station Parking at Hanuman
Mandir- Approx. 5- 7 Minutes’ walk to the Metro Station Basement Level Parking at Palika Bazar- 7- 10 Minutes’ walk to the Metro Station.
Note: Vehicles are allowed to drop and pick up right at the entry of the Shivaji Stadium Metro Station
“Applicants need to pay the visa fees, VFS service charge and convenience fee along with any other value added service which has been
availed
“From 1st April 2019, it will be mandatory for the applicants to submit both the online application form along with online check list".
V

Please note: Your safety is our priority. Customers visiting our Visa Application Centres may be subjected to body temperature checks to
assess their health conditions and may be required to wear face mask and gloves. Customers exhibiting COVID-19 symptoms, including
fever (higher than 38 degrees Celsius), cough and difficulty breathing will be allowed to reschedule their appointment for another day and
will be advised to seek medical attention at the nearest healthcare facility of their choice.
Apart from the safety procedures conducted, please note that you should have Aarogya Setu App installed on your mobile phone.
Customers can collect the passport from 09:00 AM to 04:00 PM. Customers need to bring original acknowledgement receipt along with a
copy of the govt.ID Proof for the collection of the passport.
Please be informed applicant can contact us on +91 22 6786 6014 or +91 22 6201 8418 between 8:00am to 5:00pm, from Monday to
Friday.
Please be informed the mode of delivery opted by the customer at the of submission of visa application will not be changed post
submission of visa application. i.e., counter delivery to courier delivery or courier delivery to counter delivery.
Also, if the customer opted for counter delivery of the passport/ Envelope customer need to collect the passport from the visa application
centre they have applied.
In case the processed passport/envelope came with a letter issued by the Embassy, customer needs to come in person to the visa
application centre customer have applied from to collect the passport irrespective of the mode of delivery opted by the customer at the
time to submission of the visa application. As customer need to sign the letter.
Thank you for your understanding. Additional Charges are applicable for Weekend appointments 10/31/2018 9:03:16 AM -05:00 US
Eastern Standard Time 141 DEL

© VFS Global. All rights reserved. Manage Appointment | Contact us | Disclaimer Page 1
 Appointment Confirmation
Group URN - FRB15828539744

CUSTOMERS ARE REQUESTED TO CARRY A PRINT OUT OF THE APPOINTMENT LETTER AT THE TIME OF SUBMITTING THE
APPLICATION AT VFS CENTRE.
Important Information:
Please note that any Queries/ Refund Requests/ All matters related to the above transaction, can and must only be addressed to
info.lebanonin@vfshelpline.com within 1 month of the date of this receipt. Refunds are subject to the applicable Embassy and VFS
Refund Policies applicable.

L
VISIT ARRIVE COLLECT SUBMIT PAY TRACK

BA
Visit Visa Arrive 15 min prior to Collect token in Submit your Make payment and Track progress
application Center the appointment reception and wait documents and collect receipt of application
in person time for your turn biometrics(if through
applicable) website/subscri
be for SMS
LO
Premium Lounge Travel Assistance with
G

Insurance

Know more.. Know more..

FS

Payment Invoice

GST No. : PAN No. : TRUE

Transaction Id : 113083199974 Transaction Date : 11/20/2023 20:19:43
Transaction status : Transaction Success Transaction Amount : INR 3044.00
V

VFS Service fees:

Applicant Name Service Unit Price Service Tax/VAT Units IsPaid Total

JUGAL SINGH VFS Service Fee 2274.00 N/A 1 Yes 2274.00

KAHLON

Total Amount : INR 2274.00

Additional services booked

Applicant Name Service Unit Price Service Tax/VAT Units IsPaid Total

© VFS Global. All rights reserved. Manage Appointment | Contact us | Disclaimer Page 2
 Appointment Confirmation
Group URN - FRB15828539744

JUGAL SINGH Courier Assurance fee 652.54 TAX 18.00 % 1 Yes 770.00
KAHLON France

Sub Total : INR 770.00

Grand Total : INR 3044.00

Travel insurance is mandatory for all Schengen countries. If you have not purchased one please click here.

L
Please note:

Please note it may take more than the prescribed time mentioned on your Appointment letter while submitting your Visa Application at VFS

BA
Centre.

Applicants will be issued with a token number at the Application Centre and will be entertained as per the token number assigned.

It may take more time depending on the number of Applications submitted at the counter by an Individual.

KEY MEASURES FOR YOUR HEALTH & SAFETY AT OUR VISA APPLICATION CENTRES
Our Visa Application Centres follow the highest health and safety standards based on the guidelines from WHO and local health authorities.
LO
We count on your cooperation and strict adherence to ensure a healthy and safe environment for you and our employees. After all, safety is
our top priority

Temperature screening before entry, where applicable

Use of masks and gloves as required.

G

No-contact security screening.

Strict adherence to social distancing of 2 metres / 6 feet.

FS

Regular sanitization of premises with disinfectants approved by WHO.

Regular disinfection of frequently touched surfaces.

V

Measures may vary across different regions and centres based on local health guidelines. For
more information, please visit vfsglobal.com/customer-advisories
Watch this video to learn more about the health & safety measures implemented at our visa
application centres & how you can prepare better before your visit.

<Other disclaimers goes here>

Click here to watch the video on

the Health & Safety measures

© VFS Global. All rights reserved. Manage Appointment | Contact us | Disclaimer Page 3
VFS GLOBAL Services Courier Request Form

Date: _______________

COURIER REQUEST (To be filled by applicant in BLOCK LETTERS) for Home Address
* Courier is an optional service

1. Please fill in the following details:

Passport Number: ……………………………………………………………………………………………………………………

Applicant Name: …………………………………………………………………………………………………………………….

2. Address*required for courier delivery of Passport:

* Please reconfirm the details with the officer

Flat Number &

Floor:

Building Name &

Wing:
Street Name:

Landmark:

Area/City:

State:

Pin Code:

3. In case of Non Serviceable Location, I agree to collect the above mentioned passport from the below
mentioned BLUE DART (HAL) Location: __________________________

SO Done By & Date _______________________

(To be filled by VFS)

4. SMS:
CONTACT NO:

I,……………………………………………….………………….. holding……..……………………. Passport Number(s)…………………….. ,

have requested & authorized M/s.VFS Global (“VFS Global”) to send / deliver my --------------------- (set out the
document/s) by third party courier on my behalf. I agree not to hold VFS Global responsible for any liabilities,
claims or other consequences including expenses arising out of any loss, temporary misplacement of the
document/s, delay or damage to the document/s. I agree that my claim arising out of any of the above shall be
restricted to what the courier company pays / delivers to VFS if any of the above events occur. I confirm and
agree that this constitutes a genuine pre-estimate of damages suffered by me.
I confirm that I have read / had the same read and understood the terms of this Declaration.

SIGNATURE: PLACE:

F/OPS/10.b Effective Date: 25 Sep 2015

 Accord préalable d'inscription
Confirmation of acceptance/pre-enrollment
Attestation « Etudes en France »
'Etudes en France' certificate

Nom : KAHLON
Surname (family) name :
Prénom : Jugal Singh
First name(s) :
Date de naissance : 03/10/1998
Date of birth :
Numéro d'identifiant : IN23-06389
Application ID :
Dossier suivi par : CampusFrance - New Delhi
Contact information : Alliance Française de Delhi - 72, KK Birla Marg, Lodi Estate, New Delhi -
110003

Etablissement d'accueil : ESCP EUROPE

Host institution :
Site : Paris
Location :
Formation demandée : ESCP Europe Master in Management
Course name :
Année d'entrée : année 1
Entry year :

Après avoir obtenu votre visa de long séjour, vous devrez vous présenter à l'adresse ci-dessous muni(e) de cette
attestation et des justificatifs requis par votre établissement d'accueil, le cas échéant, pour finaliser votre
inscription.

Once you receive your long stay visa, you must come in person to the address below and present this certificate, along with
documents required by your host institution, if requested, in order to finalize your enrollment.

ESCP EUROPE - Site de Paris

79 avenue de la République Paris

Date de début des cours : 02/01/2024 Durée de la formation : 1 an

Course start date : Course duration :
Date limite d'arrivée autorisée : Non renseigné
Latest authorized arrival date :

Informations importantes de la part de votre établissement :

Important information provided by host institution :
Non renseigné

Date de délivrance : 20/11/2023

Date of issue :

Cette attestation a été générée par l'application « Etudes en France » du ministère des Affaires Etrangères et du
Développement International. Elle doit être présentée à l'ambassade, au consulat ou au centre de dépôt des
demandes de visa compétent. Elle est valable sous réserve de présentation des justificatifs demandés par
l'établissement et de leur traduction officielle, pour la rentrée qui suit le dépôt de dossier.

This certificate is issued by the Etudes en France application provided by the French ministry of Foreign Affairs and
International Development. Please present this certificate to the French Embassy, consulate or relevant visa application center.
This certificate is valid only for the term indicated, on the condition of submitting documents and official translation requested by
your host institution.
11/21/23, 1:27 AM Management Development Institute Mail - ​IN23-06389-P01 / Application review completed

JUGAL SINGH KAHLON <pgdmib23jugal_s@mdi.ac.in>

​IN23-06389-P01 / Application review completed

1 message

ne-pas-repondre.etudesenfrance@diffusion.diplomatie.gouv.fr <ne-pas- Wed, Nov 15, 2023 at

repondre.etudesenfrance@diffusion.diplomatie.gouv.fr> 11:48 AM
Reply-To: noreply
To: pgdmib23jugal_s@mdi.ac.in

Dear Jugal Singh KAHLON,

This is to inform you that your Campus France file is now fully validated and forwarded to the Consulate. You may now proceed to filling up your VFS
application online and scheduling your VFS appointment at the centre nearest to you.

Best regards.

Team Campus France India.

This is an automated message. Please do not reply.

https://mail.google.com/mail/u/0/?ik=8b1ba101a3&view=pt&search=all&permthid=thread-f:1782609778538883435&simpl=msg-f:1782609778538… 1/1
 Booking Confirmation
Please present either an electronic or paper copy of your booking confirmation upon check-in.
agoda agoda agoda agoda agoda agoda agoda agoda agoda agoda agoda

Booking ID : 1115764733 Number of Rooms : 1

Booking Reference No : Number of Extra Beds : 0
Client : Jugal Singh Kahlon Number of Adults : 1
Member ID : 402285252
Number of Children : 0
Country of Residence : India
Room Type : Double Room Non-Smoking
Property : Austin's Saint Lazare Hotel
Hôtel Austin's Saint Lazare Promotion :

Address : 26 rue d'Amsterdam, Opera, Paris, For Full Promotion details and conditions see confirmation email
France, 75009

Property Contact Number : +33148744871

Cancellation Policy: Risk-free booking! You can cancel until 21 December 2023 and pay nothing! Any cancellation received within 7 days prior to the arrival
date will be charged for the entire stay. Failure to arrive at your hotel or property will be treated as a No-Show and will incur a charge of 100% of the booking
value (Hotel policy).

Benefits Included Coffee & tea, Express check-in, Free WiFi

Arrival : December 29, 2023 Departure : January 27, 2024

Booked And Payable By :

Agoda Company Pte, Ltd.
30 Cecil Street, Prudential Tower #19-08,
Singapore 049712

Remarks :
Included : Taxes and fees INR 60241.74
Not Included : City Tax (Pay at the property) INR 4972.63
NonSmoke,LargeBed
You chose a future price: payment by you in INR will be due on Wednesday, 20 December 2023; On
that date, a INR amount will be calculated from EUR 7,265.27 and charged to you, subject to these
terms affecting your price.
All special requests are subject to availability upon arrival
Call our Customer Service Center 24/7 :
Customer Support : +33 185 148 161, +44 20 3027 7900
(Long distance charge may apply)

Notes
IMPORTANT: At check-in, you must present a valid photo ID with your address confirming the same name as the lead guest on the booking. For
bookings paid with a credit card, you may also need to present the card used to make the payment. Failure to do so may result in the hotel
requesting additional payment or your reservation not being honored.
All rooms are guaranteed on the day of arrival. In the case of a no-show, your room(s) will be released and you will be subject to the terms and
conditions of the Cancellation/No-Show Policy specified at the time you made the booking as well as noted in the Confirmation Email.
The total price for this booking does not include mini-bar items, telephone usage, laundry service, etc. The property will bill you directly.
In cases where Breakfast is included with the room rate, please note that certain properties may charge extra for children travelling with their
parents. If applicable, the property will bill you directly. Upon arrival, if you have any questions, please verify with the property.
 I 2010
6
GURGAON BRANCH
*dlaib-sllir'3Gar
Central Eank ot rndio
CETTRAL TO YOU SI'{CE I9IT
DIST:' GURGAON HARYANA

TO WHOMSOEVER IT MAY CONCERN

CAPABILITY CERTIFICATE

This is to certiry that Mr. Jugal Singh Kahlon S/O Mr. Saravj it Singh Kahlon has availed an
Education Loan ofRs. 40,00,000/-(Forty Lakhs Only) from us. Out ofthe total limit Rs.9.00.000/-
(Rupees Nine Lakhs only) will be disbursed against him Full-Term Student Exchange Program at
ESCP Business School, Paris, France.
The detail of which is as under:-

1 Name of student Mr. Jugal Singh Kahlon

2 IOAN AMOUNT Rs. 40,00,000/-(Forty Lakhs Onll )
3 PURPOSE Tuition fee and other fee
paid to college : Rs.2816200
lnsurance premium : Rs.43800
During the full term Student Exchange
At abroad : Rs.900000
Living Expenses : Rs.240000
TOTAL : Rs.4000000
4 LOAN SANCTIONED FOR Rs.9,00,0001(Rupees Nine Lakhs onll )
EXCHANGE PROGRAM AT
ABROAD
5 RATE OF INTEREST 8.20%
5 REPAYAMENT period 214 Months (34 Months of moratorium)

This certificate is issued at the specific request of the customer for enable him to appl-v for VISA.

B
C en India
B/O Gurgaon
Phone- 24-2221 182, 2322233
0I
Mobile- 8588870181

v
E-mail:- bmdrlcl 026@centralbankco.in
 12-9910-0004249613-00
Bajaj Allianz General Insurance Company Limited

Welcome to Bajaj Allianz Family

Jugal Singh Kahlon

Management Development Institute, Block C, Sukhrali,
, Gurgaon,122007
Haryana
Mobile No.: 9004042704
e-mail : pgdmib23jugal_s@mdi.ac.in
Customer ID : PI28742321

Dear Customer,

Thank you for choosing Bajaj Allianz General Insurer as your preferred insurer. Bajaj Allianz General
Insurance Company Limited, a consistently profitable insurer enjoys a reputation of expertise,
stability and strength. We are a customer focused market leader present in over 200 locations
across India. As an organization we strive to understand the risk management needs of our
consumers and translate it into affordable products and services of global quality that deliver value
for money. Bajaj Allianz has an ISO Certified claims process and has received iAAA rating for the last
three consecutive years from ICRA Limited, an associate of Moody's Investors Service, for claims
paying ability. The rating indicates highest claims paying ability and a fundamentally strong position
in the industry.

We request you to kindly go through the contents of the policy schedule and the terms and
conditions. In case of any clarification or disagreement, please write to us at
travel@bajajallianz.co.in within fifteen days of receipt of this policy.

We assure you the best of our services and look forward to a continual patronage and association
with you.
For & on the behalf
Bajaj Allianz General Insurance Company Ltd.
Signature Not Verified
Digitally signed by DS BAJAJ ALLIANZ GENERAL
INSURANCE COMPANY LIMITED 01
Date: 2023.11.23 22:56:43 IST

Authorized Signatory
Policy issuing office & correspondence address for communication by holder of Certificate of Insurance for claim, service request, notice, summons, etc: WEB SALES-Bajaj Finserv
Building,1st Floor,Behind Weikfield It-Park,Viman Nagar,Pune,Maharashtra,INDIA,411014
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada, Pune – 411006 (India).
Email: travel@bajajallianz.co.in , Website www.bajajallianz.com

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 12-9910-0004249613-00
Bajaj Allianz General Insurance Company Limited

TRAVEL ACE(International) Transcript of Proposal UIN. BAJTIOP20086V011920

Policy No.: 12-9910-0004249613-00 Date: 23/11/2023

Dear Jugal Singh Kahlon,

We Bajaj Allianz General Insurance Company Limited [“Company” or “Insurer”] wish to inform you that the your contract of insurance (“Policy”) will be based on the information and
declaration given by you through telephonic conversation / email / web-inputs / TAB or other means which would be considered as the final proposal, the transcript of which is as follows:

You are requested to yourself reconfirm the same at your end. In case of any disagreement or objection or any changes with respect to information mentioned below, we request you to
please revert back immediately and before start of your journey or within a period of 15 days from the date of your receipt of this document, whichever is earlier. In case of our non-
receipt of your disagreement or objection or any changes [as mentioned hereinabove] with respect to information and declaration mentioned in this transcript of proposal, it shall be
deemed that you have positively confirmed to the Company the correctness of the below mentioned information and declaration. In case you disagree to any of the information/contents of
this transcript, standard Terms and conditions, you have the option to return the original Policy, immediately before start of your travel/journey or within a period of 15 days from the date
of your receipt of this document, whichever is earlier, stating the reasons for your objection, and upon our receipt of the original Policy together with your request to cancel the Policy, you
shall be entitled to a refund of the premium paid, subject to there being no claim made under the Policy and also subject to a deduction of the stamp duty charges and other expenses
incurred by the Company.

Kindly note that as the information/contents and declarations/confirmations provided by you as contained in this transcript is the basis on which the Company is issuing / has issued the
Policy to you, we advise you to please ensure that you have provided/disclosed and or not withheld any material facts/information and declarations, as Policy becomes void ab-initio if
material facts/information/declaration is/are not provided/disclosed and or withheld and in such case no claim, if any, shall be considered by the Company apart from forfeiture of the
premium amount.

Details provided by you:

Personal Information of Proposer
Proposer Name: Jugal Singh Kahlon

Correspondence Address: Management Development Institute, Block C, Sukhrali Gurgaon Permanent Address: Management Development Institute, Block C, Sukhrali NA Gurgaon,
Haryana 122007 Haryana 122007

Mobile No. : 9004042704 e-mail id : pgdmib23jugal_s@mdi.ac.in

Date of Birth : 03/10/1998 PAN: EWNPK0692F Nationality : Indian

Insured / Beneficiary details:

Member Name Date of Birth Age Gender Passport Number Nominee Name Nominee Relation Member Relation
Jugal Singh Kahlon 03/10/1998 25 Male R3600292 Neelam Kahlon Mother Self

Coverage Details:
Plan Chosen Travel Ace Student Modular Geographical Coverage Worldwide Excluding USA and Canada
Departure Date: 29-DEC-23 Arrival Date: 28-DEC-24 Trip Duration: 366 Days

Bajaj Allianz Employee Code, if Proposer is BAGIC/BALIC Employee: NA

If you have any other policy for coverage of International Journey i.e Health/ PA/ Travel etc. (if yes please provide details): Not Applicable

Benefit Details:

Basic Benefits Sum Insured Basic Benefits Sum Insured

Emergency Dental Pain Relief USD 2000 Accidental Death and Disability (Common Carrier) USD 5000
Hospitalization Daily Allowance USD 75 per 24 Hrs. max 120 days. Compassionate Stay USD 500
Personal Accident USD 25000 Missed Connection USD 250
Sickness Medical Exigencies(Medical Expenses, Personal Liability USD 100000
USD 200000
Evacuation and Repatriation)
Bail Bond Insurance USD 5000
Delay of Checked-In Baggage USD 100 / INR 5000
Loss of Passport And Driving License USD 500
Tuition Fees USD 10000
Loss of Checked Baggage USD 1000

Please Note:
• Lifestyle Modification Benefit, Child Education Benefit and Sporting Activities Cover are Extension for Personal Accident section and hence can opted along with Personal Accident section
only.
• Cancer Screening and Mammography Cover, Alcohol and Substance Abuse, Maternity and Baby Cover, Bail Bond Insurance, Tuition Fees, Contingency to Sponsor - Covers which are
available only for the student (Only for Student plan)

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 12-9910-0004249613-00
Bajaj Allianz General Insurance Company Limited
You have opted for below cover:-
• Pre-existing Illness Cover No
• Pre-existing Injury Cover No
• Waiver of Sub-limits No
• Sporting Activities Cover No

Pre-existing disease / Habits / Medical Mr Jugal Singh Kahlon: Pre-existing disease : NA

Declaration Please refer to details pre-existing disease at wordings.
Mr Jugal Singh Kahlon Q1. Disorder of the heart, or circulatory system, chest pain, high blood pressure, stroke, asthma any respiratory
conditions, cancer tumour lump of any kind, diaetes, hepatitis, disorder of urinary teact or kidneys, blood disorder, any mental or
Questionnaire psychiatric conditions, any disease of brain or nervous system, fits(epilespy) slippeddisc, backache, any congenital/ birth defects/ urinary
diseases, any genetic disorder, AIDS or HIV positive, any other illness : NO Q2. Alcohol/Smoke/consume tobacco : NO Q3. Recreational
Drug Use : NO

Additional information to be completed by the student (Only for Student plan)

Name of the Student : Jugal Singh Kahlon

Date of Birth :
Name of the School Overseas :
Detailed Address of the School/Telephone no. :
Course Opted for :
Duration of the Course :
Number of Semesters :
Tuition Fees per Semester :

• Tuitions financed by (Self, parents, borrowing from bank or FI's), please give details
• Have you undergone medical examination/fitness test?
• Would like to state anything that is not asked which you may want the insurer to know?

DECLARATION, WARRANTIES, TERMS AND CONDITIONS:

1. The contents of the proposal [transcript of the proposal of you is this document], the detailed list of exclusions, standard terms and conditions, including the exclusion of pre-existing
ailments/diseases and connected documents have been fully explained to you and you have fully understood the significance of the proposed contract of insurance basis which you have
confirmed to the Company for Policy issuance.
2. You declare that, on your behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by you as in this transcript are complete,
true and accurate in all respects to the best of your personal knowledge and belief and that there is no other information, which is relevant to your proposal for insurance that has not been
disclosed to the Company. You are authorised to propose on behalf of these other persons.
3. You have clearly understood the terms and conditions [T & C] to the insurance contract and agree that the statements, particulars, answers and/or particulars, information, declarations,
warranties, documents given in/as per this proposal shall be held to be promissory and shall be the basis of the Policy/insurance contract between you and the Company and your proposal is
subject to the Board approved underwriting policy of the Company and that the Policy will come into force only after your full payment of the prescribed premium chargeable and the
Company’s receipt and realisation of full prescribed premium.
4.You further declare that, you will notify in writing any change occurring in general health of yours and other persons to be insured/proposer after the proposal has been submitted [as in
this transcript] but before communication of the risk acceptance by the Company. You shall immediately inform the Company if there are any subsequent changes to the information,
declarations, warranties mentioned in this transcript of the proposal or if additions or alterations are carried out in the risk proposed after the submission of this proposal. You agree to the
Standard Terms and Conditions of the Company. In case of disagreement or objection or any changes with respect to information, declarations, Standard Terms and Conditions, exclusions
and contents mentioned hereinabove, please contact Company’s toll free number & register your objections / changes / disagreement to the contents of this transcript or you may also send
to the Company email or written correspondence at the following details within a period of 15 days from date of your receipt of this transcript along with Policy.
5. The Company shall have no liability under the Policy/insurance contract if it is found that any of your statements, particulars, answers and/or particulars, information, declarations,
warranties, in your this proposal or other documents are incorrect\and or untrue or suppressed any information or provided misleading or false information in any respect on any matter
[whether material or not material] to the grant of a cover by the Company.
6. You declare that you have given consent to the Company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be
insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be insured/proposer and seeking information from
any insurer to whom an application for insurance on the person to be insured /proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
7. You authorize the Company to share information pertaining to your proposal [as in this transcript] including the medical records of the insured/proposer for the sole purpose of
underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority, reinsurers, group companies, auditors/legal counsel, service providers etc.
8. You have read and understood the privacy policy of the Company and hereby unconditionally agree and bind yourself to all terms and conditions of the Company’s privacy policy, as
amended, from time to time.
9. You agree that the Standard Terms and Conditions sent to you for the Policy taken by you for the first time shall be applicable to the renewal Policy and the Company need not send the
Standard Terms and Conditions at the time of renewal and if you require the same you will seek the same from the Company.

Prohibition of Rebates
SECTION 41 OF INSURANCE ACT, 1938:
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 punishable with a penalty, which may extend to Ten Lakh Rupees.

This is print of electronic records maintained by the Company in accordance with law and hence does not require signature.
Corporate Identification Number: U66010PN2000PLC015329 | GST Regd. Number AABCB5730G-ST-001

Policy issuing office & correspondence address for communication by holder of Certificate of Insurance for claim, service request, notice, summons, etc: WEB SALES, WEB SALES-Bajaj
Finserv Building,1st Floor,Behind Weikfield It-Park,Viman Nagar,Pune,Maharashtra,INDIA,411014

Regd. Office: Bajaj Allianz House, Airport Road, Yerwada, Pune – 411006 (India).
Email: travel@bajajallianz.co.in , Website www.bajajallianz.com

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 12-9910-0004249613-00
Bajaj Allianz General Insurance Company Limited

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of India [IRDAI] vide Regd. No.113)

TRAVEL ACE(International) Certificate cum Policy Schedule UIN. BAJTIOP20086V011920

PROPOSER DETAILS POLICY DETAILS
Customer ID : PI28742321 Policy No. 12-9910-0004249613-00
Proposer Name: Jugal Singh Kahlon Issued on 23/11/2023 | Location : 9906 | Policy Status: ACTIVE POLICY
Corresp. Address: Management Development Institute, Block C, Sukhrali , Gurgaon, Period of From: 29/12/2023 00:00 Hrs.
Haryana PIN-122007 Insurance To : 28/12/2024 Midnight
Mobile No.: 9004042704 | e-mail id: pgdmib23jugal_s@mdi.ac.in Endorsement Dt. NA Wef. NA
IMPORTANT Note: For intimation of Hospitalization please use our miss call facility by dialing +91 124 6174720 this will help us
to assist you better. You can also write an email to travel@bajajallianz.co.in. Planned hospitalization to be notified at least 7 days in
advance before admission and emergency hospitalization within 24 hours or as soon as possible before discharge.

Plan Chosen Travel Ace Student Modular Geographical Coverage Worldwide Excluding USA and Canada

Member Name Date of Birth Age Gender Passport Number Nominee Name Nominee Relation Member Relation
Jugal Singh Kahlon 03/10/1998 25 Male R3600292 Neelam Kahlon Mother Self

Basic Benefits Max Limit Deductible Basic Benefits Max Limit Deductible
Emergency Dental Pain Relief USD 2000 USD 25 Accidental Death and Disability (Common
USD 5000 Nil
USD 75 per 24 Hrs. Carrier)
Hospitalization Daily Allowance Nil Compassionate Stay USD 500 Nil
max 120 days.
Personal Accident USD 25000 Nil Missed Connection USD 250 Nil
Sickness Medical Exigencies(Medical Personal Liability USD 100000 Nil
USD 200000 USD 100
Expenses, Evacuation and Repatriation)
Bail Bond Insurance USD 5000 Nil
8 hrs for abroad/8 hrs
Delay of Checked-In Baggage USD 100 / INR 5000 Loss of Passport And Driving License USD 500 Nil
for India
Tuition Fees USD 10000 Nil
Loss of Checked Baggage USD 1000 Nil

*Travel Ace Sublimit: : Applicable for members above 50 years

Coverage Sublimit Coverage Sublimit

Sporting Activities Cover: No

Remarks Please Note: INR indicates Indian National Rupees

Important This policy does not cover any pre-existing medical condition/injury/illness/deformity and complications arising out from them that are declared or undeclared.
Note: You will not be travelling against the advice of a physician for the purpose of obtaining medical treatment and will consent to Bajaj Allianz seeking medical
information from any doctor in respect of any matter relating to my physical or mental health and you authorize and consent to him giving such information to
Bajaj Allianz and / or to the claims administrator or medical advisors.
However this policy covers emergency medical treatment for life-threatening conditions arising out of any pre-existing medical condition upto USD 3000.
Pre-existing disease Mr Jugal Singh Kahlon: Pre-existing disease : NA
Please refer to details pre-existing disease at wordings.
Special terms & This policy covers Medical Expenses arising out of Covid-19 outside India,including Medical Expenses incurred during Quarantine period subject to the policy
condition terms and conditions.
Accommodation and non-medical incidental expenses arising during Quarantine period stand excluded.
Exclusion: Not Applicable
Clauses : Not Applicable
Warranties: Not Applicable
Declaration by 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
Insured 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.
Geographical Note: Declined country list includes- Afghanistan, DR Congo, Iran, Iraq, North Korea, Pakistan, Syria, Yemen terror prone and politically unstable countries.
Exclusion Additionally Haj, Manasarovar Yatra are not covered.

Base Premium Rs. 9140 Premium Details: Premium Payer ID: PI28742321 | Payment Mode: Online Payment | If Premium paid through
Less: Discount ( ) Rs. NA Cheque, the Policy is void ab-initio in case of dishonour of Cheque.

Net Premium Rs. 9140

IGST @18% Rs. 1645
Total Premium Rs. 10785

Total Premium in words: Rupees Ten Thousand Seven Hundred Eighty-Five Only

Proposer GSTIN/UIN: |Place of Supply: 06 - HARYANA| Company GST.No.: 27AABCB5730G1ZX |Invoice Number: 062311I001337022 |Company PAN: AABCB5730G |As per the GST
regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th September of the next financial year. | In case no GSTIN or incorrect GSTIN is
provided by the Proposer at Proposal stage, Bajaj Allianz General Insurance Company Ltd shall not be responsible for any Input Tax Credit losses and no subsequent revision of invoice will
be undertaken.

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 12-9910-0004249613-00
Bajaj Allianz General Insurance Company Limited
I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under sub-rule (4) of rule
48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.
Previous Policy No: NA Expiry Dt. NA

Code: 55555557| Name: WEB SALES|Contact No.:8459754281, E-Mail : BAGICHELP@BAJAJLALLIANZ.CO.IN | | |

For & on the behalf Stamp Duty Consolidated Stamp Duty of Rs. .5/- paid towards Insurance Stamps vide
Bajaj Allianz General Insurance Company Ltd. .5 Challan No. MH004724512202324M Defaced No. 0003585898202324 ORDER
NO.CSD/105/2023/3494 ORDER DATED 21/08/2023 DEFACED DATE dated
21/08/2023 timing 15:32:10 of General Stamp Office, Mumbai, India

This document is system generated, hence counter signature / stamp is not required.
Corporate Identification Number: U66010PN2000PLC015329 | Service Tax Regd. Number AABCB5730G-ST-001

Policy issuing office & correspondence address for communication by holder of Certificate of Insurance for claim, service request, notice, summons, etc: WEB SALES, WEB SALES-Bajaj
Finserv Building,1st Floor,Behind Weikfield It-Park,Viman Nagar,Pune,Maharashtra,INDIA,411014

Regd. Office: Bajaj Allianz House, Airport Road, Yerwada, Pune – 411006 (India).
Email: travel@bajajallianz.co.in , Website www.bajajallianz.com
Demystify Insurance https://www.facebook.com/BajajAllianz; https://twitter.com/BajajAllianz;

Signature Not Verified

Digitally signed by DS BAJAJ ALLIANZ
GENERAL INSURANCE COMPANY LIMITED 01
Date: 2023.11.23 22:56:43 IST

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 12-9910-0004249613-00
Bajaj Allianz General Insurance Company Limited

TRAVEL ACE(INTERNATIONAL) ANNEXURE DETAILS

IMPORTANT NOTICE: International Contact Numbers

Country Toll Free Number with Exact Dialing Pattern Mobile PayPhone/Landline Our overseas travel assistance department:
AUSTRALIA 1800161400 Yes Yes Tel: +91 7507245858
AUSTRIA 0800296764 Yes Yes e-mail: travel@bajajallianz.co.in
BELGIUM 080019946 Yes No
CANADA 18339371046 Yes Yes
DENMARK 80254114 Yes Yes
0800916110
FINLAND Yes Yes
0800916111 Contact Details
FRANCE 0800992597 Yes Yes
Bajaj Allianz General Insurance Co. Ltd., 2nd Floor,
GERMANY 08000801356 Yes Yes Bajaj Finserv Building, Survey No. 208 / B - 1, Behind
HONG KONG 0800938183 Yes Yes Weik field IT Park, Off Nagar Road, Viman Nagar, Pune
HUNGARY 0680080529 Yes Yes - 411014
IRELAND 1800947246 Yes Yes
www.bajajallianz.co.in
No access from Paltel &
ISRAEL 1809455174 Jawal/Watania mobile Yes
networks.
ITFS mobile accessible
from following mobile
ITALY 0800729207 networks: Tim, Yes For any queries please contact:
Vodafone, Wind. Email: travel@bajajallianz.co.in
06633814376 Mobile networks access:
06633814377 NTT Docomo,Au (KDD)
JAPAN and Softbank. Yes
06633814378
06633814379
MALAYSIA 1800819860 Yes Yes
NETHERLANDS 08000231639 Yes Yes
NEW ZEALAND 0800497242 Yes Yes
Mobile access available
PHILIPPINES 180011102860 from Sun Cellular & No
Smart Mobile networks.
PORTUGAL 800827716 Yes Yes
Accessible through ITFS access from
Mobile1, Singtel & Payphones is
Starhub - airtime available from
charged. All mobile Singtel network
SINGAPORE 8001014293 callers need to pre- only, free of charge
register with Singtel. and for UIFN, there
UIFN not available to is a local charge.
prepaid subscribers.
00798142030103
SOUTH KOREA Yes Yes
00798142030103
SPAIN 900805804 Yes No
THAILAND 1800014035 Yes Yes
UK 08000314801 Yes No
UNITED STATES 18339371059 Yes Yes

For & on the behalf

Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory

Signature Not Verified

Digitally signed by DS BAJAJ ALLIANZ
GENERAL INSURANCE COMPANY LIMITED 01
Date: 2023.11.23 22:56:43 IST

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 12-9910-0004249613-00
Bajaj Allianz General Insurance Company Limited

RECEIPT

Receipt Number : 54-23-000000882018/1

Receipt Date : 23/11/2023
Business Channel : Websales
Received with thanks from Jugal Singh Kahlon
(Customer ID: PI28742321) a total sum of Rupees TEN THOUSAND SEVEN HUNDRED EIGHTY-FIVE ONLY
Instrument Type Inst./Ref. No. Instrument Date Bank Name Branch Name Amount (Rs.)
Online Payment 101802111 23-Nov-2023 BN00000158 BN00000158 10,785.00
Total Amount 10785

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.
* Cheque/DD/PO receipt is valid subject to realisation of the instrument.
On specific request and subject to terms and conditions, record of information exchange will be made available.
For & on behalf of
Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory
Policy issuing office & correspondence address for communication by holder of Certificate of Insurance for claim, service request, notice, summons, etc: WEB SALES-Bajaj Finserv Building,1st
Floor,Behind Weikfield It-Park,Viman Nagar,Pune,Maharashtra,INDIA,411014
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada, Pune – 411006 (India).
Email: travel@bajajallianz.co.in , Website www.bajajallianz.com

Signature Not Verified

Digitally signed by DS BAJAJ ALLIANZ
GENERAL INSURANCE COMPANY LIMITED 01
Date: 2023.11.23 22:56:43 IST

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