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Rajikul

The document provides the certificate of insurance for Mr. MD Rajiqul Isla for accidental death coverage up to Rs. 100,000 from October 6, 2012 to October 5, 2013, with his wife Mukrema Bibi named as the nominee. It outlines the claim procedures and required documents for death and disability claims. The document also lists important exclusions from coverage such as accidents occurring while crossing railway tracks, intentional self-injury, and claims related to pregnancy.

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Md Rajikul Islam
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604 views1 page

Rajikul

The document provides the certificate of insurance for Mr. MD Rajiqul Isla for accidental death coverage up to Rs. 100,000 from October 6, 2012 to October 5, 2013, with his wife Mukrema Bibi named as the nominee. It outlines the claim procedures and required documents for death and disability claims. The document also lists important exclusions from coverage such as accidents occurring while crossing railway tracks, intentional self-injury, and claims related to pregnancy.

Uploaded by

Md Rajikul Islam
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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GROUP PERSONAL ACCIDENT INSURANCE POLICY (for Members / Customers of M/s.

Srei Sahaj e-Village Ltd)

CERTIFICATE OF INSURANCE
Master Policy Number Certificate Number Name of the Insured Person Address Date of Birth Gender Period of Insurance Coverage Accidental Death Name of Nominee MUKREMA BIBI Gross Premium Rs. 49/Service Tax Rs. 6/PASAHAJ001 PASAHAJ001 - 00013655 MD RAJIQUL ISLA SONARDI HAJI PARA SUJAPUR CHAMAGRAM MALDA WEST BENGAL 732206 05/05/1979 M From 00.01 hrs. on 06/10/2012 To: Midnight of 05/10/2013 Sum Insured 100000/Relationship with Insured person WIFE Total Premium Rs. 55/Affinity No 190026126

IN WITNESS WHEREOF this Certificate has been signed at Chennai on 17th 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, wherever applicable and / or legal heir certificate/succession 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 legal heir of the insured person, in case of death claims and to the insured person in case of disability 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.

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