To, 28/02/2025

Date: 01/10/2024
URN NO : SBIPAGP11005V011011
Customer Name VIKASH KUMAR
Address S/O MUKESH KUMAR PH 8433226293
VIL SIHALINAGAR BULANDSHAHR
Bulandshahr
UTTAR PRADESH
203398

Please scan the code to view the policy details

Subject : Policy Number : 226630478

XXXXXXXXXXX0101010

Dear Customer,

Welcome to SBI General. Thank you for choosing SBI General’s Personal AccidentInsurance Policy. We are
delighted to have you as our esteemed Customer.
· Policy Schedule
· Policy Clauses & Wordings.
·Grievance Redressal Letter
We have taken care that the documents reflect details of risk and cover as proposed by you. We request you
to verify and confirm that the documents are in order. Please ensure safety of these documents as they form
part of our contract with you. For all your future correspondence you may have with us, kindly quote your
Customer ID and Policy No.

Customer ID : Policy No. : 226630478

The Postal Address of your SBI General Branch that will service you in future is:
SBI General Insurance Company Limited
A and B Wing, Fulcrum Building, 9th-Floor, Sahar Road, Andheri East, Mumbai, 400099

In case of any queries or suggestions, please do not hesitate to get in touch with us. You can contact us at
customer.care@sbigeneral.in or call our Customer Care Number 1800-22-1111/1800-102-1111.

We look forward to a continuing and mutually beneficial relationship.

Yours sincerely,
Authorized Signatory
SBI General Insurance and SBI are separate legal entities and SBI is working as Corporate Agent of the
company for sourcing of insurance products
0000000000374

SBI General Insurance Company Ltd., Registered Office: & Corporate Office: SBI General Insurance Company Ltd.
9th Floor, A&B Wing, Fulcrum Building, Sahar Road, Andheri East, Mumbai – 400099. Company Identity
Number - U66000MH2009PLC190546. IRDAI Registration No: 144. UIN No: SBIPAGP11005V011011
 Personal

POLICY SCHEDULE

Policy NO : 226630478 Issue Date : 2025-02-07 00:00:00.0

Intermediary Details :

Intermediary Name :
Intermediary Code
Intermediary Contact Details Mobile No: 8433226293 Landline No:

Insured Details:

Policy No: 226630478 Policy Issue Date: 2025-02-07 00:00:00.0

Insured Name VIKASH KUMAR

Mailing Address Contact Details: 8433226293

S/O MUKESH KUMAR PH 8433226293
VIL SIHALINAGAR BULANDSHAHR
Bulandshahr UTTAR PRADESH
Period of Insurance From: 2025-02-07 00:00:00.0to: 2026-02-06 00:00:00.0
Midnight

Previous insurance policy no, if any

Total No of Insured Persons Covered

Sum Insured 40,00,000
Premium NA
(Per Account Holder Inclusive Taxes as applicable)
Details of Insured Persons
As per annexure attached
CoverageDetails Permanent Total Disability
Add ON’S or Riders Opted As per Annexure “A”
Deductible As per annexure attached
Details of Other Policies Declared in The NA
Proposal

Additional Conditions : Subject to the following additional Conditions and attached Clauses / Endorsements /
Warranties :

Signed at: Mumbai HO For SBI General Insurance Company Limited

Date:30/08/2024
Authorized Signatory

Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.

UIN No: SBIPAGP11005V011011
 Declaration

The digital copy of your policy document in PDF format will be sent to the registered mobile number or
registered email ID However, if you need a physical copy of the policy document, please send SMS
“PRINT <Policy Number>” to 561612 from your registe red mobile number.

1. Account Holders shall be covered for a period of 1 year from date of debit of their account.

2. Benefit/Cover: Accidental Death and Permanent Total Disability (PTD).

3. Sum insured Per Person: Rs.100

4. Maximum any one life limit shall not exceed Rs.2000000.

5. Mid-term increase in SI is not allowed.

6. Maximum age at entry is restricted to 65 years

7. Coverage, Exclusion and Claim Procedure as per annexure ‘A’, ‘B’ & ‘C’ as attached.

8.All other Terms And Conditions As Per Group Personal Accident Insurance Policy Wordings As attached.
Consolidated Stamp Duty of Rs.75.00 paid towards Insurance Policy Stamps vide Order No. CSD/208/2021/5074
Date:- 30/08/2024 Dated of General Stamps Office, Mumbai.

Annexure A: Scope of Cover:

ACCIDENTAL DEATH We will pay the Sum Insured, as mentioned in the COI, for any injury that is caused due to an
Accident that immediately or eventually results in Insured’s loss of life, provided that such loss occurs under the
circumstances described in the policy within 365 Days from the date of the Accident which caused the Injury.

1. PERMANENT TOTAL DISABILITY Permanent Total Disability (Including Loss of Sight and Hearing) - % of
Selected / available Sum insured for the member as per the table below

Table Losses
Loss of : % of Sum Insured
Both Hands and Both Feet 100%
Sight of Both Eyes 100%
One Hand and One Foot 100%
Either Hand or Foot and Sight of One Eye 100%
Speech and Hearing in Both Ears 100%
Either Hand or Foot 50%
Sight of One Eye 50%
Speech or Hearing in Both Ears 50%
Hearing in One Ear 50%
Thumb and Index Finger of Same Hand 25%

Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.

UIN No: SBIPAGP11005V011011
 2. Child education cover up to maximum of 1% of Accidental Death’s Sum Insured or
Rs. 20,000/- whichever is Lower for First & Second child of insured member (In case of
Death or PTD admissible claim).
3. Repatriation and Funeral Expenses - 1% Accidental Death’s Sum Insured subject to a maximum of
Rs.10,000/- .
4. Adaptation Allowance (Home and Vehicle) - 1% Accidental Death’s Sum Insured subject to a maximum of
Rs.20,000 in case of PTD admissible claim.
5. Ambulance Cover - 1% Accidental Death’s Sum Insured up to a maximum of Rs.1,500/- per
incident/accident towards admissible claim of Death or PTD.

Exclusion Annexure “B”

The Company shall not be liable for any claim or claims under this Policy arising from

1. Any pre-existing disability, condition or any complication arisingfrom it; or

2. Suicide, attempted suicide (whether sane or insane) or intentionally self-inflicted injury or illness, or sexually
transmitted conditions,mental or nervous disorder, anxiety, stress or depression, Acquired Immune Deficiency Syndrome
(AIDS), Human Immune deficiency Virus (HIV) infection; or
3. Occupations like serving in any branch of police, paramilitary, military & armed forces of any country, whether in
peace or war; or4. Being under the influence or abuse of drugs, alcohol, or other intoxicants or hallucinogens unless
properly prescribed by a physician and taken as prescribed; or
4. Participation in an actual or attempted felony, riot, crime, misdemeanour, or civil commotion or
5. Operating or learning to operate any aircraft, or performing duties as a member of the crew on any aircraft apart
from a ScheduledAirline; or whilst engaged in aviation or ballooning, or whilst mounting into, dismounting from or
travelling in any balloon or aircraft other than as a passenger (fare paying or otherwise) in any duly licensed standard
type of aircraft anywhere in the world
6. Any loss arising out of War, civil war, invasion, insurrection, revolution, act of foreign enemy, hostilities (whether
War be declared ornot), rebellion, mutiny, use of military power or usurpation of government or military power; or
7. Payment of compensation in case of death of the Insured person from Nuclear damage caused by, contributed to,
by or arisingfrom ionising radiation or contamination by radioactivity from: - any nuclear fuel or from any nuclear waste;
or
8. From the combustion of nuclear fuel (including any self-sustaining process of nuclear fission);- nuclear weapons
material; - nuclear equipment or any part of that equipment; or
9. The dispersal or application of pathogenic or poisonous biological or chemical materials; the release of pathogenic
or poisonousbiological or chemical materials, or Congenital anomalies or any complications or conditions arising there
from; or
10. Participation in winter sports, skydiving/parachuting, hand gliding, bungee jumping, scuba diving, ballooning,
mountain climbing(where ropes or guides are customarily used), riding or driving in races or rallies using a motorized
vehicle or bicycle, caving or pot-holing, hunting or equestrian activities, skin diving or other underwater activity, rafting
or canoeing involving white water rapids, yachting or boating outside coastal waters (2 Nautical miles), participation in
any Professional Sports, any bodily contact sport or/and any other hazardous or potentially dangerous sport for which
You are untrained.
11. Death resulting directly or indirectly, contributed or aggravated or prolonged by childbirth or from pregnancy, or
12. For any loss to which a contributing cause was insured person’s actual or attempted commission, or wilful
participation in, an illegalact or any violation or attempted violation of the law or resistance to arrest or insured person
committing any breach of law with criminal intent.

4.
Claim Procedure Annexure “C”
INTIMATING A CLAIM

Claims Procedure
Personal Accident Claims intimations :
Written Notice of claim must be given by to SBI General within 7 days after an actual or potential loss begins or as
soon as is reasonably possible and in any event, not later than 30 Days after an actual or potential loss begins."
Personal Accident Claims shall be handled centrally from SBI General Insurance Company Limited’s claims department.
Insured person or claimant will be encouraged to report details of the personal Accident claims to SBI General Call
Centre. However, Insured person or claimant may notify a claim using one of the following communication channels :
· Toll Free No. 1800 22 1111 / 1800 102 1111

Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.

UIN No: SBIPAGP11005V011011
 · Email notification to central email Customer.care@sbigeneral.in · By letter/ Fax to our
Corporate office.
· By completing a manual Claim Form and mailing it to us. · Via our website.

Minimum Information required for the Intimation:

The person/team receiving the claim intimation shall take down the following minimum required initial details
during the first interaction for furtherance of the claim:
• Notifier details
• Insured Details like Master Policy number, Certificate number, Insured’s name. Type of loss/Accident
• Brief of how the loss/Accident has taken place
Once the claim is registered a unique Intimation ID/Claim Reference Number will be provided to the notifier.

Claim submission :
Claim Form can be downloaded from SBI General’s website (www.sbigeneral.in--> Claims Downloads-->
Download Claim Forms) or can be obtained from nearest SBI General Branch office or nearest SBI
Branch. Completed claim forms and written evidence of loss must be furnished to Us within thirty (30)
Days after the date of such loss. Failure to furnish such evidence within the time required shall not
invalidate nor reduce any claim if You can satisfy us that it was not reasonably possible for You to give
proof within such time.
However, no proof will be accepted if furnished later than one (1) year from the time the loss occurred.
Claim Procedure Annexure “C”

List of Documents:
• Duly signed Claim Form
• Copy of Original Certificate duly signed and attested by an authorized official of any Branch of State Bank of
India
• FIR / MLC Copy /Spot Panchnama / Inquest Panchnama
• Death Certificate
• Post Mortem Report
• Final Police Report Affidavit from the legal heirs of the deceased (in case nomination has not been filed by
deceased) We may require any other relevant document post assessment of submitted documents.

Deficient Documentation :
Post submission of the claim documents to SBI General, the claim file will be reviewed to ascertain if SBI General
is able to proceed with settlement of the claim. In case there are any additional documents required for
settlement of claim SBI General will advise the claimant to provide the requisite documentation within 7 days of
receipt of such advice from SBI General. In case of non receipt of the requisite documents, first reminder will be
sent to the claimant advising an extension of further 15 days period. Even after expiry of such period if the
documents are not received final reminder cum closure letter will be sent stating that if documents are not
received within 07 days of the issuance of the final reminder cum closure letter, the claim will be closed.

Claim Finalisation :
Upon satisfactory completion of assessment, claim will be finalised and once the payability of claim is finalised
SBI General would affect payments /remittance to Insured/Beneficiary as applicable. Once the final payment has
been made to all parties involved in a claim the claim will then be considered closed.
Declination of Personal Accident Claims :
In the event that a claim is not valid under the policy the claimant will be notified in writing of our decision and
reasons for doing so, included in the letter. The claimant will also be advised of the Grievance Redressal process
should they disagree with the decision to decline the claim.

Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.

UIN No: SBIPAGP11005V011011
Grievances Redressal Procedure

Stage 1
If you are dissatisfied with the resolution provided above or for lack of response, you may write to
head.customercare@sbigeneral.in We will look into the matter and decide the same expeditiously within 14
days from the date of receipt of your complaint.

For Senior Citizens: Senior Citizens can reach us at seniorcitizengrievances@sbigeneral.in; Toll Free - 1800 22
1111 / 1800 102 1111 (24*7)

Stage 2
In case, you are not satisfied with the decision/resolution communicated by the above office, or have not
received any response within 14 days, you may send your Appeal addressed to the Grievance Redressal Officer
at : gro@sbigeneral.in. or contact at: 022-45138021
Address: Grievance Redressal Officer, 9th Floor, A & B Wing, Fulcrum Building, Sahar Road, Andheri
(East), Mumbai 400 099 List of Grievance Redressal Officers at Branch:
https://content.sbigeneral.in/uploads/0449cac1bcd144bbb160d3f6b714fbbd.pdf/

Stage 3
In case, you are not satisfied with the decision/resolution communicated by the above office, or have not
received any response within 14 days, you may Register your complaint with IRDAI on the below given link
https://bimabharosa.irdai.gov.in/Home/Home

Stage 4
If your grievance remains unresolved from the date of filing your first complaint or is partially resolved, you may
approach the Insurance
Ombudsman falling in your jurisdiction for Redressal of your Grievance. The details of the Insurance
Ombudsman can be accessed at https://www.cioins.co.in/Ombudsman

Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.

UIN No: SBIPAGP11005V011011
 CUSTOMER INFORMATION SHEET
This document provides key information about your policy. You are also advised to go through your policy document.

SL Title Description Policy Clause

No Please refer to applicable policy clauses number in next column Number
1 Name of Group Personal Accident
Insurance
Product
/Policy
2 Policy 226630478
Number
3 Type of Both Indemnity and Benefit
Insurance
Product/Pol
icy
4 Sum
Insured Individual Sum Insured
(Basis) Individual Sum Insured Base
Insured Name Sum
Insured
40,00,000 VIKASH KUMAR
Note : This is the base Sum Insured for policy. Please refer the policy
schedule for cover wise limits.
5 Policy Following are covered as basic cover up to the limit specified in the policy Coverage
Coverage schedule :
(What the • Accident Death- Accident Death Cover.
Policy • Permanent Total Disability- Coverage for and Permanent Partial
Covers) Disability.

Following additional coverages :

• Child education cover - Payment towards the education support of
child and spouse.
• Repatriation and Funeral Expenses - Payment towards expenses
incurred for preparing body for burial or cremation and transportation of
body to city of residence
• Adaptation Allowance (Home and Vehicle) - Coverage for
modification of vehicle or make some changes in house.
• Ambulance cover - Payment towards expenses incurred for availing
an Ambulance service.

Note : Insurer's Liability in respect of all claims admitted during the period of
insurance shall not exceed the Sum Insured for the insured person as
mentioned in he schedule.

6 Exclusions Following is a partial list of the policy exclusions. Please refer to the General
(What the policy document for the General Exclusions complete list of Exclusions
policy does exclusions :
not cover) 1. Any pre-existing disability, disease or any complication
arising from it; or
2. Suicide, attempted suicide (whether sane or insane) or
intentionally self-inflicted injury or illness, or sexually
transmitted conditions, mental or nervous disorder, anxiety,
stress or depression, Acquired Immune Deficiency Syndrome
(AIDS), Human Immune deficiency Virus (HIV) infection; or
3. Serving in any branch of the Military or Armed Forces of any
country, whether in peace or War; or
4. Being use/ abuse of drugs, alcohol, or other intoxicants or
Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.
UIN No: SBIPAGP11005V011011
 hallucinogens unless properly prescribed by a physician and
taken as prescribed; or
5. Participation in an actual or attempted felony, riot, crime,
misdemeanour, or civil commotion or.
6. Operating or learning to operate any aircraft, or performing
duties as a member of the crew on any aircraft apart from a
Scheduled Airline; or whilst engaged in aviation or
ballooning, or whilst mounting into, dismounting from or
travelling in any balloon or aircraft other than as a passenger
(fare paying or otherwise) in any duly licensed standard type
of aircraft anywhere in the world.
7. Any loss arising out of War, civil war, invasion, insurrection,
revolution, act of foreign enemy, hostilities (whether War be
declared or not), rebellion, mutiny, use of military power or
usurpation of government or military power.

Note: The exclusions mentioned above shall not be applicable if cover is

opted under the policy.

7 Waiting Not Applicable

period
8 Financial In case of a claim, this policy requires you to share the following costs: Coverage
Limits of
the 1. Child education cover up to maximum of 1% of Accidental Death’s
Coverage Sum Insured or Rs. 20,000/- whichever is Lower for First & Second
child of insured member (In case of Death or PTD admissible
claim).
2. Repatriation and Funeral Expenses - 1% Accidental Death’s Sum
Insured subject to a maximum of Rs.10,000/-.
3. Adaptation Allowance (Home and Vehicle) - 1% Accidental Death’s
Sum Insured subject to a maximum of Rs.20,000 in case of PTD
admissible claim
4. Ambulance Cover - 1% Accidental Death’s Sum Insured up to a
maximum of Rs.1,500/- per incident/accident towards admissible
claim of Death or PTD.

9 Claims a. For Cashless Service: Insured may refer Pre-Authorization form attached Terms and
/Claims as Annexure-C to the Policy Wordings and for updated Hospital Network Condition
Procedure details refer the link https://www.sbigeneral.in/portal/contact-us/hospital
Terms and Conditions
b. For Reimbursement of Claim: For reimbursement of claims the Insured
Person may submit the necessary documents to TPA/Company within the
prescribed time limit as specified in the Policy Wordings.
Turn Around Time (TAT) for claim settlement
i. TAT for pre-authorization of cashless facility - within 1 hour from
receipt of complete documents.
ii. TAT for cashless final bill settlement - within 3 hours from receipt of
complete documents
Hospital Network details can be obtained from link:
https://www.sbigeneral.in/portal/contact-us/hospital

• Toll Free number: 1800 210 3366, 1800 210 6366

• List of Hospitals which are blacklisted or from where no claims will be
accepted by the insurer is available in below
link: https://www.sbigeneral.in/contact-us/hospital

• Claim forms can be downloaded from below

link: https://www.sbigeneral.in/claim/claims-form-download
Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.
UIN No: SBIPAGP11005V011011
 Note: For cover wise claims procedure, please refer to policy wordings.

10 Policy Email: customer.care@sbigeneral.in

Servicing Toll-Free number 1800102111 (24*7)
Website: www.sbigeneral.in

11 Grievances Stage 1: If you are dissatisfied with the resolution provided above or for lack Terms and
/Complaints of response, you may write to head.customercare@sbigeneral.in We will Condition
look into the matter and decide the same expeditiously within 14 days from
the date of receipt of your complaint. For Senior Citizens: Senior Citizens
can reach us at seniorcitizengrievances@sbigeneral.in; Toll Free - 1800 22
1111 / 1800 102 1111 (24*7)

Stage 2: In case, you are not satisfied with the decision/resolution

communicated by the above office, or have not received any response
within 14 days, you may send your Appeal addressed to the Grievance
Redressal Officer at : gro@sbigeneral.in or contact at 022-45138021.
Address: Grievance Redressal Officer, 9th Floor, A & B Wing, Fulcrum
Building, Sahar Road, Andheri (East), Mumbai 400 099. List of Grievance
Redressal Officers at
Branch:
https://content.sbigeneral.in/uploads/0449cac1bcd144bbb160d3f6b714fbb
d.pdf/

Stage 3: In case, you are not satisfied with the decision/resolution

communicated by the above office, or have not received any response
within 14 days, you may Register your complaint with IRDAI on the below
given link
https://bimabharosa.irdai.gov.in/Home/Home
Stage 4: If your grievance remains unresolved from the date of filing your
first complaint or is partially resolved, you may approach the Insurance
Ombudsman falling in your jurisdiction for Redressal of your Grievance. The
details of the Insurance Ombudsman can be accessed at (
https://www.cioins.co.in/Ombudsman )
12 Things to 1. Free Look Cancellation: The insured will be allowed period of at Terms and
remember least 30 days from the date of receipt of the policy to review the Conditions
terms and conditions of the policy and to return the same if not
acceptable. For detailed conditions and refund summary, please
refer to policy wordings.
2. Policy renewal: The Policy shall ordinarily be renewable provided
the product is not withdrawn, except on grounds of established
fraud or non-disclosure or misrepresentation by the Insured
Person.
13 Your Please disclose all pre-existing disease/s or condition/s before buying a Conditions
Obligations policy. Non-disclosure may affect the claim settlement. Disclosure of
Information: The Policy shall be void and all premiums paid thereon shall be
forfeited to the Company in the event of misrepresentation, mis-
description, or non-disclosure of any Material Fact by the Policyholder.

Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.

UIN No: SBIPAGP11005V011011
Declaration by the Policy Holder : I have read the above and confirm having noted the details.

Place :

Date :
Signature of the Policyholder :

Note:
a. For product related documents including Customer Information Sheet, kindly refer to the below link :
https://www.sbigeneral.in/downloads
b. In case of any conflict, the terms and conditions mentioned in the policy document shall prevail

Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.

UIN No: SBIPAGP11005V011011
 GROUP PERSONAL ACCIDENT Dhanlaxmi Bank Limited

ENROLLMENT FORM

Information for fields marked with asterisk (*) are mandatory.

FOR OFFICE

Quote No.: Inward No.:

Receipt No.: Receipt Date:

INTERMEDIARY'S DETAILS (* Mandatory Fields if Sales Channel Type selected is Banca)

Sales Channel Code: Specified Person’s Code*/PF ID :

Business Type: Segment Type:

Specified Person’s Name/Or Staff Name:

Conatact Details: Alternate Contact No:

Intermediary Code: Agreement code:

Details of Policy (Name): VIKASH KUMAR Sum Insured: 40,00,000

GSTIN/ISDN: Unique enrolment ID/Member ID:

Period of Insurance: From: 2025-02-07 00:00:00.0 To 2026-02-06 00:00:00.0

Midnight

Details of the Persons Proposed to be Insured*

Name*: VIKASH KUMAR
Communication Address*: S/O MUKESH KUMAR PH 8433226293 VIL SIHALINAGAR BULANDSHAHR
Landmark: City: Bulandshahr State: UTTAR PRADESH
PIN code: 203398 Nationality*: India
Email ID *:
Date of Birth*: Gender*: Male Marital Status*:
AADHAAR No.*: PAN No.*: Form 60/61*
Contact Details*: Mobile No.: 8433226293 Alternate Contact No.:
Coverages :
• Accidental Death
• Permanent Total Disability

Sum Insured Opted (Add sheet if columns are less)*

Dependen t
Primary Dependent Dependent Parentsinlaw
Benefit Spouse Dependent Parents
Insured Child 1 Child 2

Accidental
Death
Accidental
Death and
Permanent
Total
Disablement
(PTD)

Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.

UIN No: SBIPAGP11005V011011
 DETAILS OF PERSONS TO BE INSURED*

Name * Date of Birth* Age* Gender* Marital Status*

Adi Manav
VIKASH KUMAR 2002-05-20 00:00:00.0 Male

Nationality*(Indian/
Relationship ABHA (Ayushman Bharat
Non-Indian/ Basic Sum
Occupation* with Health Account) number
Non-resident Insured* (if available) :
Proposer*
Indian/Other)

40,00,000

Note: By Family we mean Self, Spouse, Dependent children, Dependent Parents/parents in-law.

I/We hereby provide consent to share my/our medical records with the insurer or TPA.
ABHA number is not available, it can be created at www.healthid.ndhm.gov.in

AKASH KUMAR Brother

Premium
Amount : NA

Name of the Appointee Relationship Appointee contact details

Instrument Type:
Bank Name: IFSC Code:
Bank Account Number: 43795939670

Branch Name:
Cheque will be issued in the name of the Proposer only.
In case of cancellation of policy, if premium were paid through credit card the refund amount would be
credited to Credit Card account directly or refund will be paid through cheque. Please provide the
following bank details and a copy of Cancelled Cheque if you opt for direct credit of refund/ claim into

Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.

UIN No: SBIPAGP11005V011011
 your bank account: (Cancelled Cheque should be of the same bank account in which the
refund / claim needs to be credited directly.
Cheque No.: Cheque Date:
Note: The proposer agrees and undertakes to intimate in writing to SBI General Insurance for any change in bank
account details. If ECS is selected, please submit the standing instruction form available at our branches.

SBIGI does not accept Cash for Premium Payments against the Policy.
Declaration & warranty on behalf of all persons proposed to be insured
1. I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above
statements, answers and/or particulars given by me are true and complete in all respects to the best of my
knowledge and that I am authorised to propose on behalf of these other persons.
2. I understand that the information provided by me will form the basis of the insurance policy, is subject to
the Board approved underwriting policy of the insurer and that the policy will come into force only after
full payment of the premium chargeable.
3. I further declare that I will notify in writing any change occurring in the occupation or general health of the
life to be insured/proposer after the proposal has been submitted but before communication of the risk
acceptance by the company.
4. I declare that I 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.
5. I authorize the company to share information pertaining to my proposal 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.”
6. I/we are aware of premium loading , (if any declared above)for habits & diseases as declared / mentioned
by me /us above.

7. I/ We hereby agree to keep record of KYC details of all individual members covered under the Group
Insurance including but not limited to HNI, Jewellers, NGO, Film Actor/ Producer and PEPs to provide the
details of beneficiaries to the company as and when required.

8.I/We hereby encourage creation of ABHA ID for all Policy holders at www.healthid.ndhm.gov.in and may
notify in case customer wishes to the same with Insurer.
Date: 30/08/2024 Place: Mumbai HO

Signature/Thumb impression of the Proposer/Primary.

ELECTRONIC ACCOUNT DETAILS
I have eIA Number
I would like to apply for eIA with : NSDL Data Management CSDL Insurance Repository Ltd
Karvy Insurance Repository Ltd CAMS Repository Services Ltd
CKYC No (Central Know Your Customer Registry Number), (if available)

Policy Renewal Advice Slip

I authorize for automatic debit of renewal premium of this cover from my account as long as the terms and
conditions and the premium remain unchanged, I understand that this authorization can be revoked by me at
my will by submitting a written notice to the bank.
Date: 30/08/2024 Signature/ Thumb impression of the Proposer/
Insured:__________________________ For internal Purpose only (To be filled by the branch official)
Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.
UIN No: SBIPAGP11005V011011
Account No.:_____________________Journal no.:_________________________Date:
30/08/2024
AML GUIDELINES (Premium Payment shall be made by the Policyholder of the Policy)
I/We hereby confirm that all premiums have been/ will be paid from bona fide sources and no premiums have
been/will be paid out of proceeds of crime related to any of the offence listed in Prevention of Money
Laundering Act 2002. I understand that the Company has the right to call for documents to establish source of
funds. The Insurance Company has the right to cancel the Insurance Contract in case I am/ have been found
guilty by any competent court of law under any statues, directly or indirectly governing the Prevention of
Money Laundering in India.
Nationality: If Non-Indian, please specify Country:
Type of Organization:
Corporations Governments Non-Governmental Organizations Society Trust
Partnership International Organization Cooperatives Section 25 Companies

I hereby declare that the current address is different from the avalilable in the Central identities Data
Repository.

Politically Exposed Persons (PEPs) are individuals who have been entrusted with prominent public functions by a
foreign country, including the heads of States or Governments, senior politicians, senior government or judicial
or military ofcers, senior executives of state-owned corporations and important political party offcials.
SECTION 41 OF INSURANCE ACT, 1938

As per Section 41 of the Insurance Act 1938, as amended, the practice of rebating is prohibited, as follows:
1. 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 or risk relating to lives or property in India,
any rebate of 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
2. Any person making default in complying with the provisions of this section shall be punishable with fine ,
which may extend to Rupees Ten Lakhs.
The Company shall not be liable for any claim or claims under this Policy arising from:
•Suicide, attempted suicide (whether sane or insane) or intentionally self-inflicted injury or
illness, or sexually transmitted conditions, mental or nervous disorder, anxiety, stress or
depression, Acquired Immune Deficiency Syndrome (AIDS), Human Immune deficiency Virus
(HIV) infection; or
• Occupations like serving in any branch of police, paramilitary, military & armed forces of any country, whether
in peace or war; or
• Being under the influence or abuse of drugs, alcohol, or other intoxicants or hallucinogens unless properly
prescribed by a physician and takenas prescribed; or
• Participation in an actual or attempted felony, riot, crime, misdemeanour, or civil commotion; or
• Operating or learning to operate any aircraft, or performing duties as a member of the crew on any aircraft
apart from a Scheduled Airline; orwhilst engaged in aviation or ballooning, or whilst mounting into,
dismounting from or travelling in any balloon or aircraft other than as a passenger (fare paying or otherwise) in
any duly licensed standard type of aircraft anywhere in the world; or
• Any loss arising out of war, civil war, invasion, insurrection, revolution, act of foreign enemy, hostilities
(whether war be declared or not),rebellion, mutiny, use of military power or usurpation of government or
military power; or
• Payment of compensation in case of death of the Insured person from nuclear damage caused by, contributed
to, by or arising from ionisingradiation or contamination by radioactivity from:
- any nuclear fuel or from any nuclear waste; - from the combustion of nuclear fuel (including any self-sustaining
process of nuclearfission);nuclear weapons material;
- nuclear equipment or any part of that equipment;

Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.

UIN No: SBIPAGP11005V011011
• The dispersal or application of pathogenic or poisonous biological or chemical
materials; the release of pathogenic or poisonous biological orchemical materials, or
congenital anomalies or any complications or conditions arising therefrom; or
• Participation in winter sports, skydiving/parachuting, hand-gliding, bungee jumping, scuba diving, ballooning,
mountainclimbing (where ropes or guides are customarily used), riding or driving in races or rallies using a
motorised vehicle or bicycle, caving or potholing, hunting or equestrian activities, skin diving or other
underwater activities, rafting or canoeing involving white water rapids, yachting or boating outside coastal
waters (2 nautical miles), participation in any professional sports, any bodily contact sport and/or any other
hazardous or potentially dangerous sport for which the Insured is untrained; or
•Death resulting directly or indirectly, contributed or aggravated or prolonged by childbirth or from pregnancy;
or
• any loss to which a contributing cause was the Insured person’s actual or attempted commission, or wilful
participation in, an illegal act or anyviolation or attempted
• violation of the law or resistance to arrest or the Insured person committing any breach of law with criminal
intent; or
• Loss caused directly or indirectly, wholly or partly by infections (except pyogenic infections which shall occur
through an accidental cut orwound) or any other kind of disease.

Insurance is subject matter of solicitation.

Disclaimer:
The details of all the individual members covered under the group insurance needs to be maintained by Master
Policyholders. The concerned business function needs to ensure that the details of beneficiaries are made
available to the Company as and when required.

Company Identity Number - U66000MH2009PLC190546. IRDAI Registration No: 144.

UIN No: SBIPAGP11005V011011
 GROUP PERSONAL ACCIDENT INSURANCE POLICY

Whereas the Insured has made to SBI General Insurance Company Ltd (hereinafter called the
“Company”), a proposal which is hereby agreed to be the basis of this Policy and has paid the premium
specified in the Schedule, now the Company agrees, subject always to the following terms, conditions,
exclusions, and limitations and the Schedule, to indemnify the Insured as is herein provided.
The benefits covered under this policy are mentioned in the Schedule attached to this policy. The policy
wording documents all the benefits that are available to the insured but covers only the benefits opted
and as mentioned in the schedule of the policy

Part A: INTERPRETATIONS & DEFINITIONS

The terms defined below have the meanings ascribed to them wherever they appear in this Policy
Document and, where appropriate, references to the singular include references to the plural; references
to the male include the female and references to any statutory enactment include subsequent changes
to the same:

1. Accident means a sudden, unforeseen and involuntary event caused by external, visible and violent
means.
2. Acquired Immune Deficiency Syndrome means the meanings assigned to it by the World Health
Organization. Acquired Immune Deficiency Syndrome shall include HIV (Human Immunodeficiency
Virus), encephalopathy (dementia), HIV Wasting Syndrome, and ARC (AIDS Related Complex).
3. Age means completed years as at the commencement date of the policy. Minimum Age for this
Policy is 18 Years and Maximum Age is 65 Years.
4. Ambulance means any vehicle used solely for the conveyance of injured persons from Accident
location or residential place of the insured or Hospital to any Hospital in emergency cases.

5. An AYUSH Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment

procedures and interventions are carried out by AYUSH Medical Practitioner(s) comprising of any of
the following.
a) Central or State Government AYUSH Hospital or
b) Teaching hospital attached to AYUSH College recognized by the Central Government/Central
Council of Indian Medicine/Central Council for Homeopathy;
Or
c) AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any
recognized system of medicine, registered with the local authorities, wherever applicable,
 and is under the supervision of a qualified registered AYUSH Medical Practitioner and must
comply with all the following criterion: i.

Having at least 5 in-patient beds; ii. Having qualified AYUSH Medical Practitioner in
charge round the clocks; iii. Having dedicated AYUSH therapy sections as required
and/or has equipped operation theatre where surgical procedures are to be carried out,
iv. Maintaining daily records of the patients and making them accessible to the insurance
company's authorized representative.

6. AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health
Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre which is registered with the local
authorities, wherever applicable and having facilities for carrying out treatment procedures and
medical or surgical/parasurgical interventions or both under the supervision of registered AYUSH
Medical Practitioner (s) on day care basis without in-patient services and must comply with all the
following criterion:

i. Having qualified registered AYUSH Medical Practitioner(s) in

charge; ii. Having dedicated AYUSH therapy sections as required
and/or has equipped operation theatre where surgical procedures
are to be carried out;
iii. Maintaining daily records of the patients and making them accessible to the insurance
company’s authorized representative.
.
7. Break in Policy means the period of gap that occurs at the end of the existing policy term/
installment premium due date, when the premium due for renewal on a given policy or installment
premium due is not paid on or before the premium renewal date or Grace Period
8. Common Carrier means any civilian Scheduled Railways or Scheduled Aircraft or any public service
vehicle as per Motor vehicle Act and in each case operated under a valid license for the
transportation of passengers for hire.
9. Condition Precedent means a policy term or condition upon which the Insurer's liability under the
policy is conditional upon.
10. Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with
reference to form, structure or position.
a. Internal Congenital Anomaly – Congenital anomaly which is not in the visible and accessible
parts of the body.
 b. External Congenital Anomaly - Congenital anomaly which is in the visible and accessible
parts of the body.
.
11. Complaint or Grievance means written expression (includes communication in the form of electronic
mail or voice based electronic scripts) of dissatisfaction by a complainant with respect to solicitation
or sale or purchase of an insurance policy or related services by insurer and /or by distribution
channel.
12. Complainant means a Policyholder or prospect or Nominee or assignee or any beneficiary of an
insurance Policy who has filed a Complaint or Grievance against an Insurer and /or distribution
channel.
13. Day means a period of 24 consecutive hours.
14. Day care Treatment refers to medical treatment, and/or surgical procedure which is:
a. undertaken under General or Local Anesthesia in a Hospital/Day care centre in less than 24
hrs because of technological advancement, and
b. which would have otherwise required a Hospitalisation of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition.
15. Day Care Hospital/ Centre means any institution established for day care treatment of illness and /
or injuries or a medical setup within a hospital and which has been registered with the local
authorities, wherever applicable, and is under the supervision of a registered and qualified medical
practitioner AND must comply with all minimum criteria as under
a. has qualified nursing staff under its employment
b. has qualified medical practitioner (s) in charge
c. has a fully equipped operation theatre of its own where surgical procedures are carried out
d. maintains daily records of patients and will make these accessible to the insurance
company’s authorized personnel.
16. Deductible means a cost-sharing requirement under a health insurance policy that provides that the
insurer will not be liable for a specified rupee amount in case of indemnity policies and for a
specified number of days/hours
in case of hospital cash policies which will apply before any benefits are payable by the insurer. A
deductible does not reduce the Sum Insured. .
17. Dental treatment means treatment carried out by a dental practitioner including examinations,
fillings (where appropriate), crowns, extractions and surgery excluding any form of cosmetic surgery/
implants.
18. Disclosure to information norm The Policy shall be void and all premium paid hereon shall be
forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any
material fact.
19. Eligible Children means a child (natural or legally adopted), who is financially dependent on the
primary insured or proposer and does not have his / her independent sources of income. The age be
between six (6) months to 21 years and who are unmarried.
20. Eligible Family means the Insured Person and/ or the Insured Person’s Spouse and/or, the Insured
Person’s Eligible Children.
21. EMI means Equated Monthly Installments which includes (Principal Amount + Monthly Interest). EMI
is always a fixed component throughout the tenor of the loan or as mutually agreed between the
Insured person and the scheduled commercial bank at the time when the loan was approved by the
scheduled commercial bank.
22. Emergency Care means management for a severe illness or injury which results in symptoms which
occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent
death or serious long term impairment of the insured person’s health.

23. Grace period means the specified period of time, immediately following the premium due date
during which premium payment can be made to renew or continue a policy in force without loss of
continuity benefits pertaining to waiting periods and coverage of pre-existing diseases. Coverage
need not be available during the period for which no premium is received. The grace period for
payment of the premium for all types of insurance policies shall be: fifteen days where premium
payment mode is monthly and thirty days in all other cases. Provided the insurers shall offer
coverage during the grace period, if the premium is paid in instalments duringthe policy period

24. Hospital: means any institution established for in- patient care and day care treatment of illness and
/ or injuries and which has been registered as a hospital with the local authorities under the Clinical
Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the
Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under:
a. has qualified nursing staff under its employment round the clock;
b. has at least 10 in-patient beds, in towns having a population of less than 10,00,000 and at
least 15 in- patient beds in all other places;
c. has qualified medical practitioner (s) in charge round the clock;
d. has a fully equipped operation theatre of its own where surgical procedures are carried out
e. maintains daily records of patients and makes these accessible to the Insurance company’s
authorized personnel.
25. Hospitalisation means admission in a Hospital for a minimum period of 24 In patient Care
consecutive hours except for specified procedures/ treatments, where such admission could be for a
period of less than 24 consecutive hours.
26. Illness/ Disease means a sickness or a disease or pathological condition leading to the impairment of
normal physiological function which manifests itself during the Policy Period and requires medical
treatment.
a. Acute condition - Acute condition is disease, illness or injury that is likely to respond quickly
to treatment which aims to return the person to his or her state of health immediately
before suffering the disease/illness/injury which leads to full recovery.
 b. Chronic condition - A chronic condition is defined as a disease, illness, or injury that has one
or more of the following characteristics:
i. it needs ongoing or long-term monitoring through consultations, examinations,
check-ups, and / or tests
ii. it needs ongoing or long-term control or relief of symptoms iii. it requires your
rehabilitation or for you to be specially trained to cope with it iv. it continues
indefinitely v. it recurs or is likely to recur
27. Injury means accidental physical bodily harm excluding illness or disease solely and directly caused
by external, violent and visible and evident means which is verified and certified by a Medical
Practitioner.
28. Inpatient means a person: (a) who is confined in a Hospital for availing medically necessary
treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered
event.
29. Inpatient Care means treatment for which the insured person has to stay in a hospital for more than
24 hours for a covered event.
30. Intensive Care Unit means an identified section, ward or wing of a Hospital which is under the
constant supervision of a dedicated Medical Practitioner(s), and which is specially equipped for the
continuous monitoring and treatment of patients who are in a critical condition, or require life
support facilities and where the level of care and supervision is considerably more sophisticated and
intensive than in the ordinary and other wards.
31. Insured means the group of persons/ Corporate/ organization/ institution/ firm/ society/ other entity
engaged in any trade or business in India on whose name the Policy is issued named as Insured in the
Schedule.
32. Insured Period means with respect to the Policy, the period commencing with the Effective Date of
the Policy and terminating with the Expiration Date of the Policy as stated in the Policy Schedule.
33. Insured Person means person from with age of 18 and up to Age 65 or the eligible Spouse and/or the
Eligible Children who are residents of India and are/is named in the Policy Schedule as being eligible
to become insured under this Policy and for whom a Proposal and Declaration Form for insurance
has been received from the Policyholder and approved by Us.
34. Immediate Family Member means an Insured Person's legal spouse; children; parents; mother-in-
law; Father- in-law; legal guardian.
35. Medical Advise means any consultation or advice from a Medical Practitioner including the issue of
any prescription or repeat prescription.
36. Medical Expenses means those expenses that an Insured Person has necessarily and actually
incurred for medical treatment on account of Illness or Accident on the advice of a Medical
Practitioner, as long as these are no more than would have been payable if the Insured Person had
not been insured and no more than other hospitals or doctors in the same locality would have
charged for the same medical treatment.
37. Medically Necessary any treatment, tests, medication, or stay in hospital or part of a stay in hospital
which
 a. is required for the medical management of the illness or injury suffered by the insured;
b. must not exceed the level of care necessary to provide safe, adequate and appropriate
medical care in scope, duration, or intensity;
c. must have been prescribed by a medical practitioner;
d. must conform to the professional standards widely accepted in international medical
practice or by the medical community in India.
38. Medical Practitioner means a person who holds a valid registration from the Medical Council of any
state or
Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the
Government of India or a State Government and is thereby entitled to practice medicine within its
jurisdiction; and is acting within the scope and jurisdiction of licence. Family members are excluded
from the Definition of Medical Practitioner.
39. Migration means a facility provided to Policyholders (including all members under family cover and
group policies), to transfer the credits gained for pre-existing diseases and specific waiting periods
from one health insurance policy to another with the same insurer.

40. Notification of claim means the process of intimating a claim to the insurer or TPA through any of
the recognized modes of communication.

41. OPD treatment means a treatment in which the Insured visits a clinic / hospital or associated facility
like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner.
The Insured is not admitted as a day care or in-patient.
42. Policy means the Insured’s Proposal and Declaration Form, the policy Schedule, Company’s covering
letter to the Insured and any enrolment forms, endorsements, papers or riders attaching to or
forming part hereof, either at the inception or during the Policy Period. Policy also includes the
statement made by the present Insured on the Proposal and Declaration Form at the time of signing
the Proposal and Declaration Form.
43. Policy Schedule means the Policy Schedule attached to and forming part of the Policy.

44. Portability means a facility provided to the health insurance Policyholders (including all members
under family cover), to transfer the credits gained for, pre-existing diseases and specific waiting
periods from one insurer to another insurer.

45. Proposal form means a form to be filled in by the prospect in physical or electronic form, for
furnishing the information including material information, if any, as required by the insurer in respect
of a risk, in order to enable the insurer to take informed decision in the context of underwriting the
risk, and in the event of acceptance of the risk, to determine the rates, advantages, terms and
conditions of the cover to be granted.

Explanation:
 (i) “Material Information” for the purpose of these regulations shall mean all important,
essential and relevant information and documents explicitly sought by insurer in the proposal
form.

(ii) The requirements of “disclosure of material information” regarding a proposal or policy,

apply both to the insurer and the prospect, under these regulations
46. Professional Sports means a sport which is the primary livelihood earning of the player, which
remunerates a player in excess of 30% of his or her annual income.
47. Qualified Nurse means a person who holds a valid registration from the Nursing Council of India or
the Nursing Council of any state in India.
48. Reasonable and Customary Charges means the charges for services or supplies, which are the
standard charges for the specific provider and consistent with the prevailing charges in the
geographical area for identical or similar services, taking into account the nature of the illness /
injury involved.
49. Renewal means the terms on which the contract of insurance can be renewed on mutual consent
with a provision of grace period for treating the renewal continuous for the purpose of all waiting
periods.
50. Scheduled Airline means any civilian aircraft operated by a civilian scheduled air carrier holding a
certificate, license or similar authorization for civilian scheduled air carrier transport issued by the
country of the aircraft’s registry, and which in accordance therewith flies, maintains and publishes
tariffs for regular passenger service between named cities at regular and specified times, on regular
or chartered flights operated by such carrier.
51. Senior Citizen means any person, who has attained the Age of sixty years or above
52. Solicitation means the act of approaching a prospect or a Policyholder by an Insurer or by a
distribution channel with a view to persuading the prospect or a Policyholder to purchase or to
renew an insurance Policy
53. Spouse means Your legal husband or wife.
54. Sum Insured means the sum as specified in the Schedule to this Policy against the name of Insured
Person, which sum represents the Company's maximum liability for any or all claims under this Policy
during the Policy period against the respective benefit(s) for which the sum is mentioned in the
Schedule to this Policy.
55. Surgery/ Surgical Procedure means manual and/or operative procedures required for treatment of
an Illness or Injury, correction of deformities and defects, diagnosis and cure of Diseases, relief of
suffering or prolongation of life, performed in a Hospital or day care centre by a Medical Practitioner.
56. Unproven/ Experimental treatment means Treatment including drug experimental therapy which is
not based on established medical practice in India, is treatment experimental or unproven.
57. War means war, whether declared or not, or any warlike activities, including use of military force by
any sovereign nation to achieve economic, geographic, nationalistic, political, racial ,religious or
other ends.
58. We, Us, Our/Company/Insurer means SBI General Insurance Company Limited.
59. You/ Your/ Yourself - means the Insured Person(s) who is named in the Schedule/Policy Schedule.
Part B: COVERAGE

We will provide the Benefits as detailed below and as shown in the Schedule to be operative for an event or
occurrence described here below that occurs during the Policy Period. The Accidental death/Permanent
total disability benefit is a mandatory cover under the policy and the benefits under other covers are
optional and as opted by the insured. The maximum liability of the Company for each of the benefit opted
is limited to its Sum Insured as reflected in the schedule of the policy and if a claim is made for more than
one of the covered benefits resulting from any accident, only one benefit amount which is the largest
among the admissible benefits, will be paid. Regardless of one or more claim during the policy period, the
maximum amount payable towards any admissible benefit covered shall be restricted to sum insured for
the Death/Permanent total disability benefit as reflected in the schedule of the policy.

1. Accidental Death (AD)

We will pay the Sum Insured, as mentioned in the Policy Schedule, for any injury that is caused due to an
Accident that immediately or eventually results in Your loss of life, provided that such loss occurs under
the circumstances described in the policy within 365 Days from the date of the Accident which caused
the Injury.

We will pay the Sum Insured less any other amount paid or payable under Permanent Total Disability,
Permanent partial disability section of this Policy, if these coverage are offered under this Policy, as the
result of the same
Accident

Exposure: For the purposes of the Accidental Death benefit above, a loss resulting from You being
unavoidably exposed to the elements due to an Accident occurring under the circumstances described in
the policy will be payable as if resulting from an Injury. Loss must occur within 365 Days of the date of
the Accident.

Exclusions: In addition to the General Exclusions listed in this Policy this coverage under this section will
not cover any loss caused directly or indirectly, wholly or partly by:
a) infections (except pyogenic infections which shall occur through an Accidental cut or wound) or any
other kind of Disease;
b) medical or surgical treatment except as may be necessary solely as a result of Injury;

2. Permanent Total Disability (Including Loss of Sight and Hearing) (PTD)

We will pay a percentage of the Sum Insured shown against Permanent Total Disability in the Policy
Schedule if Injury to You results in one of the losses shown in the Table of Losses below. The loss must
occur under the circumstances described under the policy within 365 Days from the date of the Accident
which caused Injury.
We will pay, provided such disability has continued for a period of 12 consecutive months and is total,
continuous and Permanent at the end of this period, the Sum Insured less any other amount paid or
payable under: Permanent Partial Disability section of this Policy, if these coverage’s are offered under
this Policy, as the result of the same Accident.

If more than one loss results from any one Accident, the largest of the amount that becomes payable will
be paid.
Table of Losses

Loss of: % of Sum

Insured
Both Hands and Both Feet 100%

Sight of Both Eyes 100%

One Hand and One Foot 100%

Either Hand or Foot and Sight of One 100%

Eye
Speech and Hearing in Both Ears 100%

Either Hand or Foot 50%

Sight of One Eye 50%

Speech or Hearing in Both Ears 50%

Hearing in One Ear 25%

Thumb and Index Finger of Same 25%

Hand
“Loss” with regard to:

a) hand or foot means actual severance through or above the wrist or ankle joints respectively;
b) eye means entire and irrecoverable loss of sight;
c) thumb and index finger means actual severance through or above the joint that meets the hand at
the palm;
d) speech or hearing means entire and irrecoverable loss of speech or hearing of both ears;
Exposure:
For the purposes of the Accidental Dismemberment benefit above, a loss resulting from You being
unavoidably exposed to the elements due to an Accident occurring under the circumstances described in
 a Hazard will be payable as if resulting from an Injury. Loss must occur within 365 Days of the date of the
Accident.

Definitions:
Permanent - means lasting twelve calendar months and at the expiry of that period being beyond
reasonable hope of improvement.
Permanent Total Disability - means You are unable to engage in each and every occupation or
employment for compensation or profit for which You are reasonably qualified by education, training or
experience for the rest of your life. If at the time of loss You are unemployed, Permanent Total Disability
shall mean the total and Permanent inability to perform all of the usual and customary duties and
activities of a person of like age and sex.

Exclusion:
In addition to the General Exclusions listed in this Policy this coverage section shall not cover loss caused
directly or indirectly, wholly or partly by:

a) infections (except pyogenic infections which shall occur through an Accidental cut or wound) or any
other kind of Disease;

b) Medical or surgical treatment except as may be necessary solely as a result of Injury.

3. Permanent Partial Disability (PPD)
When as the result of Injury occurring during the policy period and commencing within 365 Days from
the date of the Accident, You suffer a Permanent Partial Disability, We will pay, provided such disability
has continued for a period of 12 consecutive months and is continuous and Permanent, at the end of this
period, a percentage of the Sum Insured shown in the Policy Schedule if Injury to You results in one of
the losses shown in the Scale below less any other amount paid or payable under the Accidental
Dismemberment, or Permanent Total Disability, or Permanent Total Loss of Use sections of this Policy as
the result of the same Accident.
Scale Percentage of Sum
Insured:
Loss of toes – all (both feet) 20%

Great toe 5%

Other than great toe, if more than one toe lost, 1%

each
Loss of four fingers and thumb of one hand 40%

Loss of four fingers 25%

 Loss of thumb 15%

Loss of index finger 10%

Loss of middle finger 6%

Loss of ring finger 5%

Loss of little finger 4%

"Loss" with regard to:

a) Toe, finger, thumb means actual complete severance from the foot or hand;

b) Hearing means entire and irrecoverable loss of hearing.

When more than one form of disability results from one Accident, We add the percentages from each
together. However, We will not pay more than 100% of the Sum Insured shown in the Policy Schedule.
If claim is payable for loss or loss of use of a whole member of the body, a claim for parts of that member
cannot also be made.
If the Insured Person has an existing medical condition and they suffer Injury, We will assess whether the
Insured Person’s medical condition has contributed to their disability; and whether the disability makes
the Insured Person’s medical condition worse. In either case, We will assess the difference between the
Insured Person’s medical condition before, and their disability after the Accident. Any payment We make
will be based on the difference, expressed as a percentage, and applied to the appropriate benefit above
or in the Scale.

Definitions:
Permanent - means lasting twelve calendar months and at the expiry of that period being beyond
reasonable hope of improvement.
Permanent Partial Disability - means the Insured Person has suffered a Permanent loss of physical
function or anatomical loss of use of a body part, substantiated by a diagnosis by a Medical Practitioner.

Exclusion:
In addition to the General Exclusions listed in this Policy this coverage section shall not cover loss caused
directly or indirectly, wholly or partly by:

a. infections (except pyogenic infections which shall occur through an Accidental cut or wound) or
any other kind of Disease;
b. medical or surgical treatment except as may be necessary solely as a result of Injury.
 4. Temporary Total Disability or Weekly Indemnity (TTD)
We Shall Pay a weekly benefit amount during the a period of continuous Temporary Total Disability of the
Insured Person resulting from Injury during the policy period after completion of the Elimination Period
shown in the Policy Schedule, provided that:
a) Such period of disability commences within 30 days aster the date of the Accident causing the Injury
and
b) Such amount shall be payable as stated in the Policy Schedule as applicable to the Insured Person;
and
c) The maximum period for which such amount shall be payable for any one such period of disability
shall not exceed the maximum number of weeks payable as stated in the Policy Schedule and in no
event to exceed 104 weeks whichever is lesser.
d) This coverage is not available for Insured Person whose Age is above 60 years or Below 18 years.
Any payment made under this benefit shall be deducted from any Accidental Death, or Permanent Total
Disability, or Permanent Partial Disability, benefits if available under this Policy, which ultimately
becomes payable under this Policy as a result of the same Accident.

Definitions:
Elimination Period: means the number of consecutive days of Temporary Total Disability that must
elapse before the weekly benefit amounts become payable. The Elimination Period is shown under the
Policy Schedule. Weekly benefits are not payable, nor do they accrue, during the Elimination Period.
Temporary Total Disability: means disability which wholly and continuously prevents such Insured
Person from performing each and every duty pertaining to his occupation.

Compensation:

1. In case of claim by death or permanent total disablement compensation will be made only after
deleting the name of the deceased/ injured person in respect of whom such sums shall become
payable.
2. In case of claim by permanent partial disablement , compensation will be made only after reduction
of Capital Sum by the amount admissible under the claim in respect of the injured person.
3. In case of Temporary Total Disablement Benefit ,compensation will be made only upon termination of
such disablement in respect of Injured person or on the expiry of 104 weeks of disablement,
whichever occurs earlier

Part C: GENERAL EXCLUSIONS

The Company will not be liable under the Policy in respect of loss or damage due to -

1. Any pre-existing disability, disease or any complication arising from it; or

2. Suicide, attempted suicide (whether sane or insane) or intentionally self-inflicted injury or illness, or
sexually transmitted conditions, mental or nervous disorder, anxiety, stress or depression, Acquired
Immune Deficiency Syndrome (AIDS), Human Immune deficiency Virus (HIV) infection; or
3. Serving in any branch of the Military or Armed Forces of any country, whether in peace or War; or
4. Being use/ abuse of drugs, alcohol, or other intoxicants or hallucinogens unless properly prescribed
by a physician and taken as prescribed; or
5. Participation in an actual or attempted felony, riot, crime, misdemeanour, or civil commotion or.
6. Operating or learning to operate any aircraft, or performing duties as a member of the crew on any
aircraft apart from a Scheduled Airline; or whilst engaged in aviation or ballooning, or whilst
mounting into, dismounting from or travelling in any balloon or aircraft other than as a passenger
(fare paying or otherwise) in any duly licensed standard type of aircraft anywhere in the world.
7. Any loss arising out of War, civil war, invasion, insurrection, revolution, act of foreign enemy,
hostilities (whether War be declared or not), rebellion, mutiny, use of military power or usurpation of
government or military power; or
8. Payment of compensation in case of death of or bodily injury to the Insured person from Nuclear
damage caused by, contributed to, by or arising from ionising radiation or contamination by
radioactivity from: a) any nuclear fuel or from any nuclear waste; or

b) from the combustion of nuclear fuel (including any self-sustaining process of nuclear fission); c)
nuclear weapons material;
d) nuclear equipment or any part of that equipment; or
e) The dispersal or application of pathogenic or poisonous biological or chemical materials; The
release of pathogenic or poisonous biological or chemical materials, or Congenital anomalies or
any complications or conditions arising there from; or
9. Participation in winter sports, skydiving/parachuting, hand gliding, bungee jumping, scuba diving,
ballooning, mountain climbing (where ropes or guides are customarily used), riding or driving in races
or rallies using a motorized vehicle or bicycle, caving or pot-holing, hunting or equestrian activities,
skin diving or other underwater activity, rafting or canoeing involving white water rapids, yachting or
boating outside coastal waters (2 Nautical miles), participation in any Professional Sports, any bodily
contact sport or/and any other hazardous or potentially dangerous sport for which You are
untrained.
10. Death or disablement resulting directly or indirectly, contributed or aggravated or prolonged by
childbirth or from pregnancy, or

11. For any loss to which a contributing cause was Your actual or attempted commission, or wilful
participation in, an illegal act or any violation or attempted violation of the law or resistance to arrest
or insured person committing any breach of law with criminal intent
 Part D: TERMS AND CONDITIONS:

1. Entire contract - changes: This Policy, together with the Proposal and Declaration Form, as well
as any forms, riders and endorsements and papers hereto, constitutes the entire contract of
insurance. No change in this Policy shall be valid until approved by Our authorised officer and
such approval is endorsed hereon. No agent has authority to change this Policy or to waive any
of the provisions of this Policy.

2. Effective date: Your Policy will start on the Effective Date as specified in the Policy Schedule
provided, it is countersigned by Us and the total premium has been paid. However, Your
coverage under this Policy begins at the latest on :
a) The Effective Date of the Policy as stated above; or
b) The date on which the premium is paid when due; or.
c) The date the person becomes a member of an eligible class of Insured Person(s) as
described in the Schedule to the Policy.

Renewal Conditions:
i. The Policy shall ordinarily be renewable provided the product is not withdrawn, except on grounds of
established fraud or non-disclosure or misrepresentation by the Insured Person. ii. The Company shall
endeavor to give notice for Renewal. However, the Company is not under obligation to give any notice for
Renewal. iii. Renewal shall not be denied on the ground that the Insured Person had made a Claim or
Claims in the preceding Policy years. iv. Request for Renewal along with the requisite premium shall be
received by the Company before the end of the Policy Period
a At the end of the Policy Period, the Policy shall terminate and can be renewed within the Grace Period of
30 days to maintain continuity of benefits without Break in Policy. Coverage is not available during the
Grace Period.
v. No loading shall apply on Renewals based on individual Claims experience

3. Withdrawal of Product – In case of withdrawal of this product insurer will communicate to

Insured at least 3 months prior to the withdrawal. Existing policy will continue to remain in
force till its expiry, and at the time of renewal, Insured will have option to migrate to insurer’s
group personal accident insurance products available at that time.

4. Free Look Period:

(1) Every Policyholder of new individual health insurance policies except those with tenure of less
than a year, shall be provided a free look period of 30 days beginning from the date of receipt of policy
document, whether received electronically or otherwise, to review the terms and conditions of such
Policy.
 (2) In the event a Policyholder disagrees to any of the Policy terms or conditions, or otherwise and
has not made any claim, he shall have the option to return the Policy to the insurer for cancellation,
stating the reasons for the same.
(3) Irrespective of the reasons mentioned, the Policyholder shall be entitled to a refund of the
premium paid subject only to a deduction of a proportionate risk premium for the period of cover and
the expenses, if any, incurred by the insurer on medical examination of the proposer and stamp duty
charges.
(4) A request received by insurer for cancellation of the Policy during free look period shall be
processed and premium shall be refunded within 7 days of receipt of such request, as stated at sub
regulation (3) above.

5. Multiple Policies:
a)Indemnity Policies:
A Policyholder can file for Claim settlement as per his/her choice under any Policy. The Insurer of
that chosen Policy shall be treated as the primary Insurer.

In case the available coverage under the said Policy is less than the admissible Claim amount, the primary
Insurer shall seek the details of other available policies of the Policyholder and shall coordinate with
other Insurers to ensure settlement of the balance amount as per the Policy conditions, without
causing any hassles to the Policyholder.

b) Benefit based Policies:

On occurrence of the Insured event, the Policyholders can Claim from all Insurers under all policies.

6. Moratorium Period:
After completion of sixty continuous months of coverage (including portability and migration) in
health insurance Policy, no Policy and claim shall be contestable by the Insurer on grounds of non-
disclosure, misrepresentation, except on grounds of established fraud. This period of sixty
continuous months is called as moratorium period. The moratorium would be applicable for the
Sums Insured of the first Policy. Wherever, the Sum Insured is enhanced, completion of sixty
continuous months would be applicable from the date of enhancement of Sums Insured only on the
enhanced limits.

7. Termination of Policy -
a) This Policy will terminate on the expiration of the period for which premium has been paid or on
the Expiration Date mentioned in the Proposal, Declaration Form and Policy Schedule, whichever
is earlier.
b) However, We may cancel this Policy at any time by giving you fifteen (15) Days notice delivered to
You, or mailed to Your last address as shown by Our records, stating when such cancellation shall
be effective.
 a. Such cancellation will be on grounds of mis-representation, fraud, non-disclosure of
material facts or non-cooperation of the insured.
b. In the event of cancellation, We will return promptly the pro-rata unearned portion of
any premium You have actually paid. Such cancellation shall be without prejudice to any
claim originating prior thereto.
c. If you cancel the Policy, the earned premium shall be computed in accordance with our
short rate table for the period the Policy has been in force, provided no claim has
occurred up to the date of cancellation in which case the whole premium shall be fully
earned and no return of premium will be made.
c) The date the Insured Person is no longer eligible within the classification of Insured Person(s)
described in the Policy Schedule.
d) This policy will terminate with respect to an insured person on payment of a Death/PTD claim for
that person.
e) You cease to be a resident of India.

8. Territory: This Policy applies to incidents anywhere in the world unless limited by Us through
endorsement. However, Coverage under Accident hospital cash and Accidental Medical Expense are
applicable only if the accident happens within the geographical limits of India. We will make payment
within India and in Indian Rupees. The construction, interpretation and meaning of the provisions of
this Policy shall be determined in accordance with Indian Law.

9. Concealment or fraud: The entire Policy will be void if, whether before or after a loss, You have,
related to this insurance,
a) Intentionally or recklessly or otherwise concealed or misrepresented what we consider to be any
material fact or circumstance or
b) Engaged in what we consider to be fraudulent, dishonest or deceitful conduct; or c) Made
false statements.
If a claim is in any respect fraudulent or if any false declaration is made or used in support thereof or
if any fraudulent means or devices are used by the insured or any one acting on his behalf to obtain
benefit under this Policy, all benefit under this Policy shall be forfeited.

10. Change in risk: The Insured Person shall at the time of payment of any premium for the renewal of
the Policy give notice in format attached to the Company of change in occupation or any disease,
physical defect or infirmity with which any of the Insured Person have become affected, since
payment of last preceding premium.

11. Notice of claim/ loss : It is a condition precedent to Our liability hereunder that written notice of
claim must be given by You to Us within 7 days after an actual or potential loss begins or as soon as is
reasonably possible and in any event, not later than 30 Days after an actual or potential loss begins.
12. Claim Forms: We, upon receipt of a notice of claim, will furnish Your representative with such forms
as We may require for filing proofs of loss.

13. Time for filing claim forms and evidence: Completed claim forms and written evidence of loss must
be furnished to Us within thirty (30) Days after the date of such loss. Failure to furnish such evidence
within the time required shall not invalidate nor reduce any claim if You can satisfy us that it was not
reasonably possible for You to give proof within such time. However, no proof will be accepted if
furnished later than one (1) year from the time the loss occurred. Requirement of all or any of the
following indicative documents will depend on the nature of claim.
a) Claim form duly signed
b) Policy copy
c) Claim Intimation
d) FIR / MLC Copy /Spot Panchnama / Inquest Panchnama
e) Death Certificate
f) Post Mortem Report (If conducted)
g) Final Police Report
h) Affidavit from the legal heirs of the deceased (in case nomination has not been filed by deceased)
i)
Investigation reports
j) Medical certificate
k) Disability Certificate
l) Photograph of the injured with reflecting disablement
m) Discharge card
n) Education ID card
o) Doctor certificate for person’s residential accommodation and/or vehicle
p) Receipt of ambulance usage

14. Payment of claim: All claims admissible under this Policy that are payable to You/ Your nominee, shall
be paid in Indian currency.

15. Penal Interest Provision: Upon acceptance of an offer of settlement by the insured, the payment of
the amount due shall be made within 7 days from the date of acceptance of the offer by the insured.
In the cases of delay in the payment, the insurer shall be liable to pay interest at a rate which is 2%
above the bank rate prevalent at the beginning of the financial year in which the claim is reviewed by
it.

16. Bank Rate means Bank rate fixed by the Reserve Bank of India (RBI) which is prevalent as on 1st day
of the financial year in which the claim has fallen due)
17. Change Of Nominee: No change of nominee under this Policy shall bind Us, unless the change
thereto is consented to and formally endorsed thereon by Our authorized officer.

18. Legal Actions: Without prejudice to Uniform Provision 14, no action at law or in equity shall be
brought to recover on this Policy prior to the expiration of sixty (60) Days after written evidence has
been furnished in accordance with the requirements of this Policy. If no evidence has been furnished
within one (1) year of the date upon which it should have been furnished then the claim shall for all
purposes be deemed to have been abandoned and shall not thereafter be recoverable under this
Policy. If We disclaim liability to You for any claim, and if You do not notify Us in writing within one (1)
year from the date of receipt of the notice of such disclaimer that You do not accept such disclaimer
and intend to recover this claim from Us, then the claim shall for all purposes be deemed to have
been abandoned and shall not thereafter be recoverable under this Policy.

19. Medical examination: We, at Our own expense, shall have the right and opportunity to get a post
mortem examination report of Your body, if conducted. Your estate's compliance with the need for
such examination report is a condition precedent to establishing liability under the Policy.

20. Misstatement of age: If Your Age has been misstated, all amounts payable under this Policy shall be
adjusted to the coverage amount that would have been purchased for the premium paid. In the
event that Your Age has been misstated, and if according to Your correct Age, the coverage provided
by the Policy would not have become effective, or would have ceased prior to the acceptance of such
premium or premiums, then Our liability during the period You are not eligible for coverage, shall be
limited to the refund, upon written request, of all premiums paid for the period not covered by the
Policy.

21. Change of occupation: If You sustain a loss after having changed occupation to one We classify as
more hazardous than that stated in the Proposal or while doing for compensation anything
pertaining to an occupation so classified, We will pay such portion of the indemnities provided in this
policy as the premium paid would have purchased at the rates and within the limits We have fixed for
such more hazardous occupation.
22. Compliance with policy provisions: Failure to comply with any of the provisions contained in this
Policy shall invalidate all claims hereunder. The due observance and fulfilment of the terms,
provisions and conditions of and endorsement on this policy and schedule in so far as they relate to
anything to be done or complied with by the Insured and the truth of the statement and answers in
the said proposal shall be conditions precedent to any liability of the Company to make any payment
under this Policy.
23. Interest On The Benefit We Pay: We will not pay any interest on any benefit except as required by
section 9(6) of the IRDA (PPI) Regulation 2002

24. Nomination and Assignment: This Policy is not assignable and no person(s) other than Insured or
Insured’s nominee(s) as mentioned in the schedule or legal representatives, wherever is applicable,
can claim or sue the Insurer under this policy.
 The payment by the Insurer to the Insured, his/her nominee or legal representative of any
compensation or benefit under the policy shall in all cases be an effectual discharge to the Insurer.

25. Choice of law: This Policy will be governed by the law in force in the Republic of India.

26. Any notice, direction or instruction under this Policy shall be in writing and if it is to:
a) Any Insured, then it shall be sent to the Insured at the address specified in the Schedule.
b) The company, it shall be delivered to the address of the company specified in the Schedule. Proof
of delivery of such notices shall be retained by the Insured and furnished to the company as and
when demanded.

27. Cancellation
a) You may cancel this Policy at any time by giving Us 15 days written notice. If no claim has been
made under the Policy then We will refund premium in accordance with the table below:
Length of time Policy in force Refund of premium

up to 1 month 75%

up to 3 months 50%

up to 6 months 25%

exceeding 6 months 0%
b) We may cancel this Policy upon 15 days notice by sending a written notice of cancellation to Your
address and We shall refund a rateable proportion of the premium actually paid in respect of any
Insured Person. Cancellation of this Policy shall not affect any claim filed prior to the date on
which cancellation becomes effective as specified in the notice of cancellation.
c) Such cancellation will be on grounds of mis-representation, fraud, non-disclosure of material
facts or non- cooperation of the insured.

28. Adjustment of Premium (applicable to policies issued on unnamed employees basis):

a) The premium payable hereon has been determined by reference to your estimate of the number
of persons and their category as stated in the Schedule. It is hereby agreed that during the Policy
Period you shall maintain a proper and contemporaneous record of the actual number of
persons within such category, which record shall be available for inspection by us at any
reasonable time.
b) Within one month from the expiry of this Policy, you shall provide us with a written record of the
actual number of persons within such category during the Policy Period and any information or
supporting documentation in respect thereof at our request. If the actual number of persons
 within such category ascertained after the expiry of this Policy shall differ from your original
estimate thereof, then:
c) if the actual number of persons within such category exceeds the estimate of the same, you shall
pay us any additional premium that we may determine by reference to the differential, or
d) if the actual number of persons within such category is less than the estimate of the same, we
will reimburse you by reference to the differential but subject to minimum retention of premium
of 50%
e) Payment and adjustment of premium shall be in compliance with sec 64 VB of Insurance Act
1938.

29. Grievances:
Stage 1: If you are dissatisfied with the resolution provided above or for lack of response, you may write
to head.customercare@sbigeneral.in We will look into the matter and decide the same expeditiously within
14 days from the date of receipt of your complaint.

For Senior Citizens: Senior Citizens can reach us at seniorcitizengrievances@sbigeneral.in; Toll Free -
1800 22 1111 / 1800 102 1111 (24*7)

Stage 2: In case, you are not satisfied with the decision/resolution communicated by the above
office, or have not received any response within 14 days, you may send your Appeal addressed to the
Grievance Redressal Officer at : gro@sbigeneral.in or contact at 022-45138021.

Address: Grievance Redressal Officer, 9th Floor, A & B Wing, Fulcrum Building, Sahar Road, Andheri
(East), Mumbai 400 099. List of Grievance Redressal Officers at Branch:
https://content.sbigeneral.in/uploads/0449cac1bcd144bbb160d3f6b714fbbd.pdf/

Stage 3: In case, you are not satisfied with the decision/resolution communicated by the above
office, or have not received any response within 14 days, you may Register your complaint with IRDAI on the
below given link https://bimabharosa.irdai.gov.in/Home/Home

Stage 4: If your grievance remains unresolved from the date of filing your first complaint or is
partially resolved, you may approach the Insurance Ombudsman falling in your jurisdiction for Redressal of
your Grievance. The details of the Insurance Ombudsman can be accessed at
(https://www.cioins.co.in/Ombudsman)

Annexure A

Names of Ombudsman and Addresses of Ombudsmen centers

 Areas of Jurisdiction Office of the Insurance Ombudsman

Shri Collu Vikas Rao

Insurance Ombudsman
Office of the Insurance Ombudsman, Jeevan Prakash
Gujarat, UT of Dadra & Nagar Haveli, Daman Building, 6th floor, Tilak Marg, Relief Road,
AHMEDABAD - 380 001.
and Diu
Tel.: 079 - 25501201/02/05/06
Email: bimalokpal.ahmedabad@cioins.co.in

Mr Vipin Anand
Insurance Ombudsman
Office of the Insurance Ombudsman, Jeevan Soudha
Karnataka. Building,PID
No. 57-27-N-19 Ground Floor, 19/19, 24th Main Road,
JP Nagar, Ist Phase, Bengaluru - 560 078. Tel.: 080 -
26652048
/
26652049
Email: bimalokpal.bengaluru@cioins.co.in

Shri R. M. Singh
Insurance Ombudsman
Office of the Insurance Ombudsman, 1st floor,"Jeevan
Madhya Pradesh, Chhattisgarh Shikha",
60-B,Hoshangabad Road, Opp. Gayatri Mandir, Bhopal -
462
011.
Tel.: 0755 - 2769201 / 2769202
Email: bimalokpal.bhopal@cioins.co.in
 Shri Manoj Kumar Parida
Insurance Ombudsman
Office of the Insurance Ombudsman, 62, Forest park,
Orissa. Bhubaneswar - 751 009.
Tel.: 0674 - 2596461 /2596455
Email: bimalokpal.bhubaneswar@cioins.co.in

Mr Atul Jerath
Punjab,Haryana, Insurance Ombudsman
Himachal Pradesh, Office of the Insurance Ombudsman,
Jammu & Kashmir, S.C.O. No. 101, 102 & 103, 2nd Floor,
Chandigarh. Batra Building, Sector 17 - D, Chandigarh - 160 017.
Tel.: 0172 - 2706196 / 2706468
Email: bimalokpal.chandigarh@cioins.co.in

Shri Segar Sampathkumar

Insurance Ombudsman
Office of the Insurance Ombudsman,
Tamil Nadu, PuducherryTown and Karaikal Fatima Akhtar Court, 4th Floor, 453, Anna Salai,
(which are part of Puducherry). Teynampet, CHENNAI - 600 018.
Tel.: 044 - 24333668 / 24335284
Email: bimalokpal.chennai@cioins.co.in

Ms Sunita Sharma
Insurance Ombudsman
Office of the Insurance Ombudsman, 2/2 A, Universal
Delhi & following Districts of Haryana - Insurance
Gurugram, Faridabad, Sonepat & Bahadurgarh. Building, Asaf Ali Road, New
Delhi - 110 002.
Tel.: 011 - 23232481/23213504
Email: bimalokpal.delhi@cioins.co.in
 Shri Somnath Ghosh
Insurance Ombudsman
Assam, Meghalaya, Office of the Insurance Ombudsman, Jeevan Nivesh, 5th
Manipur, Mizoram, Floor,
Arunachal Pradesh, Nagaland and Nr. Panbazar over bridge, S.S. Road, Guwahati -
Tripura. 781001(ASSAM).
Tel.: 0361 - 2632204 / 2602205
Email: bimalokpal.guwahati@cioins.co.in

Shri N. Sankaran
Andhra Pradesh, Insurance Ombudsman
Telangana, Yanam and part of Office of the Insurance Ombudsman, 6-2-46, 1st floor,
Territory of UT of Pondicherry. "Moin
Court", Lane Opp. Saleem Function Palace,
A. C. Guards, Lakdi-Ka-Pool, Hyderabad - 500 004.
Tel.: 040 - 23312122
Email: bimalokpal.hyderabad@cioins.co.in

Shri Rajiv Dutt Sharma

Insurance Ombudsman
Office of the Insurance Ombudsman, Jeevan Nidhi - II
Rajasthan. Bldg., Gr. Floor, Bhawani Singh Marg, Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: bimalokpal.jaipur@cioins.co.in

Shri G. Radhakrishnan Insurance Ombudsman

Office of the Insurance Ombudsman, 2nd Floor, Pulinat
Bldg., Opp. Cochin Shipyard, M. G. Road, Ernakulam -
Kerala, Lakshadweep, Mahe-a part of Union 682 015.
Territory of Puducherry Tel.: 0484 - 2358759 / 2359338
Email: bimalokpal.ernakulam@cioins.co.in
 Ms Kiran Sahdev
Insurance Ombudsman
West Bengal, Office of the Insurance Ombudsman, Hindustan Bldg.
Sikkim, Annexe, 7th Floor, 4, C.R. Avenue, KOLKATA - 700 072.
UT of Andaman & Nicobar Islands. Tel.: 033 - 22124339 / 22124340
Email: bimalokpal.kolkata@cioins.co.in

Districts of Uttar Pradesh : Shri. Atul Sahai

Laitpur, Jhansi, Mahoba, Hamirpur, Banda, Insurance Ombudsman
Chitrakoot,Allahabad, Mirzapur, Sonbhabdra, Office of the Insurance Ombudsman, 6th Floor, Jeevan
Fatehpur,Pratapgarh, Jaunpur,Varanasi, Gazipur, Bhawan, PhaseII, Nawal Kishore Road, Hazratganj,
Jalaun, Kanpur,Lucknow, Unnao, Sitapur, Lucknow - 226 001.
Lakhimpur, Bahraich, Barabanki, Raebareli, Tel.: 0522 - 2231330 / 2231331
Sravasti, Gonda, Faizabad, Amethi, Email: bimalokpal.lucknow@cioins.co.in
Kaushambi,Balrampur, Basti,
Ambedkarnagar, Sultanpur,
Maharajgang,Santkabirnagar, Azamgarh,
Kushinagar, Gorkhpur, Deoria, Mau,
Ghazipur, Chandauli, Ballia, Sidharathnagar.

Ms Susmita Mukherjee
Insurance Ombudsman
Office of the Insurance Ombudsman, 3rd Floor, Jeevan
Goa, Mumbai Metropolitan Region (excluding Seva Annexe, S. V. Road, Santacruz (W), Mumbai - 400
Navi Mumbai & Thane). 054.
Tel.: 69038821/23/24/25/26/27/28/28/29/30/31
Email: bimalokpal.mumbai@cioins.co.in
 State of Uttaranchal and the following Districts Shri Bimbadhar Pradhan
of Uttar Pradesh: Insurance Ombudsman
Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Office of the Insurance Ombudsman, Bhagwan Sahai
Bulandshehar, Palace 4th Floor, Main Road, Naya Bans, Sector 15, Distt:
Etah, Kanooj, Mainpuri, Mathura, Meerut, Gautam Buddh Nagar, U.P-201301.
Moradabad, Tel.: 0120-2514252 / 2514253
Muzaffarnagar, Oraiyya, Pilibhit, Etawah, Email: bimalokpal.noida@cioins.co.in
Farrukhabad, Firozbad,
Gautambodhanagar, Ghaziabad, Hardoi,
Shahjahanpur, Hapur,
Shamli, Rampur, Kashganj, Sambhal, Amroha,
Hathras,
Kanshiramnagar, Saharanpur.

Ms Susmita Mukherjee Insurance Ombudsman

Office of the Insurance Ombudsman, 2nd Floor, Lalit
Bhawan, Bailey Road, Patna 800 001.
Bihar, Jharkhand. Tel.: 0612-2547068
Email: bimalokpal.patna@cioins.co.in

Shri Sunil Jain

Insurance Ombudsman
Maharashtra, Areas of Navi Mumbai and Thane Office of the Insurance Ombudsman, Jeevan Darshan
(excluding Mumbai Metropolitan Region). Bldg., 3rd Floor, C.T.S. No.s. 195 to 198, N.C. Kelkar Road,
Narayan Peth, Pune - 411 030.
Tel.: 020-41312555
Email: bimalokpal.pune@cioins.co.in

An updated list of Ombudsmen Offices is available at the following link: http://www.gbic.co.in/ombudsman.html

ADDITONAL COVERS WHICH CAN BE AVAILED UNDER THE GROUP PERSONAL ACCIDENT POLICY UPON PAYMENT OF ADDITIONAL PREMIUM

a. ACCIDENTAL MEDICAL EXPENSES – INPATIENT

We will pay the Reasonable and Customary Charges, subject to the Deductible shown in the Policy Schedule,
for Covered Medical Expenses incurred in the Republic of India by You as an Inpatient in a Hospital for medical
services which are not due to a Pre-existing Disease up to the maximum amount and benefit period stated in
the Policy Schedule and subject to any Deductible mentioned in Policy Schedule, for Immediate Medical
Treatment of an Injury sustained by You due to an accident, while this Policy is in effect.
Definitions:
Covered Medical Expenses - means expenses incurred within the Republic of India by you for medical
services and supplies which are recommended by the attending Physician for an accidental injury. They
include: a) The services of a Physician;
b) Hospital confinement and use of operating room;
c) Anaesthetics (including administration), radiological or imaging investigations or treatments, and
laboratory
tests;
d) Ambulance service;
e) Drugs, medicines, and therapeutic services and supplies;.

Immediate Medical Treatment - means treatment commencing within 24 hours of the time and date of
the Accidental bodily Injury. Only Covered Medical Expenses are covered.

In addition to the General Exclusions listed in this Policy this coverage section shall not cover:
1. Any treatment of any disease, sickness or illness.
2. This coverage is not available for Insured Person whose Age is above 60 years or Below 18 years.
3. Services, supplies, or treatment, including any period of Hospital confinement, which were not
recommended, approved, and certified as Medically Necessary by a Physician; or
4. Routine physicals or other examinations where there are no objective indications of impairment in
normal health, and laboratory diagnostic or X-ray examinations except in the course of a disability
established by the prior call or attendance of a Physician; or
5. Elective, cosmetic, or plastic surgery, except as a result of an Injury caused by a covered Accident
while Our Policy is in force; or
6. Dental care, except as a result of Injury caused by Accident to Sound Natural Teeth while this Policy
is in effect;
or
7. Expenses incurred in connection with weak, strained, or flat feet, corns, calluses, or toenails;or 8.
The diagnosis and treatment of acne; or
9. Deviated Nasal septum, including sub mucous resection and/or other surgical correction thereof; or
10. Organ transplants that are considered experimental in nature; or
11. Child care including routine investigations and immunizations; or
12. Expenses which are not exclusively medical in nature; or
13. Eyeglasses, contact lenses, hearing aids, and examination for the prescription or fitting thereof,
unless Injury or no Sickness cover has caused impairment of vision or hearing; or
14. Treatment provided in a government Hospital or services for which no charge is normally made; or
15. Mental, nervous, or emotional disorders or rest cures; or
16. Pregnancy and all related conditions, including services and supplies related to the diagnosis or
treatment of infertility or other problems related to inability to conceive a child; birth control,
including surgical procedures and devices; or
17. Medical expenses covered under any workers’ compensation or similar policy; or
18. Medical expenses incurred as the result of alcohol and/or drug abuse, addiction or overdose ;or
Therapeutic services unless conclusive scientific evidence proves, that it improves health outcome.

19. 19. Medical expenses incurred outside the Republic of India

b. ACCIDENT HOSPITALISATION (OUTPATIENT)

If any Insured Person suffers an Accident during the Policy Period that requires Outpatient Treatment, We
will pay the Reasonable and Customary Charges, subject to the Deductible shown in the Policy Schedule,
for Covered Medical Expenses incurred in the Republic of India by You as an Outpatient for medical
services which are not due to a Pre- existing Disease up to the maximum amount and benefit period
stated in the Policy Schedule and subject to any
Deductible mentioned in Policy Schedule, for Immediate Medical Treatment of an Injury sustained by
You, while this Policy is in effect.

c. HOSPITAL CONFINEMENT ALLOWANC

We will pay a Daily Benefit for each Day You are an Inpatient in a Hospital due to Injury or Accidents
subject to the Deductible shown in the Policy Schedule, that occurs within the Republic of India. The
Period of Confinement must be Medically Necessary and recommended by a Physician. The total benefits
provided for any One Period of Confinement are subject to the In-Hospital maximum shown in the Policy
Schedule.
Definitions:

Daily Benefit - means the amount payable for each Day spent in the Hospital.
One Period of Confinement - means a Hospital confinement due to the same Injury or Accident unless
separated by at least 45 Days.

Period of Confinement - means a period of consecutive Days of confinement as an Inpatient caused by

an Accident, or Injury. However, successive confinements as an Inpatient caused by or attributable to the
same Accident, or Injury, are considered to be part of the same Period of Confinement, unless the
discharge date for the prior confinement is separated from the admission date for the next confinement
by at least 45 Days

Only one Daily Benefit is provided for any one Day of confinement, regardless of the number of covered
Accidents, or Injuries, for which the confinement is required.

Exclusions:
In addition to the General Exclusions listed in this Policy this coverage section shall not cover:

a) hospitalisation due to any Disease or Sickness; or pregnancy and resulting childbirth, miscarriage or
Disease of the female organs of reproduction; or
b) routine physical exams; or
c) elective cosmetic or plastic surgery, except as a result of an Injury caused by a covered Accident
while our policy is in force; or
d) Any mental, nervous or emotional disorders or rest cures
e) This coverage is not available for Insured Person whose Age is above 60 years or Below 18 years.

d. CHILD EDUCATION SUPPORT

In the event of We making payment for a claim for Death or Permanent Total Disablement, We will also
make payment towards the education support of Your child and spouse, the Sum Insured mentioned
against this benefit per year, minimum of - till the 21st birthday of Your child or four continuous years or
till the time your child ceases to be enrolled in any regular education programme. This benefit shall be
provided to Your first and second child whose names are mentioned in the proposal form and who are
covered in the same Policy as Yours. Sum Insured for this benefit will be 1% of Accidental Death’s Sum
Insured or Rs. 50,000/- , whichever is Lower.

e. LOAN PROTECTOR

In the event of We making a payment for Death or Permanent Total Disablement, We will also pay the
sum mentioned in the Schedule against this benefit per year or the actual Loan EMI You are liable to pay,
whichever is less for the maximum period mentioned in the Schedule. The maximum payment during the
policy period shall be the number of months mentioned in the Schedule. The Loan must have started
before the Effective Date of the Policy. Sum Insured for this benefit will be 2% of Accidental Death’s Sum
Insured or Rs. 1,00,000/- , whichever is
Lower. This benefit is applicable only to housing/car/education loan taken from scheduled commercial
banks only.
f. REPATRIATION BENEFIT AND FUNERAL EXPENSES

In the event of We making payment for a claim for Accidental Death We will also make payment towards
expenses incurred for preparing Your body for burial or cremation and transportation of Your body to
Your city of residence. We shall reimburse such expenses up to a limit of 1% Accidental Death’s Sum
Insured subject to a maximum of Rs.10,000/-

g. ADAPTATION ALLOWANCE

If You are required to modify Your vehicle or make some changes in Your house as necessitated by a
Permanent Total Disability which resulted from an accident covered under this Policy, We shall reimburse
such expenses up to a limit of 1% Accidental Death’s Sum Insured subject to a maximum of Rs.25, 000
per policy period provided we have paid the claim towards Permanent Total Disability.

h. FAMILY TRANSPORTATION ALLOWANCE

Following an accidental injury which results in Death, Permanent Total or Permanent Partial Disability
indemnifiable under this policy, if the Insured Person is confined in a hospital within 12 months from the
date of accident, and the attending person recommends the personal attendance of an immediate family
member, we shall reimburse the expenses incurred for the Immediate Family Member for transportation
by the most direct route by a licensed Common Carrier to the place of confinement of the Insured
Person. The maximum amount payable for this cover shall be limited to 1% Accidental Death’s Sum
Insured subject to maximum Rs.10,000/-.

i. AMBULANCE COVER

In the event of We making payment for a claim for any of Accidental Death or Permanent Total Disability
or
Permanent Partial Disability or Accidental Medical Reimbursement (Inpatient) or Accidental Hospital
Cash or Temporary Total Disability benefits, We will also make payment towards expenses incurred for
availing an
Ambulance Service to transfer the Insured Person to a Hospital from the location of Accident or Injury
during the Policy Period as described in the Policy. We shall reimburse such expenses up to1% Accidental
Death’s Sum Insured upto a maximum of Rs.1,500/- per incident/accident provided we have paid the
claim towards any of Accidental Death or Permanent Total Disability or Permanent Partial Disability or
Accidental Medical Reimbursement (Inpatient) or Accidental Hospital Cash or Temporary Total Disability
benefits.
j. BROKEN BONES

If an Accident causes an Insured Person who is aged 60 years or less suffers a fracture (a break in the
continuity of a bone) and this is certified by a Doctor and also confirmed by imaging or radiological
investigations such as by X-ray etc, then We will pay the percentage of the Sum Insured specified in the
table below.
% of Sum
Insured
Spinal Column (Vertebrae but excluding coccyx)

All compression fractures 100%

All spinous, transverse process of pedicle fractures 100%

Fracture leading to permanent neurological damage 50%
All other vertebral fractures 50%
PelvisHip or Pelvis (excluding thigh or coccyx)
Multiple fractures, at least one compound and at least 100%
one complete
All other compound fractures 50%
Multiple fractures, at least one complete 25%
All other fractures 20%
Lower leg, skull(excluding nose and teeth), clavicle, ankle, elbows, upper or
lower arm
(including wrist but excluding Colles-type fractures) (excluding nose and teeth)
Multiple fractures, at least one compound and at 100%
least one complete
All other compound fractures 63%
Multiple fractures, at least one complete 50%
Depressed fracture of the skull needing surgical Intervention 30%

All other fractures 25%

Rib or ribs, cheekbone, coccyx, upper jaw, nose, toe or toes, finger or fingers
Multiple fractures, at least one compound and at least one complete 100%

All other compound fractures 76%

 Multiple fractures, at least one complete 51%
All other fractures 25%
Shoulder blade, knee cap, sternum, hand
(excluding fingers and wrist), foot (excluding toes or heel)
All compound fractures 100%
All other fractures 50%
Wrist (collies or similar fractures) 10%
Ankle (Potts or similar fracture) 10%
Coccyx 5%
Hand including fingers 3%
Foot including toe 3%
Nasal bone 3%

a) If more than one fracture results from any one Accident, only one amount, the largest, will be paid
b) If a claim in respect of any fracture of a whole bone also encompasses some or all of its parts, Our
liability to make payment will be limited to the whole bone only and not any of its parts.
c) Any fracture resulting either directly or indirectly due to osteoporosis is not covered under this
benefit.
d) For the purpose of determining the benefits for the section, the terms defined below have the
meanings ascribed to them wherever they appear in this Policy Document and, where appropriate,
references to the singular include references to the plural;
• “Coccyx” means Four fused vertebrae at the bottom of the spine.
• “Colles’ fracture means ” A break in the radius (one of the lower arm bones, just above the wrist)
• “Complete fracture” means a fracture where the bone is broken completely across.
• “Compound fracture” means a fracture where the bone breaks the skin.
• “Compression fracture” means Crushing on the vertebrae.
• “Multiple fracture” means more than one fracture in the same bone.

Note: In this Benefit:

• Pelvis means all pelvic bones, which shall be treated as one bone. The sacrum is part of the
vertebral column.
• Skull means all skull and facial bones, (excluding nasal bones and teeth) which shall be treated as
one bone.
k. LOSS OF BOOKS/SPECTACLES/DAMAGE TO BICYCLES OF SCHOOL CHILDREN

Following an accidental injury which results in Death, Permanent Total or Permanent Partial Disability
indemnifiable under this policy, We shall reimburse such expenses up to1% Accidental Death’s Sum
Insured upto a maximum of Rs.1,500/- per incident/accident provided we have paid the claim towards
any of Accidental Death or Permanent Total Disability or Permanent Partial Disability or Accidental
Medical Reimbursement (Inpatient).

l. REIMBURSEMENT OF EXAM FEES / SCHOOL FEES IF THE STUDENT IS NOT ABLE TO ATTEND EXAM/ SCHOOL AND
MISS A YEAR BECAUSE OF ACCIDENTAL DEATH / PERMANENT TOTAL DISABLEMENT/ PERMANENT
PARTIALDISABLEMENTOR DUE TOHOSPITALISATION AS INPATIENTOF THE COVEREDSTUDENT ARISING OUT OF AN
ACCIDENT

Following an accidental injury which results in Death, Permanent Total or Permanent Partial Disability
indemnifiable under this policy, We shall reimburse such expenses up to1% Accidental Death’s Sum
Insured up to a maximum of Rs.2,500/- per incident/accident provided we have paid the claim towards
any of Accidental Death or Permanent Total Disability or Permanent Partial Disability or Accidental
Medical Reimbursement (Inpatient).

m. PURCHASE OF BLOOD

Following an accidental injury which results in Death, Permanent Total or Permanent Partial Disability
indemnifiable under this policy, then We will in addition reimburse the actual expenses incurred in
purchasing blood through a Hospital or lawful blood bank for the purpose of the Insured Person’s
medical or surgical treatment provided that such treatment is necessitated by the Accident up to 1%
Accidental Death’s Sum Insured with a maximum liability of Rs.1,500/- per incident/accident for the
benefit provided we have paid the claim towards any of Accidental Death or Permanent Total Disability
or Permanent Partial Disability or Accidental Medical Reimbursement (Inpatient) or Accidental Hospital
Cash or Temporary Total Disability benefits.