Risk Assumption Letter Date : 27-Oct-2012 Dear Sir / Madam, We thank you for placing your confidence with

ICICI Lombard for your Health Insurance needs. Please find attached herewith Policy No.: 4034i/FPP/74859064/00/000 which has been issued based on the details furnished by the applicant : Name of the proposer: Mailing Address: Mobile No.: Telephone No.: Email ID: Product Name: No of Insured: Policy Duration (years): Age of the eldest member(years): Period of Insurance (Year 1) Period of Insurance (Year 2 Annual Autorenewal) Insured Details
Sr No. 1 Name of the Insured Antony Mathew Relationship with Applicant Son Years 13 Age Months 6 Pre-Existing illness/injury None Sum Insured 300000

K A Mathew No. 1c, Gandhi Nagar, 1st Street, Alwar Thiru Nagar, Alwarthirunagar, Chennai, Tamil Nadu - 600087 9840734106 32985311 mathewa2@yahoo.co.in Family Protect Premier Renewal 1 2 13 From 11-Nov-2012 To 10-Nov-2013 From 11-Nov-2013 To 10-Nov-2014

Please go through the details as furnished in the format and the policy document and confirm that same are in order. In case there is any discrepancies/ variations, you are requested to write back to us immediately at customersupport@icicilombard.com or contact at 24 hour helpline number 1800 2666 for necessary changes/rectification. In the absence of any communication from you in this connection within a period of 15 days of receipt of this letter, we would take it that the issued policy is in order and as per your proposal. Thanking You, Yours Sincerely,

Authorised Signatory ICICI Lombard General Insurance Company Limited.

ICICI Lombard Health Care Policy Number 4034i/FPP/74859064/00/000 PREAMBLE:ICICI Lombard General Insurance Company Limited ("the Company"), having received a proposal and the premium from the proposer named in the Schedule referred to herein below, and the said Proposal, Declaration and Annexure thereto together with any statement, report or other document leading to the issue of this Policy and referred to therein having been accepted and agreed to by the Company and the Proposer as the basis of this contract do, by this policy agree, in consideration of and subject to the due receipt of the subsequent premiums, as set out in the schedule with all its parts, and further, subject to the terms and conditions contained in this policy, as set out in the schedule with all its parts, that in proof to the satisfaction of the Company of the compensation having become payable as set out in Part I of the schedule to the title Policy, the Sum Insured/appropriate benefit will be paid by the Company. ICICI Lombard General Insurance Company LTD , ICICI LOMBARD HOUSE , 414, Veer Savarkar 27-Oct-2012 Policy Issuing Office Policy Issued On Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025 Part I Of Schedule Details of Policy Holder/ Proposer: 4034i/FPP/74859064/00/000 (R):44-32985311 Policy No Contact No(s) 4034i/CHI/05581195/00/000 9840734106 Previous Policy No Mobile No From 00:00 hrs 11-Nov-2012 to Period of Insurance (Year 1) Midnight of 10-Nov-2013 K A Mathew Name of the Proposer From 00:00 hrs 11-Nov-2013 to Period of Insurance (Year 2 Midnight of 10-Nov-2014 Annual Autorenewal) No. 1c, Gandhi Nagar, 1st Street, Alwar Thiru Nagar, Alwarthirunagar mathewa2@yahoo.co.in Correspondence Address Email Address Chennai Tamil Nadu- 600087 Details of Family Members covered under the Policy :
Name of the Insured(s) Antony Mathew Years 13 Age Months 6 Gender M Relation Son Sum Insured 300000 Additional SI 60000 Pre-Existing illness/injury None Health Member ID No. 100612145

Premium Schedule : Year 1 Basic Premium (Rs.) 2715.91 Service Tax (Rs.) 325.91 Secondary and Education Cess Higher (Rs.) Education Cess (Rs.) 6.52 3.26 Year 2 Secondary Service Education and Total Basic Premium Tax Cess Higher Premium (Rs.) (Rs.) (Rs.) Education (Rs.) Cess (Rs.) 1810.61 217.27 4.35 2.17 5086 Service Tax Registration No. : GIS/MUMBAII/1528/2001 Service Tax Code Number : AAACI7904GST001 Category: General Insurance Business Services 00440005.

Plan Name

Fpp Individual

For ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED

Authorised Signatory

Important Note :This schedule and the attached policy shall be read together as one contract or any word or expression to which a specific meaning has been attached in any part of this policy or of the schedule shall bear the same meaning wherever it may appear. IMPORTANT :Insurance benefit shall become voidable at the option of the Company, in the event of any untrue or incorrect statement, misrepresentation, non description or non-disclosure of any material particular in the Proposal Form/ personal statement, declaration and connected documents, or any material information has been withheld by beneficiary or anyone acting on beneficiary's behalf to obtain insurance benefit. Please note that any claims arising out of pre-existing illness/injury/symptoms is excluded from the scope of this policy subject to applicable terms and conditions. Refer to attached Part II and III of the schedule for the terms and conditions.All disputes are subject to the jurisdiction of Mumbai High Court only. The stamp duty of Rs 1.00 paid in cash or by demand draft or by payorder,vide Receipt/Challan no. 24267 dated 17-oct-2012 On the happening of a claim, please call immediately at 1800-2666 (Toll Free) or e-mail us at iheatlhcare@icicilombard.com You can also write to us at ICICI Lombard GIC, I Health Care, TGV Mansion, 6th Floor, Plot No. 6-2-1012, Khairatabad, Hyderabad - 500004, Andhra Pradesh. ICICI Lombard General Insurance Company Ltd Corp Office:ICICI Lombard General Insurance Company LTD , ICICI LOMBARD HOUSE , 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025 Mailing Address:4th Floor, Interface 11, Off Malad Link Road, Behind Goregaon Sports Club, Malad(w), Mumbai- 400064. Toll Free 24 X 7 Call Center No 1800-2666. E-mail :customersupport@icicilombard.com

Premium Certificate For the purpose of deduction under section 80D of Income Tax amendment act, 1961 and any amendments made thereafter. To, K A Mathew No. 1c, Gandhi Nagar, 1st Street, Alwar Thiru Nagar, Alwarthirunagar Chennai Tamil Nadu- 600087 This is to certify that the Company has received the premium of Rs. 5086 for Health insurance coverage under the "Health Insurance Policy" policy no 4034i/FPP/74859064/00/000 vide Cheque/credit card dated 26/10/2012. The Product is eligible for deduction u/s 80 D of the Income Tax,1961 and any amendments made there to.

For ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED

Note: This c this de

Authorised Signatory

Information Sheet To, K A Mathew Date : 27-Oct-2012 No. 1c, Gandhi Nagar, 1st Street, Alwar Thiru Nagar, Alwarthirunagar Chennai Tamil Nadu- 600087 Sub : Verbal proposal for Health insurance policy from ICICI Lombard GIC Ltd. Dear K A Mathew , Thank you for choosing ICICI Lombard Health Insurance Policy. It is a pleasure to have you as our esteemed customer. This letter is with reference to your tele-conversation dated 11-Nov-2012 with the representative of ICICI Lombard GIC Ltd for the purchase of Health Insurance Policy. The information provided by you has been mentioned below and the HEALTH CARE policy No : 4034i/FPP/74859064/00/000 has been issued based on the same. You are requested to kindly go through the details mentioned below vide the tele-conversation. In case of any discrepancy or error in the information mentioned below or in the policy copy attached, you are requested to intimate us at our call center no 1800-2666 within 15 days of issue of this letter. K A Mathew Name of the Proposer : No. 1c, Gandhi Nagar, 1st Street, Alwar Thiru Nagar, Alwarthirunagar Address : Chennai Tamil Nadu- 600087 Details of the insured:
Name Antony Mathew Sex Date of Birth M 27-Apr-1999 Relationship with proposer SON Name of Pre-Existing illness None Sum Insured 300000 Tenure 2

5086 Premium : Exclusions : Any illness/disease/injury existing before the inception of the policy for the first 2 yrs for HAP and 4 yrs for the rest of the products specifically as a. per the policy wordings. b. Pregnancy and childbirth related diseases, cosmetic aesthetic and obesity related treatments and congenital diseases. Any illness contracted during the first 30 days of the inception of the policy except those that are incurred as a result of accident, the exclusion does c. not apply for subsequent renewals without a break of the policy with the company. Non allopathic treatment, expenses arising from HIV or AIDS and related diseases, use or misuse of liquor, intoxicating substances or drugs as well d. as intentional self injury/attempted suicide/suicide. e. War, riot, strike, nuclear weapons induced hospitalization. Certain ailments will be excluded from treatment for 2-years: Cataract, Hernia, Benign Prostatic Hypertrophy , Hydrocele, Sinusitis and related f. disorders, Arthritis, Gastric and Duodenal ulcers etc. Disclaimer: The details mentioned herein are indicative and not exhaustive, for complete details on coverage's, exclusion, terms and conditions please refer to policy wordings provided along with the policy kit. Regards,

Authorized Representative ICICI Lombard General Insurance Company Ltd.

Reference No: 1130528267

Sr. No. 1

Insured Name ANTONY MATHEW

Age 13

Health Checkup Date

Authorization No.

Card No. 100612145

Policy No.:4034i/FPP/74859064/00/000

Valid up to:10-Nov-2014

Name

:Antony Mathew

Policy No.:4034i/FPP/74859064/00/000 Card No. :100612145 Gender :Male Age :13 Valid Upto: 10-Nov-2014 Dob :27-Apr-1999