RiskAssumptionLetter

Date: 04Nov2015
DearSir/Madam,
WethankyouforplacingyourconfidencewithICICILombardforyourhealthInsuranceneeds.
PleasefindattachedherewithPolicyNo.:4128i/iH/108915572/00/000whichhasbeenissuedbasedonthedetails
furnishedbytheapplicant:
Nameoftheproposer:
MailingAddress:
MobileNo.:
TelephoneNo.:
EmailID:

ChiragSharma
402DWingShreeSharnamKanakiaLayoutUniqueGardenMiraRoad
(E),Thane,Maharashtra401107.
9004310607
sharma.chirag82@gmail.com

ProductName:
No.ofMembers:
PolicyDuration(years):
Ageoftheeldestmember
(years):

iHealth
3
1

PolicyPeriod

From04Nov2015To03Nov2016

33

InsuredDetails
Name of the
Insured(s)

Relationship with
Proposer

Age
P r e- Existing
Y e a r M o n t h s illness/injury

Chirag Sharma

Self

33

None

Sheena Sharma

Spouse

29

None

Meera Sharma

Daughter

None

Annual Sum
Insured

300000

Optional Add- o n
Cover

S u blimit

Voluntary
Deductible

None

Pleasegothroughthedetailsasfurnishedintheformatandthepolicydocumentandconfirmthatsameareinorder.
Incasethereareanydiscrepancies,youarerequesttowritebacktousimmediatelyat
customersupport@icicilombard.comorcontactat24hourhelplinenumber18002666fornecessary
changes/rectification.
Intheabsenceofanycommunicationfromyouinthisconnectionwithinaperiodof15daysofreceiptofthisletter,
wewouldtakeitthattheissuedpolicyisinorderandasperyourproposal.Thereon,anynondisclosurerelatedto
PreExistingillness/injurywouldresultinrejectionofclaimsandcancellationofpolicy
ThankingYou,
YoursSincerely,

AuthorisedSignatory
ICICI Lombard General Insurance Company Limited,IRDA Regn.No.115


ICICILombardCompleteHealthInsurance
PolicyNumber:4128i/iH/108915572/00/000
ICICILombardGeneralInsurance
CompanyLTD.,IRDARegn.No.115,
ICICILOMBARDHOUSE,414, PolicyIssued
04Nov2015
VeerSavarkarMarg,NearSiddhi
On
VinayakTemple,Prabhadevi,Mumbai
400025

PolicyIssuingOffice

PartIOfSchedule
DetailsofPolicyHolder/Proposer:
ContactNo(s)
(R):
MobileNo
9004310607
Policy
From00:00hrs04Nov2015to
Period
Midnightof03Nov2016

4128i/iH/108915572/00/000

PolicyNo.

NameoftheApplicant ChiragSharma
402DWingShreeSharnam
KanakiaLayoutUniqueGarden
MiraRoad(E),

Correspondence
Address

EmailAddress

sharma.chirag82@gmail.com

Thane,
Maharashtra401107.

NameofNominee

RelationshipofNominee

withProposer

DetailsofFamilyMemberscoveredunderthePolicy:
Age

Name of the
Insured(s)

Date Of
Joining

Chirag Sharma

04-Nov-2015 33

Self

Sheena Sharma

04-Nov-2015 29

Spouse

Meera Sharma

04-Nov-2015 0

Daughter

Years Months

Gender Relation

Annual Sum
Insured

Pre-Existing
illness/injury

300000

Health Member ID
No.
None

102956402

None

102956403

None

102956404

Optional Add-on
Cover

Sublimit

Voluntary
Deductible

None

PremiumSchedule:
PlanName
Ih_2adults_1child_1year

BasicPremium
(Rs.)

ServiceTax
(Rs.)

8058.77

1128.23

ForICICILOMBARDGENERALINSURANCE
COMPANYLIMITED

Secondaryand
EducationCess
HigherEducation
(Rs.)
Cess(Rs.)
0
0

TotalPremium
(Rs.)
9187

ServiceTaxRegistrationNo.:GIS/MUMBAI
I/1528/2001
ServiceTaxCodeNumber:AAACI7904GST001

Category:GeneralInsuranceBusinessServices
AuthorisedSignatory
00440005.
ImportantNote:Thisscheduleandtheattachedpolicyshallbereadtogetherasonecontractoranywordor
expressiontowhichaspecificmeaninghasbeenattachedinanypartofthispolicyorofthescheduleshallbearthe
samemeaningwhereveritmayappear.
IMPORTANT:InsurancebenefitshallbecomevoidableattheoptionoftheCompany,intheeventofanyuntrueor
incorrectstatement,misrepresentation,nondescriptionornondisclosureofanymaterialparticularintheProposal
Form/personalstatement,declarationandconnecteddocuments,oranymaterialinformationhasbeenwithheldby
beneficiaryoranyoneactingonbeneficiary'sbehalftoobtaininsurancebenefit.Pleasenotethatanyclaimsarisingout
ofpreexistingillness/injury/symptomsisexcludedfromthescopeofthispolicysubjecttoapplicabletermsand
conditions.RefertoattachedPartIIandIIIofthescheduleforthetermsandconditions.Alldisputesaresubjectto
thejurisdictionofcompetentcourtsofINDIA.
ThestampdutyofRs1.00paidincashorbydemanddraftorbypayorder,videReceipt/Challanno.4063856dated

08oct2015
Intheeventofaclaim,pleasecallour24X7tollfreenumber18002666oremailusat
ihealthcare@icicilombard.com.
Pleasesendtherelevantdocumentsto:ICICILombardHealthCare,PlotNo:12,ICICIBank
Towers,Nanakramguda,Gachibowli,Hyderabad500032
ICICILombardGeneralInsuranceCompanyLtd
CorpOffice:ICICILombardGeneralInsuranceCompanyLTD.,IRDARegn.No.115,ICICI
LOMBARDHOUSE,414,VeerSavarkarMarg,NearSiddhiVinayakTemple,Prabhadevi,Mumbai400025
MailingAddress:4thFloor,Interface11,OffMaladLinkRoad,BehindGoregaonSportsClub,Malad(w),
Mumbai400064.
TollFree24X7CallCenterNo18002666.Email:customersupport@icicilombard.com


PremiumCertificate
Forthepurposeofdeductionundersection80DofIncomeTaxamendmentact,1961andanyamendments
madethereafter.
To,
ChiragSharma
402DWingShreeSharnamKanakiaLayoutUniqueGardenMiraRoad(E),
Thane,
Maharashtra401107.
ThisistocertifythatthecompanyhasreceivedthepremiumofRs.9187forHealthinsurancecoverageunderthe
policyno4128i/iH/108915572/00/000videCheque/creditcarddatedNov042015.
TheProductiseligiblefordeductionu/s80DoftheIncomeTax,1961andanyamendmentsmadethereto.
For ICICI Lombard General Insurance Company Limited,IRDA Regn.No.115

AuthorizedSignatory
Note:
l ThiscertificatemustbesurrenderedtotheInsuranceCompanyincaseofCancellationofthepolicy.In
theeventofincorrectrepresentationofthisdeclaration,theliabilityshallbeuponthepolicyholder.