Risk Assumption Letter Date : 17-Oct-2012 Dear Sir / Madam, We thank you for placing your confidence with

ICICI Lombard for your Tax Gain - Health Advantage Plus Insurance needs. Please find attached herewith Policy No.: 4063i/HAP/74541734/00/000 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 Insured Details
Sr No. 1 2 Name of the Insured K A Mathew Siba Mathew Relationship with Applicant Self Spouse Years 53 43 Age Months 0 3 Pre-Existing illness/injury None None Sum Insured 200000

K A Mathew No. 1c, Gandhi Nagar, 1st Street, Alwar Thiru Nagar, Alwarthirunagar, Chennai, Tamil Nadu - 600087 9840734106 32985311 mathewa2@yahoo.co.in Tax Gain - Health Advantage Plus 2 1 53 From 26-Nov-2012 To 25-Nov-2013

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 4063i/HAP/74541734/00/000 Alternate Policy Number 4063i/HAP/04145379/04/000 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 23-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: 4063i/HAP/74541734/00/000 (R):44-32985311 Policy No Contact No(s) 4063i/HAP/04145379/03/000 9840734106 Previous Policy No Mobile No From 00:00 hrs 26-Nov-2012 to Midnight of 25Period of K A Mathew Name of the Proposer Nov-2013 Insurance 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) K A MATHEW SIBA MATHEW Age Years 53 43 Months 0 3 Gender M F Relation SELF SPOUSE Benefit A Hospitalization 200000 Benefit B OPD 3000 Additional SI Pre-Existing illness/injury 40000 None None Health Member ID No. 100584471 100584472

Premium Schedule : Plan Name

2 Adults

Basic Premium (Rs.) 13349.95

Service Tax (Rs.) 1601.99

Education Cess (Rs.)

Secondary and Higher Education Cess (Rs.) 32.04 16.02

Total Premium (Rs.) 15000

For ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED

Authorised Signatory

Service Tax Registration No. : GIS/MUMBAII/1528/2001 Service Tax Code Number : AAACI7904GST001 Category: General Insurance Business Services 00440005.

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.

Agent details: Agent Name - Ibsl Chennai 8, Agent code - 2613930, Contact number - 9819797632
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. NA dated NA 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. 15000 for Health insurance coverage under the "Health Insurance Policy" policy no 4063i/HAP/74541734/00/000 vide Cheque/credit card dated 20/09/2012. 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

Reference No: 1129389087

Sr. No. 1 2

Insured Name K A MATHEW SIBA MATHEW

Age 53 43

Health Checkup Date

Authorization No.

Card No. 100584471 100584472

Policy No.:4063i/HAP/74541734/00/000

Valid up to:25-Nov-2013

Name

:K A Mathew

Policy No.:4063i/HAP/74541734/00/000 Card No. :100584471 Gender :Male Age :53 Valid Upto: 25-Nov-2013 Dob :21-Nov-1959

Name

:Siba Mathew

Policy No.:4063i/HAP/74541734/00/000 Card No. :100584472 Gender :Female Age :43 Valid Upto: 25-Nov-2013 Dob :15-Aug-1969