Risk Assumption Letter

Dear Sir / Madam,

We thank you for placing this Insurance busi ness with us.
Please find attached herewith Policy No.: 500065170 , which has been issued based on the details furnished to us by
insured:
1. Name of the Insured : DIKSHIT DHARMENDRA

2. Mailing Address : SKF INDIA MGM BLDG NS RD CHARNI

RD, MUMBAI ,
MAHARASHTRA
3. Risk Address :
4. Telephone No. : 000 -000 -66337777
5. Mobile No. : 000
6. E-mail Id :

10. Visa Type : no n-immigrant

11. Period of Insurance / Trip
Particulars : From: 21-Jul-2009 To: 27-Jul-2009 Days: 7
12. Geographical Scope : EXCLUSCANADA
13. Plan Type : GOLD X100
14. Pre-existing Diseases : NA
15. Medical Treatment History : NA
16. Family Doctor’s Details :

Please go through the de tails as furn ished in th e format and a lso a s p rovided in the policy document and confirm that
they are in order. Sh oul d you feel that there are any discrepancies/variations, you are requested to write back to us
immediately at customersupport@icicilombard.com for necessary changes/rectification. In the absence of any
communication from you with in 15 days or before the risk inception date of the policy in this connection, we would
take it that you have accepted the contents and the coverage to be confirming to your proposal.

It brings us pleasure in announcing that our operations function has been ISO 9001:2000 certified with effect from 7th
September 2004. The certifying agency was De t Norske Veritas (DNV). This would mean that we would meet the
service related promises that we make to our custome rs.

Thanking you,

Authorised Signatory
ICICI Lombard General Insurance Company Limited
 PART 1 OF THE SCHEDULE - OVERSEAS INDIVIDUAL TRAVEL
INSURANCE
POLICY
DETAILS
Policy No.: 500065170 Agent Location: MUMBAI Agent: CUST-510870

Period of Insurance/Trip
Particulars : From: 22-Aug-2009 To: 28-Aug-2009 Midnight(Single Trip) or actual date of arrival whichever is earlier
Insured no of travel days : 7
Geographical Scope : EXCLUSCANADA

DETAILS OF THE PLAN NAME : GOLD X100

INSURED Benefits Sum Insured
Name PENDSEABHIJIT S MR
Deductibles
Personal Accident USD 15,000 -
Mailing Address SKF INDIA MGM BLDG NS RD CHARNI
RD, MUMBAI , MAHARASHTRA
Medical Cover (includes
Pin Code 400002 medical evacuation *USD 100,000 US D 100
cost).
Telephone No. 000 -000 -66337777 Dental Treatment USD 250 US D 100
Repatriation of
Mobile No. 000
Remains under Medica... USD 7000 -
(Included

E-mail Id Loss of Passport USD 200 US D 50

Total Loss of Checked
Date Of Birth 11-May-1975
Baggage USD 500 -
Passport No. G8112390 Delay of Checked Baggage USD 100 12 Hrs
Nominee Name SMITA Personal Liability USD 100,000 -
Visa Type non-immigrant Financial Emergency USD 300 -

Special Terms & Conditions : Hijack Distress Allowance USD 125 for max
7 days 12 Hrs

Pre-existing Ailments History : Hospitalisation / Medical Treatment History : Family doctor's

NA NA Name ,Address and
Contact No.:

The above records the information of pre-existing illnesses / hospitalization etc. details given by the insured pursuant to Clause 4 (4) of
the
IRDA (Policyholder's interest) Regulations, 2002. If the information shown above is found to be either incomplete or incorrect at the time
of
claim, the same shall be construed as non disclosure of material information.

Higher
Net Claim Amount
Start Date End Date Premium Service Tax Education
Education Cess Premium Details (Rs.)
Cess
Original
Details 22-Aug-2009 28-Aug-2009 624.00 62.40 1.25 0.62 688.00 - -

For ICICI LOMBARD GENERAL INSURANCE

CO. LTD.

Authorised Signatory
Date of Issue :24-Aug-200 9
Place of issuance: Mumbai
Service tax registration number-GIS/Mumbai-I/1528/2001.
Service tax Code number-AAACI7904GST001.
Category : General Insurance Business Services - 00440005
The stamp duty of Rs. 1 (Rupee One only) paid in cash or by demand draft or by pay order,vide Receipt/Challan no. 9955
dated 09-Jun-2009.”
Contact the ICICI Lombard 24hr Help Line number for assistance and registering your claim: In USA & Canada: +1866 625 8529 (Toll Free),
From the rest of the world: +91 11 4189 8868 (Call Back Facility), In India: 1800 113 666 (Toll Free & Accessible only in India), Fax: +91 11 4189
8801, and E-Mail: travelclaims@icicilombard.com. Failure to call this number and register your claim as soon as the loss occurs shall
invalidate
your claim Now you can call on 1800-209-8888 ( Toll Free : Also accessible from your mobile phone ) To Buy /Extend policy or any other
customer service. *Subject to sub-limits provided in the terms of cover incorporated in the Part II of the policy. Please ensure that the you
have
received, read and understood the terms and conditions as contained in Part II and III of the Policy. Kindly acknowledge receipt of this
policy.
In case you find any variations against your proposal or any discrepancy in the policy, kindly contact us immediately or have not received
Part
II and Part III of the Policy, please email at customersupport@icicilombard.com In the event of an accident or sudden illness or any other
claim
caused by a contingency covered under the insurance policy, immediately contact the Help Line number stating the necessary details. If
a
claim is not registered with the Help Line number and prior authorization is not taken from the claims assistance company before making
the
expense, the company will be relieved of its liability to pay the claim. Even if no assistance is required and no expenses are incurred,
please
contact the Help Line number while abroad, and inform the claims assistance company of the claim that will be lodged on the company
on
return back to the Republic of India. If this is not done, then the company will be relieved of its liability to pay the claim. Policy extension
is
valid only if all claims that are put up / that will be put up by the insured on return back to the Republic of India, for the original policy
duration
have been informed as soon as they occur and well in advance to the extension request to the Help Line Number stated below; and that
you
are unaware today of any health condition that might lead to claims in the extended policy duration. The multi trip (Annual Cover) insurance
is
valid in respect of trips undertaken during the 12 months of policy period as specified in PART 1 OF THE SCHEDULE, subject to the duration of
any one trip not exceeding the 'Maximum Trip Duration', as specified in PART 1 OF THE SCHEDULE. Please note, the first US$100 of your
medical expenses is deductible, and must be borne by you.
Note:Kindly acknowledge receipt of this policy. In case you find any variations against your proposal or any discrepancy in the policy ,
kindly
contact us
immediately. ICICI Lombard General Insurance Company Limited
Zenith House, Keshavrao Khadye Marg, Opp. Race Cource, Mahalaxmi, Mumbai - 400 034