RiskAssumptionLetter

Date: 02Mar2015
DearSir/Madam,
WethankyouforplacingyourconfidencewithICICILombardforyourhealthInsuranceneeds.
PleasefindattachedherewithPolicyNo.:4128i/iH/1089144241/00/000whichhasbeenissuedbasedonthe
detailsfurnishedbytheapplicant

Nameoftheproposer:

Abu Sufiyan Azad Kazi

MailingAddress:

104 Sehar Residency Near Bilal Hospital Kausa

Mumbra ,Thane,Maharashtra400612.
7738407457

MobileNo.:
TelephoneNo.:
EmailID:
ProductName:
No.ofMembers:
PolicyDuration(years):
Ageoftheeldestmember
(years):

sufiyankazi@medco.co.in
iHealth
2
2
27
From02Mar2015To01Mar2016

PolicyPeriod
InsuredDetails
Name of the
Insured(s)

Relationship with
Proposer

Abu Sufiyan Kazi

Self

Age
P r e- Existing
Y e a r M o n t h s illness/injury
27
NA
4

Farah Kazi

Spouse

27

NA

Annual Sum
Insured
1000000

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

PolicyIssuingOffice

ICICILombardCompleteHealthInsurance
PolicyNumber:4128i/iH/108915572/00/000
ICICILombardGeneralInsurance
CompanyLTD.,IRDARegn.No.115,
ICICILOMBARDHOUSE,414, PolicyIssued
02-Mar-2015
VeerSavarkarMarg,NearSiddhi
On
VinayakTemple,Prabhadevi,Mumbai
400025
PartIOfSchedule

DetailsofPolicyHolder/Proposer:
4128i/iH/1089144241/00/000

PolicyNo.

NameoftheApplicant Abu Sufiyan Azad Kazi

Correspondence
Address

104 Sehar Residency,

Near Bilal Hospital
Kausa Mumbra
Thane

EmailAddress

Maharashtra400612
NameofNominee

ContactNo(s)
(R):MobileNo
7738407457
Policy
From00:00hrs02-Mar2015to
Period Midnightof01-Mar-2016

sufiyankazi@medco.co.in

RelationshipofNominee

withProposer

DetailsofFamilyMemberscoveredunderthePolicy:
Name of the
Insured(s)
Abu Sufiyan Kazi
Farah Kazi

Age
Annual Sum
Pre-Existing
Gender Relation
Insured
illness/injury
Years Months
Self
4
02-Mar-2015 27
M
Spouse
1000000
02-Mar-2015 27
3
F
Date Of
Joining

Health Member ID
No.
None

102965007

None

102965008

Optional Add-on
Cover

Sublimit

Voluntary
Deductible

None

PremiumSchedule:
PlanName
Senior Health - i Health

BasicPremium
(Rs.)
15015.38

ServiceTax
(Rs.)
738.62

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

TotalPremium
(Rs.)
15754

ForICICILOMBARDGENERALINSURANCE
COMPANYLIMITED

ServiceTaxRegistrationNo.:GIS/MUMBAII/1528/2001
ServiceTaxCodeNumber:AAACI7904GST001
Category:GeneralInsuranceBusinessServices
AuthorisedSignatory
00440005.
ImportantNote:Thisscheduleandtheattachedpolicyshallbereadtogetherasonecontractoranywordor
expressiontowhichaspecificmeaninghasbeenattachedinanypartofthispolicyorofthescheduleshallbear
thesamemeaningwhereveritmayappear.
IMPORTANT:InsurancebenefitshallbecomevoidableattheoptionoftheCompany,intheeventofanyuntrue
or incorrect statement, misrepresentation, non description or non-disclosure of any material particular in the
ProposalForm/personalstatement,declarationandconnecteddocuments,oranymaterialinformationhasbeen
withheld by beneficiaryoranyoneactingonbeneficiary'sbehalftoobtaininsurancebenefit.Pleasenotethatany
claimsarisingoutof pre-existingillness/injury/symptomsisexcludedfromthescopeofthispolicysubjectto
applicabletermsandconditions.RefertoattachedPartIIandIIIofthescheduleforthetermsandconditions.All
disputesaresubjecttothejurisdictionofcompetentcourtsofINDIA
ThestampdutyofRs1.00paidincashorbydemanddraftorbypayorder,videReceipt/Challanno.4063856

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,
Abu Sufiyan Azad Kazi
Sehar Residency Near Bilal Hospital Kausa Mumbra
Thane,
Maharashtra400612.
ThisistocertifythatthecompanyhasreceivedthepremiumofRs.15754forHealthinsurancecoverage
underthepolicyno4128i/iH/1089144241/00/000videCheque/creditcarddatedMar022015.
TheProductiseligiblefordeductionu/s80DoftheIncomeTax,1961adanyamendmentsmadethereto.
For ICICI Lombard General Insurance Company Limited,IRDA Regn.No.115

AuthorizedSignatory
Note:
l ThiscertificatemustbesurrenderedtotheInsuranceCompanyincaseofCancellationofthepolicy.In
theeventofincorrectrepresentationofthisdeclaration,theliabilityshallbeuponthepolicyholder.