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PERSONAL PROTECT POLICY SCHEDULE CERTIFICATE CUM POLICY SCHEDULE CERTIFICATE CUM POLICY NO: 4111/W-7955730/00/000 PREAMBLE

ICICI Lombard General Insurance Limited("The Company"),having received a proposal and the premium from the policy holder named in the Schedule referred to here in below and the said Proposal and Declaration together with any statement, report or other document leading to the issue of this policy and referred to there in having been accepted and agree to by the Company and policy holder 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 on 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 of the said person or persons claiming payments or upon the happening of an event upon which one or more benefits becomes payable under this Policy, the Sum Insured/ appropriate benefit amount will be paid by the Company.
PART-I OF POLICY SCHEDULE Policy Number: 4111/W-7955730/00/000 1. Name of the Proposer: 2.Mailing Address Of Proposer: Issued At: MUMBAI Stamp Duty:Rs. 50

3.Policy Period: 4.Plan Name: PP_10L_3Y_AD 5.Benefits And Extension Table:

Mr JASWANT DAMANIA House No. 407, B Wing, Asha Nagar, Building No.1, Near Jesal Park, Chandan Park, Bhyander East Dist. Thane , THANE, 401105, MAHARASHTRA Policy Start Date: 25-May-2012 Policy End Date: 24-May-2015

Cover Death resulting from Accident SectionA Permanent Total Disablement resulting from Accident
6.Details Of Insured Person:

Section

Benefit Amount 100% of Sum Insured 100% of Sum Insured

Sum Insured(Rs.) 1000000

Sr.No 1

Name in Full Mr JASWANT DAMANIA

Date of Relationship with Gender birth Proposer 03-SepM Self 1960

Beneficiary/Nominee ROHINI JASWANT DAMANIA

Relationship with Nominee with Insured Spouse

7.Premium Details:

Basic Premium: Extension Premium: Total Premium: Discount: Net Premium: Service Tax(As applicable): Stamp Duty:
Total Amount:

Rs. 3014 Rs. 0 Rs. 3388 Rs. 0 Rs. 3014 Rs. 372 Rs. 50 Rs. 3388

Alternate Policy No.:

Signed For and Behalf Of ICICI Lombard General Insurance Company Limited at Mumbai on the date 25-May-2012 Service Tax Registration No. GIS / MUMBAI-I /1528 /2001 Service Tax Code No: AAACI7904GST001 Category: General Insurance buisness Services 00440005

Authorised Signatory

The Stamp Duty of Rs: 50 Paid in Cash or by Demand draft or by payorder,vide receipt/challon no. Dated: Retail Claim Address:

ICICI Lombard General Insurance Company Limited ,ICICI Lombard Health Care, ICICI Bank Tower, Plot No. 12 Financial District, Nanakram Guda, Gachibowli, Hyderabad, Andhra Pradesh, Pin Code: 500032, India
ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED. INSURANCE IS THE SUBJECT MATTER OF THE SOLICITATION

Now one number for all insurance needs call us on 1800 2666 (toll free)also accessible from your mobile phone. Visit us at www.icicilombard.com, Mail us at customersupport@icicilombard.com Registered Office :ICICI Lombard General Insurance Company Limited, ICICI Bank Towers, Bandra Kurla Complex, Mumbai - 400 051.

Corporate Office : ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025