Certificate of Insurance

Group Safeguard Insurance

On receipt of full premium from the Policyholder as named in this Schedule, Group
Policy Certificate
Safeguard Insurance 4148/GSG/170868968/00/000 dated 26/12/2019 has been issued at Mumbai, by
ICICI Lombard General Insurance Company Limited to the Policyholder, “FINO Payments Bank
Limited”, as specified in the Policy, and is governed by, and is subject to, the terms, conditions &
exclusions therein contained or otherwise expressed in the said Policy.

The certificate issued to the customers of “FINO Payments Bank Limited”, under the signature of an
authorized signatory of ICICI Lombard General Insurance Company Limited, represents the availability
of the Benefits under the Policy to the Insured Person named below, subject to the terms, conditions and
exclusions expressed in the said Policy, but not exceeding the Sum Insured as specified below.

Policy Certificate Number: 915617133559

Master Policy Number: 4148/GSG/170868968/00/000
Issued At: Mumbai

Insured Person Details

Name ASHOKMANJHI
Gender Male
Date of Birth 1990-01-01
Age as on Policy Start Date 29
Address with Pin code
VILL RAJPURA POST
DAULATPUR,Bihar - 811313
Mobile Number 7739184812
Email ID
PAN No.
Aadhaar No.
Date from which the policyholder has been continuously obtaining health
insurance cover in India without break

Policy Details
Period of Insurance From : 26-12-2019 To:25/12/2020

BENEFITS TABLE
 Sum Periodical Claim Payment
Section and Benefits
Insured (If applicable & opted)
Payout Payout
Periodicity
(Rs) Period
SECTION - B (Animal, Insect & Reptile Attack
Benefit)
Death due to Animal, Insect & Reptile Attack Benefit Rs. 100,000
Not Applicable
PTD due to Animal, Insect & Reptile Attack Benefit Rs. 100,000
Section C (Specific Vector Borne Disease and Malaria
Benefit)
Specific Vector Borne Disease related Hospitalization
Rs. 10,000
Benefit Not Applicable
Malaria related Hospitalization Benefit Rs. 10,000

Premium Details
Net Premium (in Rs.) 41
GST (in Rs.) 8
Total Premium (in Rs.) 49
The stamp duty of Rs. 5/- has been paid in cash or by demand draft or by pay order

SPECIAL CONDITION:
Section C:

Waiting period applicable if 30 days

Minimum 48 hours of hospitalization is mandatory for the Hospitalization benefit to be triggered

IMPORTANT NOTES:

1. Insurance cover will start only on receipt of full premium (First Installment in case the customer has
opted for Periodic Premium Payment option) stated in PART I of the Policy Schedule by ICICI
Lombard General Insurance Company Limited.
2. Insurance cover is subject to the terms and conditions mentioned in the Policy wordings provided to
you with this Certificate.
3. The above covers would not be applicable for persons occupied in underground mines, explosives
and electrical installations on high tension lines unless otherwise covered and stated in the Policy
Schedule.
4. Major exclusions: Intentional self-injury, suicide or attempted suicide whilst under the influence of
intoxicating liquor or drugs, any loss arising from an act of breach of law with or without criminal
intent. Please refer to the Policy wordings for a complete list of exclusions.
5. For any endorsements such as name correction or change in nominee details, you can contact us at
Toll Free Number 1800-2666 or Email us at customersupport@icicilombard.com or visit our nearest
branch.
6. The claimant can contact the nearest FINO Payments Bank Limited branch for lodging the claim.
7. Address for claim notification: IL Health Care, ICICI LOMBARD HEALTHCARE ICICI BANK
TOWER,PLOT NO.12, FINANCIAL DISTRICT, NANAKRAM GUDA, GACHIBOWLI,
HYDERABAD, ANDHRA PRADESH PIN CODE: 500032

Agent Details
Agent/Intermediary Name FINO Payments Bank Limited
Agent/Intermediary Code (ID) (AQ) CA0480
Agent/Intermediary Contact No. 1860 266 3466
For ICICI Lombard General Insurance Company Limited
Issuing office: Mumbai

Misc Code - 148

Authorised Signatory

ICICI Lombard General Insurance Company Limited (IRDAI Reg No.115)

CIN : L67200MH2000PLC129408

UIN: ICIPAGP18102V011718