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Date : 02May2019
Dear Sir / Madam,
We thank you for placing your confidence with ICICI Lombard for your health Insurance needs.
Please find attached herewith Policy No.: 4128i/iH/1089144241/00/000 which has been issued based on the
details furnished by the applicant
Mailing Address: Flat 219 Mahaveer Lakes Dr Vishnuvardhan Road Uttarahalli Main Road KengeriBengaluru 560060
9844729394
Mobile No.:
Telephone No.:
Email ID: himanshutater@gmail.com
Product Name: iHealth
No. of Members : 2
Policy Duration (years): 2
Age of the eldest member 27
(years):
From 02Mar2015 To 01Mar2016
Policy Period
Insured Details
Name of the Relationship with Age P r e- Existing Annual Sum Optional Add- o n S u b- Voluntary
Insured(s) Proposer Y e a r M o n t h s illness/injury Insured Cover limit Deductible
Abu Sufiyan Kazi Self 27 4 NA
Farah Kazi Spouse 27 3 NA 1000000 None 0
Please go through the details as furnished in the format and the policy document and confirm that same are in order.
In case there are any discrepancies, you are request 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. Thereon, any non disclosure related to
PreExisting illness/injury would result in rejection of claims and cancellation of policy
Thanking You,
Yours Sincerely,
Authorised Signatory
ICICI Lombard General Insurance Company Limited,IRDA Regn.No.115
Maharashtra 400612
Relationship of Nominee
Name of Nominee -
with Proposer
Details of Family Members covered under the Policy :
Name of the Date Of Age Annual Sum Pre-Existing Health Member ID Optional Add-on Sub- Voluntary
Gender Relation
Insured(s) Joining Years Months Insured illness/injury No. Cover limit Deductible
Abu Sufiyan Kazi 02-Mar-2015 27 4 M Self None 102965007
Farah Kazi 02-Mar-2015 27 3 F Spouse 1000000 None 102965008 None 0
Premium Schedule :
Secondary and
Basic Premium Service Tax Education Cess Total Premium
Plan Name Higher Education
(Rs.) (Rs.) (Rs.) (Rs.)
Cess (Rs.)
Senior Health - i Health 15015.38 738.62 0 0 15754
For ICICI LOMBARD GENERAL INSURANCE Service Tax Registration No. : GIS/MUMBAI-
COMPANY LIMITED I/1528/2001
Service Tax Code Number : AAACI7904GST001
Category: General Insurance Business Services
Authorised Signatory 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.
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 competent courts of INDIA
The stamp duty of Rs 1.00 paid in cash or by demand draft or by payorder,vide Receipt/Challan no. 4063856
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In the event of a claim, please call our 24X7 tollfree number 1800 2666 or email us at
ihealthcare@icicilombard.com.
Please send the relevant documents to: ICICI Lombard Health Care,Plot No:12 ,ICICI Bank
Towers ,Nanakramguda ,Gachibowli, Hyderabad 500032
ICICI Lombard General Insurance Company Ltd
Corp Office:ICICI Lombard General Insurance Company LTD., IRDA Regn. No. 115 , 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 18002666. Email :customersupport@icicilombard.com
The Product is eligible for deduction u/s 80 D of the Income Tax,1961 ad any amendments made there to.
For ICICI Lombard General Insurance Company Limited,IRDA Regn.No.115
Authorized Signatory
Note:
l This certificate must be surrendered to the Insurance Company in case of Cancellation of the policy. In
the event of incorrect representation of this declaration, the liability shall be upon the policyholder.