Shishi Joshpura

Risk Assumption Letter
Dear Sir / Madam,
We thank you for placing this Insurance business with us.
Please find attached herewith Policy No.:4030/2880435/00/000, which has been issued based on the details furnished to
us by insured:
1. Name of the Insured : Mr. SHISHIR JOSHIPURA
: SKF INDIA MAHATMA GANDHI BLDG, NETAJI SUBHASH RD CHARNI RD
2. Mailing Address
MUMBAI, MUMBAI , MAHARASHTRA
3. Telephone No. : - -66337777

4. Mobile No. : NA
5. E-mail Id :
6. Date of Birth : 22-Jan-1962
7. Passport No. : Z1724823
8. Nominee Name : MEGHAL
9. Visa Type : non-immigrant
10. Period of Insurance
: From: 07-Dec-2009 To: 06-Dec-2010 Days: 365
(Multi Trip)
11. Geographical Scope : WORLDWIDE
12. Plan Type : GOLD MULTI 100
13. Pre-existing Diseases : NA
14. Medical Treatment
: NA
History
15. Family Doctor’s Details : NA
Please go through the details as furnished in the format and also as provided in the policy document and confirm that they
are in order. Should you feel that there are any discrepancies/variations, you are requested to write back to us
immediately at [email protected] 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 Det Norske Veritas (DNV). This would mean that we would meet the service
related promises that we make to our customers.
Thanking you,
Authorised Signatory
ICICI Lombard General Insurance Company Limited
PART 1 OF THE SCHEDULE - OVERSEAS INDIVIDUAL TRAVEL INSURANCE
POLICY DETAILS
Policy No.: 4030/2880435/00/000 Agent Location: Hyderabad Agent: CUST-440668
Period of Insurance (Multi Trip) : From: 07-Dec-2009 To: 06-Dec-2010 Midnight (Multi Trip)
Maximum Trip Duration : 45
Insured no of travel days : 365
Geographical Scope : WORLDWIDE
DETAILS OF THE INSURED PLAN NAME : GOLD MULTI 100

Name Mr. SHISHIR JOSHIPURA Benefits Sum Insured Deductibles
SKF INDIA MAHATMA GANDHI Personal Accident USD 15,000 -
Mailing Address BLDG, NETAJI SUBHASH RD CHARNI RD
MUMBAI, MUMBAI , MAHARASHTRA Medical Cover (includes
USD 100,000* USD 100
medical evacuation cost).*
Pin Code 400002
Dental Treatment USD 250 USD 100
Telephone No. - -66337777
Repatriation of
Mobile No. NA Remains(Included under USD 7000 -
Medica...
E-mail Id
Loss of Passport USD 200 USD 50
Date Of Birth 22-Jan-1962
Total Loss of Checked
Passport No. Z1724823 USD 500 -
Baggage
Nominee Name MEGHAL
Delay of Checked Baggage USD 100 12 Hrs
Visa Type non-immigrant
Personal Liability USD 100,000 -
Financial Emergency USD 300 -
Special Terms & Conditions : USD 125 for max 7

Hijack Distress Allowance 12 Hrs
days
Pre-existing Ailments History : Hospitalisation / Medical Treatment History: Family doctor's Name
NA NA ,Address and Contact
No.:
NA
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.
Premium Details in Rs. (for persons)

Start Date End Date Premium Service Tax Education Higher Net Claim Amount(Rs.)
Cess Education Premium Details
Cess
Original Details 07-Dec-2009 06-Dec-2010 3,680.00 368.00 7.36 3.68 4,059.00 - -
For ICICI LOMBARD GENERAL INSURANCE CO.
LTD.
Authorised Signatory
Date of Issue:04-Dec-2009
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. 19232 dated
13-Aug-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: [email protected]. 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 [email protected] 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
Do not forget to collect the print of Global Assistance card after policy
print
Name : SHISHIR JOSHIPURA

Policy No. : 4030/2880435/00/000
DOB : 22-Jan-1962 UHC ID : 107523071
Plan : GOLD MULTI 100 UHC Group No. : 713055
From : 07-Dec-2009 To : 06-Dec-2010
This plan is administered by UnitedHealthcare Options PPO-in the United

States of America. Please produce this card along with
License/Passport to prove identity. Valid up to policy expiration
date or cancellation date whichever is earlier.
.................................................................................................
24X7 CUSTOMER HELPLINE NUMBERS

From USA & Canada - + 1 866 625 8529 (toll free)
From rest of the world - +91 11 4189 8868 (call back facility)
Fax No - +91 11 4189 8801 Email - [email protected]
This card does not guarantee benefits.Please confirm coverage.Cashless benefits only
for inpatient hospitalization subject to confirmation. US Hospitals/Doctors:
To verify eligiblity please call United Healthcare at 1(972) 461-5103 For US
physician/hospital only - Submit claims to UnitedHealthCare.P.O. Box 869035. Plano TX
75086-9035 Electronic Payer ID: 87726
This Card is not transferable. Use of this card is governed by the policy terms
and conditions. If found in the United States, please
return to UnitedHealthcare, Plano,TX. If found outside of the United States,
please return to ICICI Lombard Corporate Office.

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Risk Assumption Letter

Dear Sir / Madam,

We thank you for placing this Insurance business with us.

3. Telephone No. : - -66337777

DETAILS OF THE INSURED PLAN NAME : GOLD MULTI 100

Special Terms & Conditions : USD 125 for max 7

Premium Details in Rs. (for persons)

Service tax registration number-GIS/Mumbai-I/1528/2001.

Name : SHISHIR JOSHIPURA

This plan is administered by UnitedHealthcare Options PPO-in the United

24X7 CUSTOMER HELPLINE NUMBERS

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