Risk Assumption Letter

Dear Sir / Madam,

4
We thank you for placing your confidence with ICICI Lombard for your Health Insurance Needs.
4
Please find attached herewith Policy No. 4128i/iH/185292760/00/000 which has been issued based on the details furnished by the applicant.
4
Name of Proposer MANOHAR KUMAR CHAUDHARY Policy Tenure (in Years) 2
S/O SHIV JI CHAUDHARY RZ 137,GALI NO 2 KARAN
VIHR PART 1 KIRARI,-,-,KARAN VIHAR
TRANSFORMER,DELHI,DEL-110086 - - NANA, S/O
From 00:00 hrs 07-Nov-2019 To 23:59 hrs
Address SHIV JI CHAUDHARY RZ 137,GALI NO 2 KARAN VIHR Period of Insurance
06-Nov-2021
PART 1 KIRARI,-,-,KARAN VIHAR
TRANSFORMER,DELHI,DEL-110086 - - NANA, DELHI,
DELHI - 110086
Policy Issued On 07-Nov-2019 Email Address [email protected]
GSTIN (Customer) Mobile No. 9990577061

Insured Details
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Name of the Date of Age Gender Relationship with Annual Sum Pre-existing Sub-limit Voluntary Optional add
insured (s) Birth Y M policy holder Insured illness / injury Deductible on cover

MANOHAR
KUMAR 04-Jun-1987 32 5 Male SELF None None
CHAUDHARY
SAMARTH
26-Jan-2016 3 9 Male SON 500000 None None 0 None
CHAUDHARY
SARIKA KUMARI 04-Mar-1991 28 8 Female SPOUSE None None
SHIVANSH
10-Mar-2018 1 7 Male SON None None
CHAUDHARY

Please go through the details as furnished in the format and the policy document and confirm that same are order. In case there is any discrepancies / variations,
you are requested to write back to us immediately at [email protected] or contact at 24 hour helpline number 1800 2666 for necessary changes
/ rectifications.

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 as per your proposal.

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE COMPANY
LIMITED
Date: 2019.11.07 22:03:15
IST
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP10001V020910
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Savarkar Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Near Siddhi Vinayak Temple, Email: [email protected]
Link Road, Malad (West), Mumbai - 400 064 Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com
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Policy Certificate
POLICYALL
Proposer Name MANOHAR KUMAR CHAUDHARY Policy No. 4128i/iH/185292760/00/000
Address S/O SHIV JI CHAUDHARY RZ 137,GALI NO 2 Period of Insurance From 00:00 hrs 07-Nov-2019 To 23:59 hrs
KARAN VIHR PART 1 KIRARI,-,-,KARAN 06-Nov-2021
VIHAR TRANSFORMER,DELHI,DEL-110086 - -
NANA, S/O SHIV JI CHAUDHARY RZ 137,GALI
NO 2 KARAN VIHR PART 1 KIRARI,-,-,KARAN Policy Tenure 2
VIHAR TRANSFORMER,DELHI,DEL-110086 - -
NANA, DELHI, DELHI - 110086

Contact No. 9990577061 LAN No. NA

Email Address [email protected] Policy Issuing Office Prabhadevi
Nominee Name SARIKA KUMARI Policy Issued On 07-Nov-2019
Relationship With SPOUSE Previous Policy No.
Policyholder
Appointee Name Nominee Age NA
GSTIN Number (Customer) Servicing Branch Name Mumbai
Servicing Branch Address 414, ICICI LOMBARD HOUSE, VEER Invoice Number 101119260770
SAVARKAR MARG, NEAR SIDDHI VINAYAK
TEMPLE MAIN GATE, PRABHADEVI, MUMBAI,
400025, MAHARASHTRA

Insured's Name(s) Date of Age Date of Gender Relation With Annual Sum Pre-existing Optional Add-on
Birth Joining Proposer Insured (`) Illness/ Injury Cover*
Y M
MANOHAR KUMAR
04-Jun-1987 32 5 07-Nov-2019 Male SELF None None
CHAUDHARY
SAMARTH
26-Jan-2016 3 9 07-Nov-2019 Male SON None None
CHAUDHARY 500000
SARIKA KUMARI 04-Mar-1991 28 8 07-Nov-2019 Female SPOUSE None None
SHIVANSH
10-Mar-2018 1 7 07-Nov-2019 Male SON None None
CHAUDHARY
Plan Details
GSTIN Reg. No HSN/SAC code The stamp duty of ` 1 paid vide
Plan Name Additional Sum Insured Sub-limit Voluntary
deface no. MH007639701201920M
(`) Deductible
dated 23-Oct-2019
9971 GENERAL
iH_2Adults_2Child_2Y
0 None 0 27AAACI7904G1ZN INSURANCE
ears
SERVICES
Premium Details (`)
IGST
Basic Premium Total Tax Payable Total Premium
% `
23060.17 18 4150.83 4150.83 27211

4 Agent Details
Agent ICICI BANK LTD Agent Agent
2470377 8886637187
Name CSPB CREDIT Code contact No.
SYSESB00102415318

Important: Insurance benefit shall become voidable at the option of the company, in the event of any untrue or incorrect statement, misrepresentation
non-description 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 i s excluded from the scope of this policy subject to applicable terms and conditions. Refer to policy wordings for the terms and conditions. All disputes
are subject to the jurisdiction of Mumbai High Court only. For claims, please call us at our toll free no. 1800 2666 or e-mail to us at [email protected] or
write to us at ICICI Lombard GIC, ICICI Bank Tower, Plot no-12, Financial district Nanakramguda, Gachibowli, Hyderabad, Andhra Pradesh 500032.
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP10001V020910
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Savarkar Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Near Siddhi Vinayak Temple, Email: [email protected]
Link Road, Malad (West), Mumbai - 400 064 Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com
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This policy has been issued based on the details furnished by the policyholder. Please review the details furnished in the policy certificate and confirm that same
are in order. In case of any discrepancy/ variation, you are requested to call us immediately at our toll free no. 1800 2666 or write to us at
[email protected]. In the absence of any communication from you within the period of 15 days of receipt of this document, the policy would be
deemed to be in order and issued as per your proposal. All refunds and claim payment will be done through NEFT only. In case of addition of member/ increase in
sum insured, fresh waiting period will be applicable to new member/ increased sum insured. This policy certificate is to be read with the policy wordings, as one
contract or any word or expression to which a specific meaning has been attached in any part of this policy shall bear the same meaning wherever it may appear.

109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP10001V020910
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Savarkar Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Near Siddhi Vinayak Temple, Email: [email protected]
Link Road, Malad (West), Mumbai - 400 064 Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com
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 Tax Certificate
4

To
MANOHAR KUMAR CHAUDHARY
S/O SHIV JI CHAUDHARY RZ 137,GALI NO 2 KARAN VIHR
PART 1 KIRARI,-,-,KARAN VIHAR
TRANSFORMER,DELHI,DEL-110086 - - NANA
S/O SHIV JI CHAUDHARY RZ 137,GALI NO 2 KARAN VIHR
PART 1 KIRARI,-,-,KARAN VIHAR
TRANSFORMER,DELHI,DEL-110086 - - NANA
DELHI
DELHI - 110086

Subject: Premium certificate for the purpose of deduction under section 80D of Income Tax
Act, 1961 and any amendments made thereafter.

Dear MANOHAR KUMAR CHAUDHARY,

This is to certify that the Company has received the premium dated Nov 07, 2019 for Health
insurance coverage under "Health Insurance Policy" with the following details.

Policyholder's MANOHAR KUMAR Policy Number 4128i/iH/185292760/00/00

Name CHAUDHARY 0
Policy Start Date Nov 07, 2019 Policy End Date Nov 06, 2021
Plan Name iH_2Adults_2Child_2Years Total Premium Paid 27211
GSTIN Number GSTIN Reg.No (ICICI 27AAACI7904G1ZN
(Customer) Lombard)
Servicing Branch Mumbai Servicing Branch 414, ICICI LOMBARD
Name Address HOUSE, VEER
SAVARKAR MARG, NEAR
SIDDHI VINAYAK
TEMPLE MAIN GATE,
PRABHADEVI, MUMBAI,
400025, MAHARASHTRA
Premium Details (`)
IGST
Basic Premium Total Tax Payable Total Premium
% `
23060.17 18 4150.83 4150.83 27211

The product is eligible for deduction u/s 80D of the Income Tax, 1961 and any amendments
made there to.

Note: 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.
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP10001V020910
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Savarkar Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Near Siddhi Vinayak Temple, Email: [email protected]
Link Road, Malad (West), Mumbai - 400 064 Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com
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Name : MANOHAR KUMAR CHAUDHARY
Policy No. : 4128i/iH/185292760/00/000
Card No. : 120143198
Gender : Male Age : 32 Dob : 04-Jun-1987
Valid Upto : 06-Nov-2021

Name : SAMARTH CHAUDHARY

Policy No. : 4128i/iH/185292760/00/000
Card No. : 120143199
Gender : Male Age : 3 Dob : 26-Jan-2016
Valid Upto : 06-Nov-2021
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP10001V020910
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Savarkar Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Near Siddhi Vinayak Temple, Email: [email protected]
Link Road, Malad (West), Mumbai - 400 064 Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com
5/6
Name : SARIKA KUMARI
Policy No. : 4128i/iH/185292760/00/000
Card No. : 120143200
Gender : Female Age : 28 Dob : 04-Mar-1991
Valid Upto : 06-Nov-2021

Name : SHIVANSH CHAUDHARY

Policy No. : 4128i/iH/185292760/00/000
Card No. : 120143201
Gender : Male Age : 1 Dob : 10-Mar-2018
Valid Upto : 06-Nov-2021
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP10001V020910
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Savarkar Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Near Siddhi Vinayak Temple, Email: [email protected]
Link Road, Malad (West), Mumbai - 400 064 Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com
6/6