Risk Assumption Letter

Ref. No. : W260401123

20-Nov-2023

Dear Customer,

We value your relationship with ICICI Lombard General Insurance Company Limited and thank you for choosing us as
your preferred service partner.

Please find enclosed herewith your policy having policy number 4129/316454043/00/000 which has been issued based
on the details furnished to us by the insured:-

Insured Name Pankaj Rathi Policy No. 4129/316454043/00/000 EXCLUS

Mailing Address House No C 108, Rishi Period of Insurance / From : 20-Nov-2023
Nagar|||,FARIDABAD,HARYANA,INDIA Trip Particulars To : 29-Nov-2023 ,
- 121004 Days : 10
Contact Number 98******79 / 98******79 Geographical Scope EXCLUSCANADA
Email Id gu************@gmail.com Plan Type GOLD_X_250
Nominee Name Mahesh Chandra Rathi Visa Type Non Immigrant
Insured Age 48.0 Alternative Policy No. 4129/W-177524181/00/000
Product Code / 4129 - Internationaltravel UIN No. ICITIOP22093V032122
Product Name
DOB 24-Jan-1975 Passport No 526313578

Politically Exposed Person (PEP)/close relative of PEP: No

Note:
Medical expenses due to Covid-19 is covered if contracted during the travel period as per policy terms and
conditions

This policy does not cover any injury/illness and complications arising out of pre-existing condition whether declared or
undeclared.

Pre-existing Condition shall mean and include any condition, ailment or injury or related condition(s) for which you had
signs or symptoms, and/ or were diagnosed, and/ or received medical advice/ treatment within 48 months prior to the
first policy issued by the insurer.

Important:This policy has been issued based on the details furnished by the policyholder. Please review the details
furnished in the policy certificate cum information sheet and confirm that same are in order. In case of any
discrepancy / variation, you are requested to write back to us immediately at [email protected] or
contact our toll free no. 1800 2666 for necessary changes / rectifications. In the absence of any communication from
you with in period of 15 days of receipt of this document, the policy would be deemed to be in order and issued as per
your proposal. 102/20141021/66

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 Part 1 of the schedule - International Travel Insurance
Policy No. 4129/316454043/00/000 Travel Days 10
Period of Insurance From : 20-Nov-2023 Geographical Scope EXCLUSCANADA
To : 29-Nov-2023
GSTIN Number (Customer) - Invoice number 1011232410431

Insured Name Pankaj Rathi Date of Birth 24-Jan-1975

Mailing Address House No C 108, Rishi Gender male
Nagar|||,FARIDABAD,HARYANA,I
NDIA - 121004 Nominee Name Mahesh Chandra Rathi
Contact Number 98******79 / 98******79 Relationship with Father
Nominee
Email Id gu************@gmail.com Passport No 526313578
Sum Insured (USD) 250000 IL ID 863986351
Medical Treatment History NA Pre-Existing Disease None-None
Family Doctor Name & -
Address
Servicing Branch Mumbai Servicing Branch 414, ICICI LOMBARD
Address HOUSE, VEER SAVARKAR
MARG, NEAR SIDDHI
VINAYAK TEMPLE MAIN
GATE, PRABHADEVI,
MUMBAI, 400025,
MAHARASHTRA

Please Note: Any claim due to or arising out of pre-existing disease/ailment whether declared or
undeclared is not covered under the policy
The above records details given by the insured pursuant to Clause 8(2) of the IRDA (Protection of policy holder's
interest) Regulations, 2017. 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

Plan Name : GOLD_X_250

Benefits Sum Insured Deductibles
Accidental Death (Common Carrier) USD 5000 NA
Delay of Checked-In Baggage USD 100 6 Hours
Dental Expenses USD 300 USD 100
Emergency Cash Advance USD 1000 NA
Hijack Distress Allowance USD 125 per day for max 7 days 12 Hours
Loss of Passport USD 300 USD 50
Medical Cover(Includes Medical USD 100 (Total amount applicable for
Evacuation cost, Sublimit applicable Medical Expenses alongwith the
USD 250,000
for age 51 yrs and above. Please applicable extensions under Medical
refer policy wordings for details) Expenses)
Missed Flight Connection USD 500 3 Hours
Personal Accident USD 15000 NA
Personal Liability USD 100,000 5% of Actuals
Political Risk and Catastrophe
USD 7500 NA
Evacuation
Repatriation of Remains(Included in
USD 7500 NA
Medical Expenses)
Total Loss of Checked-In Baggage USD 500 NA
Trip Cancellation and Interruption USD 500 NA
Trip Delay Upto USD 500 6 Hours
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 Premium Details (`)
Basic Premium IGST Total Tax Payable Total Premium
% `
830.42 18 149.48 149.48 980
We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more
than the aggregate turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms
of the provisions of the said sub-rule.

GSTIN Reg.No HSN/SAC code The stamp duty of `1 paid vide deface no. CSD6920232872 dated
997136 GENERAL 14-Jun-2023 .
27AAACI7904G1ZN
INSURANCE SERVICES

Date of Issue : 20-Nov-2023

Place of Issuance : MUMBAI

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 behalf of the beneficiary to obtain insurance benefit.
Please visit our website www.icicilombard.com for branch office address
Please refer to Part II and Part III of the policy schedule for detailed terms and conditions of the covers described
above.
Claims Procedure:
In the event of an accident or sudden illness or any other claim (cashless or reimbursement) caused by a contingency
covered under the insurance policy, immediately contact the helpline number stating the necessary details.
Contact the ICICI Lombard 24hr Help Line number for assistance and registering your claim:
From USA and Canada: +18448711200 (Toll Free)
From Rest of the World: +91 124 4498778 (Call back facility)
In India: 1800 102 5721 (Toll free and accessible in India (available from Mon-Fri between 9am- 6pm))
Fax: + 91 124 4006674
E-mail: [email protected]
Website : www.falck.com

Failure to send immediate notice on the happening of a loss resulting in a claim may prejudice the insured's claim under
the policy. The documents required in support of the claim shall be forwarded to the Company at the address
mentioned below immediately upon return of the Insured to the Republic of India and in no case beyond a period of 30
days from the date of return of the Insured to the Republic of India.
CLAIMS DEPARTMENT
ICICI LOMBARD
C/O Falck India Pvt Ltd
Upper Floor
The Peach Tree, Block - C
Sushantlok-I, Sector 43,Gurgaon,
Haryana-122015 (India)

IMPORTANT NOTE: This certificate has to be read in conjunction with the Terms & Conditions, coverage and
exclusions, which is available with ICICI Lombard. Kindly acknowledge receipt of this policy. In case you find any
variation against your proposal or any discrepancy in the policy, kindly contact us immediately. You may email us at
[email protected]. In cases of any product related query, please call us at 1800 2666 (Toll Free and
accessible in India only).

Disclaimer: Insurance is the subject matter of solicitation. Please refer to policy wordings for terms and conditions,
coverage and exclusions.

ICICI Lombard General Insurance Company Limited

ICICI Lombard House,414,Veer Savarkar Marg,Near Siddhi Vinayak Temple,Prabhadevi,Mumbai 400 025.
IRDA Reg. No.115, CIN L67200MH2000PLC129408, Misc 129, www.icicilombard.com
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 KEY INFORMATION SHEET (KIS)
no

S.No. Title Description(Description is illustrative and not exhaustive) Reference to Policy

1 Product Name International Travel Insurance
• Hospitalisation expenses for Injury/illness during the trip
• Cost of transportation of mortal remains in the event of death during the
trip
• Transportation expenses for medical evacuation with prior approval
What is • Accidental injury leading to Death/PTD during the trip
Part II of the
2 covered under • Value of Checked-In Baggage lost whilst in custody of common carrier
Schedule
the policy • Allowance for the delay of Checked-In Baggage whilst on trip
• Loss of Passport whilst on Trip abroad
(Note: This is an indicative list. The list of benefits applicable as per
your plan is mentioned in Part I of the schedule. Please refer to policy
wordings for details of applicable benefits)
• Any claim due to or arising out of pre-existing medical
condition/ailment is not covered under the policy.
• Cosmetic treatment or Plastic surgery in any form or manner
• Rehabilitation and/or physiotherapy or the costs of
What are the prostheses/prosthetics(artificial limbs)etc Part II of the
major
3 • Self inflicted injuries; Drug or alcohol abuse Schedule Exclusions
exclusions in
• Partial loss of items in the checked in Baggage to respective benefits
the policy
• Loss of Valuables and money
• Theft of passport unless reported to police within 24 hours
• Any claim arising out of sporting or adventurous activities/aircraft
operation unless specifically covered under the policy.
• Sublimits are not applicable for Schengen countries upto 85 years
• For policies with sum insured over US$ 100,000, the benefit of medical
expenses is restricted to US$ 100,000 per sickness or accident leading to
one or more hospitalizations
For persons aged 51 years and above, maximum eligible medical
• Part II of the
expenses are as follows:
Schedule
Limit of ° Hospital Room and boarding,- US$ 1,800 per day up to max of 30 days
4 covered ° ICU - max US$ 3,250 per day up to max of 7 days Benefit 1- Medical
expenses ° Surgery -Max. upto US$ 15,000 Expenses
° Anesthetist services -max up to 25% of surgical treatment
° Medical Practitioners visit fees - max US$ 100 per day per visit up to - Special Conditions
10 visits
° Diagnostic and radiology services - Max. US$ 1000
° Ambulance services - Max upto US$ 500
• Misc Expenses - Max upto US$ 2000
• Register and intimate your claim by calling at following numbers for
Overseas Policies
° In USA & Canada +1 844 871 1200 (Toll Free)
° From the rest of the World +91 124 4498778 (Call Back Facility)
° In India 1800 102 5721 (Toll Free & Accessible in India Only) Part II of the
Claims Schedule
5 ° Fax +91 124 4006674
Contact
° E-mail - [email protected] Claims Information
• Promptly give the Company any and all information and documentation
concerning the claim or the Company’s liability for it.
• Any other document as required by the Company or Company’s TPA to
investigate the Claim or our obligation to make payment for it
Extension You can extend the policy by logging at our website www.icicilombard.com
6 -
Condition
7 Cancellation This policy would be cancelled in below conditions: Part II of the
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 • We may cancel this Policy on grounds of misrepresentation, fraud, non
disclosure of material facts or non cooperation of Insured/Policy Holder
by sending 15 days written notice by registered post to your last known
Part II of the
address, and then we shall refund a pro-rata premium for the unexpired
7 Cancellation Schedule General
Policy Period.
Condition -7
• You may cancel this Policy any time before date of expiry of insurance
by giving us 15 days written notice and in such case We shall refund
premium on short term basis for the unexpired Policy Period provided no
claim has been reported on your behalf under the Policy
An annual cover valid in respect of trips undertaken subject to the duration
8 Multi Trip Part I of schedule
of any one trip not exceeding 'Maximum Trip Duration'

NOTE: The information must be read in conjunction with the product brochure and policy certificate. In case of any conflict
between the KIS and the policy document, the terms and conditions mentioned in the policy document shall prevail.

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 Global Assistance E-Card

Name : Pankaj Rathi

Policy No. : 4129/316454043/00/000

Date of Birth : 24-Jan-1975

Valid From : 20-Nov-2023

Valid To : 29-Nov-2023

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2023.11.20 16:36:37 IST
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