Risk Assumption Letter Date : 02Mar2015 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
Name of the proposer:
Abu Sufiyan Azad Kazi
Mailing Address:
104 Sehar Residency Near Bilal Hospital Kausa Mumbra ,Thane,Maharashtra 400612. 7738407457
Mobile No.: Telephone No.: Email ID: Product Name: No. of Members : Policy Duration (years): Age of the eldest member (years):
[email protected] iHealth 2 2 27 From 02Mar2015 To 01Mar2016
Policy Period Insured Details Name of the Insured(s)
Relationship with Proposer
Abu Sufiyan Kazi
Self
Age P r e- Existing Y e a r M o n t h s illness/injury 27 NA 4
Farah Kazi
Spouse
27
3
NA
Annual Sum Insured 1000000
Optional Add- o n Cover
S u blimit
Voluntary Deductible
None
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
[email protected] 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
0
Policy Issuing Office
ICICI Lombard Complete Health Insurance Policy Number : 4128i/iH/108915572/00/000 ICICI Lombard General Insurance Company LTD., IRDA Regn. No. 115 , ICICI LOMBARD HOUSE , 414, Policy Issued 02-Mar-2015 Veer Savarkar Marg, Near Siddhi On Vinayak Temple, Prabhadevi, Mumbai 400 025 Part I Of Schedule
Details of Policy Holder/ Proposer: 4128i/iH/1089144241/00/000
Policy No.
Name of the Applicant Abu Sufiyan Azad Kazi
Correspondence Address
104 Sehar Residency, Near Bilal Hospital Kausa Mumbra Thane
Email Address
Maharashtra 400612 Name of Nominee
Contact No(s) (R): Mobile No 7738407457 Policy From 00:00 hrs 02-Mar2015 to Period Midnight of 01-Mar-2016
[email protected]
Relationship of Nominee with Proposer
-
Details of Family Members covered under the Policy : Name of the Insured(s) Abu Sufiyan Kazi Farah Kazi
Age Annual Sum Pre-Existing Gender Relation Insured illness/injury Years Months Self 4 02-Mar-2015 27 M Spouse 1000000 02-Mar-2015 27 3 F Date Of Joining
Health Member ID No. None
102965007
None
102965008
Optional Add-on Cover
Sublimit
Voluntary Deductible
None
0
Premium Schedule : Plan Name Senior Health - i Health
Basic Premium (Rs.) 15015.38
Service Tax (Rs.) 738.62
Secondary and Education Cess Higher Education (Rs.) Cess (Rs.) 0 0
Total Premium (Rs.) 15754
For ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED
Service Tax Registration No. : GIS/MUMBAII/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
In the event of a claim, please call our 24X7 tollfree number 1800 2666 or email us at
[email protected]. 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 :
[email protected]
Premium Certificate For the purpose of deduction under section 80D of Income Tax amendment act, 1961 and any amendments made thereafter. To, Abu Sufiyan Azad Kazi Sehar Residency Near Bilal Hospital Kausa Mumbra Thane, Maharashtra 400612. This is to certify that the company has received the premium of Rs. 15754 for Health insurance coverage under the policy no 4128i/iH/1089144241/00/000 vide Cheque/credit card dated Mar022015. 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.
