COPY ICICI Lombard Health Care Policy Number : 4034i/FPP/04812914/00/000 4034i/FPP/04812914/00/000
PREAMBLE:ICICI PREAMBLE :ICICI Lombard General Insurance Company Limited ("the Company"), having received a proposal and the premium from the proposer named in the Schedule referred to herein below, and the said Proposal, Declaration and Annexure thereto together with any statement, report or other document leading to the issue of this Policy and referred to therein having been accepted and agreed to by the Company and the Proposer as the basis of this contract do, by this policy agree, in consideration of and subject to the due receipt of the subsequent premiums, as set out in the schedule with all its parts, and further, subject to the terms and conditions contained in this policy, as set out in the schedule with all its parts, that in proof to the satisfaction of the Company of the compensation having become payable as set out in Part I of the schedule to the title Policy, the Sum Insured/appropriate benefit will be paid by the Company. Zenith House, Keshavrao Khade Marg, Mahalaxmi, Mumbai - 400034
Policy Issuing Office
Policy Issued On
06-Jul-2009
Part I Of Schedule Details of Policy Holder/ Proposer: 4034i/FPP/04812914/00/000
Policy No
Name of the Proposer
S M UBAIDULLA
SULTHAN, NEW NO-52 , HABIB NAGAR , PALLAPATTI , ARAVAKURICHI , PALLAPATTICorrespondence Address KARUR-639207, TAMILNADU KARUR - 639207 TamilNadu
Contact No(s)
(R): 2423254
Mobile No
(M1): 9898194786
Period of Issuance (Year 1 )
From 00:00 hrs 04-Jul-2009 to Midnight of 03-Jul-2010
Period of Issuance (Year 2 Annual Autorenewal )
From 00:00 hrs 04-Jul-2010 to Midnight of 03-Jul-2011
Email Address
[email protected]
Details of Family Members covered under the Policy : Age
Name of the Insured(s)
Year
S U APSARA PRAVEEN
Gender Gender
Months
40
0F
Relati Relation on
SPOUSE
Sum Insure Insured d
Pre-Ex Pre-Exist isting ing illnes illness/i s/inju njury ry
300000
Health Health Member Member ID No.
IHPN-05019365/01
Premium Schedule : Year 1 Plan Name
Family Protect Premier Inividual
Basic Premium (Rs.) 4432.28
Service Education Tax (Rs.) Cess (Rs.) 443.23 8.86
Year 2
Secondary and Higher Education Cess (Rs.)
Basic Premium (Rs.)
Service Education Tax (Rs.) Cess (Rs.)
Secondary and Higher Education Cess (Rs.)
4.43
2954.85
295.48
2.95
For ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED
5.91
Total Premium (Rs.)
8148
Service Tax Reg. No.: GIS/MUMBAI-I/1528/2001 Service Tax Code Number - AAACI7904GST001 Category : General Insurance Business Services
Authorized Signatory 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 :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 Mumbai High Court only. The stamp duty of Rs.1 (One Only) paid in cash or by demand draft or by pay order,vide Receipt/Challan no.62627 dated 16-Mar-2009 On the happening of a claim, please call immediately at 1800-209-8888 (Toll Free) or e-mail us at
[email protected] You can also write to us at ICICI Lombard GIC, i Health Care, TGV Mansion, 6th Floor, Plot No. 6-2-1012, Khairatabad, Hyderabad ' 500004, Andhra Pradesh. ICICI Lombard General Insurance Company Ltd Corp Office: Zenith House, Keshavrao Khade Marg, Mahalaxmi, Mumbai-400034. Mailing Address: 4th Floor, Interface 11, Off Malad Link Road, Behind Goregaon Sports Club, Malad(w), Mumbai- 400034. Toll Free 24 X 7 Call Center No 1800-209-8888. E-mail :
[email protected]
Premium Certificate For the purpose of deduction under section 80D of Income Tax amendment act, 1961 and any amendments made thereafter. To, S M UBAIDULLA SULTHAN, NEW NO-52 , HABIB NAGAR , PALLAPATTI , ARAVAKURICHI , PALLAPATTI-KARUR-639207, TAMILNADU KARUR - 639207 TamilNadu KARUR 639207 TamilNadu This is to certify that the Company has received the premium as detailed below for Health Insurance Policy No : 4034i/FPP/04812914/00/000. Premium eligible for deduction u/s 80D of the Income Tax Act, 1961 and any amendments made there to. Financial Year 2009 - 2010 3013.64 (Rs.) Collection Financial Year 2010 - 2011 928106 4074 No: (Rs.) Collection 04-JulFinancial Year 2011 - 2012 1060.36 Date 2009 (Rs.) Total Premium (Rs.)
8148
For ICICI Lombard General Insurance Co. Ltd.
Authorized Signatory 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. For the purpose of deduction under section 80D, the benefit shall be as per the provisions of the Income Tax Act, 1961 and any Amendments made thereafter. l
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Information Sheet To, S M UBAIDULLA Date :06-Jul-2009 SULTHAN, NEW NO-52 , HABIB NAGAR , PALLAPATTI , ARAVAKURICHI , PALLAPATTI-KARUR-639207, TAMILNADU KARUR - 639207 TamilNadu KARUR 639207 TamilNadu Sub : Verbal proposal for health insurance policy from ICICI Lombard GIC Ltd. Dear S M UBAIDULLA, Thank you for choosing ICICI Lombard Health Insurance Policy. It is a pleasure to have you as our esteemed customer. This letter is with reference to your tele-conversation dated 05-Jul-2009 with the representative of ICICI Lombard GIC Ltd for the purchase of Health Insurance Policy. The information provided by you has been mentioned below and the Family Protect Premier policy No : 4034i/FPP/04812914/00/000 has been issued based on the same. You are requested to kindly go through the details mentioned below vide the tele-conversation. In case of any discrepancy or error in the information mentioned below or in the policy copy attached, you are requested to intimate us at our call center no 1800-209-8888 within 15 days of issue of this letter. l
Name of the Proposer :
S M UBAIDULLA
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Address :
SULTHAN, NEW NO-52 , HABIB NAGAR , PALLAPATTI , ARAVAKURICHI , PALLAPATTI-KARUR-639207, TAMILNADU KARUR - 639207 TamilNadu
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Details of the insured: Name
Sex
Date of Birth
Relationship with proposer
S U APSARA PRAVEEN
F
05-Jul-1969
SPOUSE
Premium :
Name of Pre-Existing illness
Sum Tenure Insured 300000 2
8148
Exclusions : a. Any illness/disease/injury existing before the inception of the policy for the first first 2 yrs for HAP and 4 yrs for the rest of the products specifically as per the policy wordings. b. Pregnancy and childbirth related diseases, cosmetic aesthetic & obesity related treatments and congenital diseases. c. Any illness contracted during the first 30 days of the inception of the policy except those that are incurred as a result of accident, the exclusion does not apply for subsequent renewals without a break of the policy with the company. d. Non allopathic treatment, expenses arising from HIV or AIDS and related diseases, use or misuse of liquor, intoxicating substances or drugs as well as intentional self injury/attempted suicide/suicide. e. War, riot, strike, nuclear weapons induced hospitalization. f. Certain ailments will be excluded from treatment for 2-years: Cataract, Hernia, Benign Prostatic Hypertrophy , Hydrocele, Sinusitis and related disorders, Arthritis, Gastric and Duodenal ulcers etc.
Regards,
Authorized Representative ICICI Lombard General Insurance Company Ltd. Disclaimer: The details mentioned herein are indicative and not exhaustive, for complete details on coverage's, exclusion, terms and conditions please refer to policy wordings provided along with the policy kit."
