To Buy/Renew/Claim/Service your policy, log on www.icicilombard.

com or call 18002666

PROPOSAL FORM GROUP

PERSONAL ACCIDENT Barcode No._________

ID_________________

I hereby consent to avail the Group Personal Accident Insurance policy offered by ICICI Lombard General Insurance Company Limited ( "ICICI Lombard"). I
confirm that the information furnished by me in the Preliminary Savings Application form and this addendum form together shall constitute the account opening
documents for the Group Personal Accident Insurance policy.

Policy Details

Nominee Details
Nominee Name: R A M A C H A N D R A I A H Relationship of nominee with applicant: F A T H E R

Policy Information

No Coverage Sum Insured

Option I P A Death / PTD As per Grid

If any extension is required as mentioned in detailed Terms and Conditions please provide the extension details

AUTO RENEWAL CLAUSE : Yes No GST No.(if applicable):

Payment of renewal premium of your group personal accident policy (1year Tenure) can be made every year (Maximum upto 5 year) through auto debit. Under this
option, your terms & conditions, base premium shall remain the same and taxes shall be applicable as per the taxation framework existing at the time of renewal.

Declaration
I hereby declare and warrant that the above statements are true and complete in all respects and there is no other information which is relevant to my application for insurance for myself that has
not been disclosed to you. I agree that this proposal and the declarations shall be the basis on which insurance cover shall be issued to me. I have read and understood the coverage under the policy
and the Terms and Conditions governing the same. I agree to accept the policy, subject to the conditions prescribed by ICICI Lombard General Insurance Co. Ltd. I hereby apply for coverage
under the Group Insurance Policy issued to the Policy holder ICICI Bank Limited And underwritten by ICICI Lombard General Insurance Co. Ltd. I hereby declare and undertake that the amount
paid by me as premium for the aforementioned policy is out of my lawful and declared source of income.' I hereby declare, on my behalf and behalf of all persons proposed to be insured, that the
above statements, answers and / or particulars given by me are true and complete in all respects to the best of my knowledge and that I am authorised to propose on behalf of this other persons. I
understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurance company and that the policy will
come into force only after full receipt of the premium chargeable. I declare and consent to the company seeking medical information from any doctor or from a hospital who has anytime attended
on the life to be insured/ Proposer or from any past or present employer concerning anything which effect the physical or mental health of the life to be assured/ Proposer and seeking information
from any insurance company to which an application for insurance on life to be assured/ proposer has been made for the purpose of underwriting the proposer and/ or claim settlement. I agree that
this application and the declarations shall be the basis of the contract between ICICI Bank Limited and ICICI Lombard General Insurance Company Ltd and I agree to accept a policy, subject to
the conditions prescribed by ICICI Lombard General Insurance Company Ltd. I hereby apply for this Insurance Policy issued to me by ICICI Lombard General Insurance Company Ltd, subject to
all terms, conditions and provisions of the policy. I authorize the Company and their agents to exchange, share or part with all the information provided to other Agencies/ Statutory Bodies as may
be required and I will not hold the Company and their agents liable for use of this information I have been provided with the detail terms of the policy. I have read, understood and aware of the
detail terms of the policy.

Name of the applicant: G U N D A L A V E N K A T E S H W A R L U

______________________________
Place: T I M M A P U R B . O Date: 0 7 / 0 1 / 2 0 2 0 Signature of the Proposer/Customer

For detailed coverage please refer to the Policy Wordings

STATUTORY WARNING
PROHIBITION OF REBATES
(Under Section 41 of Insurance Law)
(Amendment Act 2015)

1) No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any
kind of risk relating to lives or property, in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall
any person taking out or renewing or continuing a Policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or
tables of the Insurer.

2) Any person making default in complying with the provisions of this section shall be liable for a penalty, which may extend to ten lakhs.

ICICI Lombard General Insurance Company Limited

Mailing Address: Interface Building No.11, 401/402, 4th Floor, New Link Road Malad (W), Mumbai - 400 064.
Registered Office Address: ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.
Visit us at www.icicilombard.com • Mail us at customersupport@icicilombard.com
Toll Free No.: 1800 2666 • Chargable No.: +91 92236 22666 • Insurance is the subject matter of solicitation.
IRDA Reg. No. 115. • Misc 05. • CIN: U67200MH2000PLC129408.