Policy Certificate

POLICYALL
Proposer Name ADARSH KUMAR Policy No. 4128i/HP/129831285/01/000
Address INVICTA DESIGN TECHNOLOGY, B-151, 2ND FLOOR, Period of Insurance From 00:00 hrs 17-Apr-2018 To 23:59 hrs
SECTOR-6 NOIDA, GAUTAM BUDH NAGAR, UTTAR 16-Apr-2020
PRADESH - 201301 Policy Tenure 2
Contact No. 9873378843 LAN No. NA
Email Address ADARSH.XL1@GMAIL.COM Policy Issuing Office Prabhadevi
Nominee Name KANCHAN SHARMA Policy Issued On 09-Apr-2018
Relationship With Policyholder SPOUSE Previous Policy No. 4128i/HP/129831285/00/000
Appointee Name Nominee Age 31 Years 5 Month
GSTIN Number (Customer) Servicing Branch Name New Delhi
Servicing Branch Address Fourth Parsavnath Capital Tower Bhai Veer Singh Invoice Number 100418154417
Marg, New Delhi New Delhi 110001

Insured's Name(s) Date of Birth Age Date of Gender Relation With Annual Sum Insured (`) Pre-existing Illness/ Optional Add-on
Y M Joining Proposer Injury Cover*

ADARSH KUMAR 19-Nov-1981 36 4 17-Apr-2017 Male SELF None None

UTKARSH
28-Feb-2015 3 1 17-Apr-2017 Male SON None None
SHARMA 300000
KANCHAN
22-Oct-1986 31 5 17-Apr-2017 Female SPOUSE None None
SHARMA
Plan Details
GSTIN Reg. No HSN/SAC code The stamp duty of ` 1 paid vide receipt/
Plan Name Additional Sum Insured Sub-limit Voluntary
challan no. 0006777117201718 dated
(`) Deductible
27-Mar-2018
9971 GENERAL
HP_2Adults_1Child_2Ye
30000 None 0 07AAACI7904G1ZP INSURANCE
ars
SERVICES
Premium Details (`)
IGST
Basic Premium Total Tax Payable Total Premium
% `
17782.2 18 3200.80 3200.80 20983

3 Agent Details
Agent Agent Agent
SHEETAL . 5798677 9871456782
Name 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 is 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 ihealthcare@icicilombard.com or write to us at ICICI Lombard
GIC, ICICI Bank Tower, Plot no-12, Financial district Nanakramguda, Gachibowli, Hyderabad, Andhra Pradesh 500032.

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 customersupport@icicilombard.com. 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.

Signature Not Verified

Digitally signed by
SANJAY DATTA
Date: 2018.04.09
15:00:38 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
401 & 402, 4th Floor, Interface 11, ICICI Lombard House, 414 Veer Savarkar Marg, Alternate No.: +919223622666 (chargeable)
New Linking Road, Malad (West), Near Siddhi Vinayak Temple, Prabhadevi, Email: customersupport@icicilombard.com 1/4
Mumbai - 400 064. Mumbai - 400 025. Website: www.icicilombard.com
 Tax Certificate
3

To
ADARSH KUMAR
INVICTA DESIGN TECHNOLOGY, B-151, 2ND FLOOR, SECTOR-6 NOIDA
GAUTAM BUDH NAGAR
UTTAR PRADESH - 201301

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

Dear ADARSH KUMAR,

This is to certify that the Company has received the premium dated Apr 17, 2018 for Health insurance coverage
under "Health Insurance Policy" with the following details.

Policyholder's Name ADARSH KUMAR Policy Number 4128i/HP/129831285/01/000

Policy Start Date Apr 17, 2018 Policy End Date Apr 16, 2020
Plan Name HP_2Adults_1Child_2Years Total Premium Paid (`) 20983
GSTIN Number GSTIN Reg.No (ICICI 07AAACI7904G1ZP
(Customer) Lombard)
Servicing Branch New Delhi Servicing Branch Fourth Parsavnath Capital
Name Address Tower Bhai Veer Singh Marg,
New Delhi New Delhi 110001
Premium Details (`)
IGST
Basic Premium Total Tax Payable Total Premium
% `
17782.2 18 3200.80 3200.80 20983

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
401 & 402, 4th Floor, Interface 11, ICICI Lombard House, 414 Veer Savarkar Marg, Alternate No.: +919223622666 (chargeable)
New Linking Road, Malad (West), Near Siddhi Vinayak Temple, Prabhadevi, Email: customersupport@icicilombard.com 2/4
Mumbai - 400 064. Mumbai - 400 025. Website: www.icicilombard.com
Name : ADARSH KUMAR
Policy No. : 4128i/HP/129831285/01/000
Card No. : 104889399
Gender : Male Age : 36 Dob : 19-Nov-1981
Valid Upto : 16-Apr-2020

Name : UTKARSH SHARMA

Policy No. : 4128i/HP/129831285/01/000
Card No. : 104889401
Gender : Male Age : 3 Dob : 28-Feb-2015
Valid Upto : 16-Apr-2020
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
401 & 402, 4th Floor, Interface 11, ICICI Lombard House, 414 Veer Savarkar Marg, Alternate No.: +919223622666 (chargeable)
New Linking Road, Malad (West), Near Siddhi Vinayak Temple, Prabhadevi, Email: customersupport@icicilombard.com 3/4
Mumbai - 400 064. Mumbai - 400 025. Website: www.icicilombard.com
Name : KANCHAN SHARMA
Policy No. : 4128i/HP/129831285/01/000
Card No. : 104889400
Gender : Female Age : 31 Dob : 22-Oct-1986
Valid Upto : 16-Apr-2020

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
401 & 402, 4th Floor, Interface 11, ICICI Lombard House, 414 Veer Savarkar Marg, Alternate No.: +919223622666 (chargeable)
New Linking Road, Malad (West), Near Siddhi Vinayak Temple, Prabhadevi, Email: customersupport@icicilombard.com 4/4
Mumbai - 400 064. Mumbai - 400 025. Website: www.icicilombard.com