4128i - HP - 129831285 - 01 - 000 - Adarsh - Upto 20220416

Risk Assumption Letter
Dear Sir / Madam,

3
We thank you for placing your confidence with ICICI Lombard for your Health Insurance Needs.
3
Please find attached herewith Policy No. 4128i/HPN/129831285/02/000 which has been issued based on the details furnished by the applicant.
5
Name of Proposer ADARSH KUMAR Policy Tenure (in Years) 2
INVICTA DESIGN TECHNOLOGY, B-151, 2ND FLOOR,
From 00:00 hrs 17-Apr-2020 To 23:59 hrs
Address SECTOR-6 NOIDA, GAUTAM BUDH NAGAR, UTTAR Period of Insurance
16-Apr-2022
PRADESH - 201301
Policy Issued On 08-Apr-2020 Email Address ADARSH.XL1@GMAIL.COM
GSTIN (Customer) Mobile No. 9873378843
Insured Details
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Name of the Date of Age Gender Relationship with Annual Sum Pre-existing Sub-limit Voluntary Optional add
insured (s) Birth Y M policy holder Insured illness / injury Deductible on cover
ADARSH
19-Nov-1981 38 4 Male SELF None Option 1
KUMAR
KANCHAN
22-Oct-1986 33 5 Female SPOUSE 300000 None C 0 Option 1
SHARMA
UTKARSH
28-Feb-2015 5 1 Male SON None Option 1
SHARMA
Please go through the details as furnished in the format and the policy document and confirm that same are order. In case there is any discrepancies / variations,
you are requested to write back to us immediately at customersupport@icicilombard.com or contact at 24 hour helpline number 1800 2666 for necessary changes
/ rectifications.
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 as per your proposal.
Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE COMPANY
LIMITED
Date: 2020.04.08 11:58:34
IST
109/20150914/284
ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 ICICI Lombard Complete Health Insurance UIN - lClHLlP20084V03l920
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Savarkar Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Near Siddhi Vinayak Temple, Email: customersupport@icicilombard.com
Link Road, Malad (West), Mumbai - 400 064. Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com
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Policy Certificate
POLICYALL
Proposer Name ADARSH KUMAR Policy No. 4128i/HPN/129831285/02/000
Address INVICTA DESIGN TECHNOLOGY, B-151, 2ND Period of Insurance From 00:00 hrs 17-Apr-2020 To 23:59 hrs
FLOOR, SECTOR-6 NOIDA, GAUTAM BUDH 16-Apr-2022
NAGAR, UTTAR 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 08-Apr-2020
Relationship With SPOUSE Previous Policy No. 4128i/HP/129831285/01/000
Policyholder
Appointee Name Nominee Age 33 Years 5 Month
GSTIN Number (Customer) Servicing Branch Name New Delhi
Servicing Branch Address Fourth Parsavnath Capital Tower Bhai Veer Invoice Number 100420243484
Singh Marg, New Delhi New Delhi 110001
Insured's Date of Age Date of Gender Relation With Annual Sum Pre-existing Illness/ Optional Add-on
Name(s) Birth Y M Joining Proposer Insured (`) Injury Cover*
ADARSH
19-Nov-1981 38 4 17-Apr-2017 Male SELF None Option 1
KUMAR
KANCHAN
22-Oct-1986 33 5 17-Apr-2017 Female SPOUSE 300000 None Option 1
SHARMA
UTKARSH
28-Feb-2015 5 1 17-Apr-2017 Male SON None Option 1
SHARMA
*Option 1: Hospital Daily Cash and Convalescence Benefit
Plan Details
GSTIN Reg. No HSN/SAC code The stamp duty of ` 1 paid vide
Plan Name Additional Sum Insured Sub-limit Voluntary
deface no. CSD356202011872020
(`) Deductible
dated 17-Mar-2020
9971 GENERAL
HP_2Adults_1Child_2Y
90000 C 0 07AAACI7904G1ZP INSURANCE
ears_N
SERVICES
Premium Details (`)
IGST
Basic Premium Total Tax Payable Total Premium
% `
17821.35 18 3207.84 3207.84 21029
5 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 i s 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.
109/20150914/284

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Tax Certificate
5
To
ADARSH KUMAR
INVICTA DESIGN TECHNOLOGY, B-151, 2ND FLOOR,
SECTOR-6 NOIDA
GAUTAM BUDH NAGAR
UTTAR PRADESH - 201301
ANNUAL
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, 2020 for Health
insurance coverage under "Health Insurance Policy" with the following details.
Policyholder's ADARSH KUMAR Policy Number

4128i/HPN/129831285/02/
Name 000
Policy Start Date Apr 17, 2020 Policy End Date Apr 16, 2022
Plan Name HP_2Adults_1Child_2Year Total Premium Paid 21029
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
% `
17821.35 18 3207.84 3207.84 21029
Financial Year Amount
2020-2021 10514.50
2021-2022 10514.50
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

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Name : ADARSH KUMAR
Policy No. : 4128i/HPN/129831285/02/000
Card No. : 104889399
Gender : Male Age : 38 Dob : 19-Nov-1981
Valid Upto : 16-Apr-2022
Name : KANCHAN SHARMA

Policy No. : 4128i/HPN/129831285/02/000
Card No. : 104889400
Gender : Female Age : 33 Dob : 22-Oct-1986
109/20150914/284

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Name : UTKARSH SHARMA
Policy No. : 4128i/HPN/129831285/02/000
Card No. : 104889401
Gender : Male Age : 5 Dob : 28-Feb-2015
109/20150914/284

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4128i - HP - 129831285 - 01 - 000 - Adarsh - Upto 20220416

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Risk Assumption Letter

Dear Sir / Madam,

Signature Not Verified

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

Dear ADARSH KUMAR,

Policyholder's ADARSH KUMAR Policy Number

Premium Details (`)

ICICI Lombard General Insurance Company Limited

Name : KANCHAN SHARMA

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

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