ICICI LOMBARD GIC LTD

GROUP HEALTH INSURANCE

Quote cum proposal format
Quote No.(4016/IP-02674971/000)

Proposer Details Policy Coverages

Name of the Proposer PUNJABI BITES Policy Construct Employer - Employee
Location of Proposer GHAZIABAD OPD/IPD IPD
Industry Type Packaged food and Service Category Both(Cashless +
confectionery Reimbursement)
Intermediary Name YBL MUBB AFFLUENT IPD Claim Intimation Period 30 Days
NORTH 30 Days Waiting Period Waived Off
Date 09/Nov/2022 First year exclusion Applicable
Policy Details 9 months waiting period Not Applicable
Floater/Non-Floater Non Floater Third party Administrator IL HEALTH CARE
Transaction New Policy No of Employees 33
Family Definition Self No. of Dependents 0
Premium Details Total SI 3,300,000
Gross Premium 91,119.52
Stamp Duty .50
Add: Goods & Service Tax 16,401.51
Total Premium Payable 107,522
*Premium value mentioned above is inclusive of taxes
applicable.
Basic 43459.74

Policy Conditions

Age Band 91 days to 80 years

Family Definition Employee covered under policy.

SI is restricted to Rs. 100000 per person during the policy period as per annexure attached
Sum Insured
herewith.

1% of SI(100000) maximum upto Rs.3500 for Normal and 2% of SI(100000) maximum upto
Room Rent Rs.5000 for ICU (inclusive of nursing charges) . If insured is admitted in a higher category, then
insured will bear difference of all medical expenses as in final hospital bill in same proportion.

Pre-Existing
Pre-Existing diseases are covered
Disease

Pre-Post
Pre Hospitalisation and Post Hospitalisation for 60-90 days respectively are covered.
Hospitalisation

Ambulance
Ambulance Charges limited to Rs 1000 per person.
Service

Health Assistance is a dedicated medical care service that assists you in all your health related
Health queries for identifying Specialist/Hospital/fixing an appointment with Doctors/Nutritionist
Assistance /facilitating 2nd opinion, etc. To avail this facility please call our Helpline at 040 6627 4205 (9:30
Services am to 6 pm Mon to Sat, excluding public holidays) or write to
healthassistance@icicilombard.com.

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ICICI LOMBARD GIC LTD
GROUP HEALTH INSURANCE
Quote cum proposal format
Quote No.(4016/IP-02674971/000)

Domiciliary
Excluded
Hospitalisation

Septoplasty, Infertility and Related Ailments incl.'Male sterility'; Treatment on trial/experimental

basis; Admin/Registration/Service/Misc. Charges; Expenses on fitting of Prosthesis; Any
Exclusion
device/instrument/machine contributing/replacing the function of an organ; Holter Monitoring
are outside the scope of the policy.

Policy also covers hospitalization arising out of Psychiatric ailments within a limit of Rs.30000
Special Condition as well as treatment of Functional Endoscopic Sinus Surgery within a limit of Rs.35000 The
coverage for treatment of mental illness is also covered upto Rs 30000 within the sum insured.

Day Care
Day Care Procedures are Covered as per the standard list
Procedures

Claim must be filed within 30 days from the date of completion of treatment. However, the
Company may at its discretion consider waiver based on merits of the claim, where there is
Claim submission delay in intimation or in submission of documents due to unavoidable circumstances and it is
clause proved that the delay was for reasons beyond the control of the insured and under the
circumstances in which the insured was placed it was not possible for him or any other person
to give such notice or file claim within the prescribed time-limit

Mid-Term
Mid Term Inclusion of Newly Joined Employees Only
Inclusion

Reasonable and
Customary Waived Off
Charges

Claim Intimation
and Network Waived Off
clause

Premium to be charged on Pro Rata Basis for addition/deletion endorsement. No Refund for
Add-Del of Lives
deletion-if lives less than minimum required and if insured has claimed during policy

Special Condition
Lasik Surgery is covered if correction index is +/-6.5
1

Special Condition
Terrorism is covered
2

Special Condition
Air Ambulance is covered upto Rs 100,000 or family sum insured whichever is less.
4

Attendant charges are cover upto Rs 5,000 (Per life incase case of Employee only policy or
else it's Per Family within Family sum insured) if length of stay for the patient is more than 5
Special Condition
days. Add on covers cost pertaining to boarding and lodging of the attendant in a
5
hospital/location prescribed by treating Medical Practitioner on reimbursement basis by
presenting original Bills for each cost incurred.

Special Condition
Lucentis is covered upto Rs 50,000 Per family within the Sum Insured
6

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ICICI LOMBARD GIC LTD
GROUP HEALTH INSURANCE
Quote cum proposal format
Quote No.(4016/IP-02674971/000)

Special Condition Internal Congenital disease is covered and External congenital disease is covered in life
7 threatning situation.

Special Condition 50% Co-Pay for cyberknife treatment/Stem Cell Transplantation. Cochlear Implant treatment
8 shall be restricted to 50% of the SI.

Portability Portability is available on this product as per IRDA directive and product features

Termination Policy will cease to be in effect from the date of termination of relationship with the organization.

First time GHI

Policy Underwritten considering it as a First time policy
policy Declaration

ID Cards Physical cards will not be issued

Transaction New Business

Diseases wise Sub limits

Sum Insured Diseases Metro Locations Non Metro Locations

100000 APPENDIX 12,000 10,000

100000 EYE RELATED 17,000 15,000

GALL BLADDER
100000 15,000 15,000
SURGERY

100000 HERNIA 12,000 10,000

100000 HYDROCELE 7,000 5,000

100000 HYSTERECTOMY 20,000 17,000

JOINT REPLACEMENT
100000 INCLUDING VERTEBRAL 75,000 70,000
JOINTS

KIDNEY STONE (INCL DJ

100000 STENT REMOVAL FOR 30,000 25,000
SAME STONE)

100000 PILES 10,000 7,000

Demography

Sum 76-80
0-18 19-35 36-45 46-55 56-60 61-65 66-70 71-75 Total
Insured Above

100,000 1 15 15 1 0 1 0 0 0 33

Total 1 15 15 1 0 1 0 0 0 33

RATES FOR ENDORSEMENT (Per Life)

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ICICI LOMBARD GIC LTD
GROUP HEALTH INSURANCE
Quote cum proposal format
Quote No.(4016/IP-02674971/000)

Sum 76-80
0-18 19-35 36-45 46-55 56-60 61-65 66-70 71-75
Insured Above

100,000 1513 2467 2719 4011 6242 7793 9351 11036 12720

Grievances
For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may
call toll free no.1800-2666 or may approach us at the sub section “Grievance Redressal” on our website
www.icicilombard.com (Customer Support section). However, if the resolution provided by us is not satisfactory you
may approach Insurance Regulatory and Development Authority (IRDA) through the Integrated Grievance
Management Section (IGMS) or IRDA Grievance Call Centre(IGCC) at their toll free no.155255.

Quote is valid for 45 days.Quote is liable to change with change in info.

Policy Details Contact Information

Period of Insurance From: 15/Nov/2022 HR Name

To: 14/Nov/2023
HR Contact No
Policy conditions as per quote format.
HR Email Id

Communication Details
Mailing Address
Address of Recipient
Address 1
Address 2
District/City
State
Country
Pincode

I/We, the undersigned hereby declare that the above statements and particulars are true, accurate and complete
and I/We declare and agree that this declaration and the answers given above shall be held to be promissory and
shall be the basis of contract between me/us and the company.
I/We, the undersigned have read and understood the Guidelines on Group Insurance Policies issued by the
Authority vide ref. no. 015/IRDA/Life/Circular/GI Guidelines 2005 dated July 14, 2005, as amended from time to
time, and shall adhere to its provisions at all times.
Place:_________________ Proposer's Signature:______________
Name:___________________
Date:_____________

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ICICI LOMBARD GIC LTD
GROUP HEALTH INSURANCE
Quote cum proposal format
Quote No.(4016/IP-02674971/000)

GUIDELINE FOR COMPLETION OF THE FORM

1.Insurance is a contract of utmost good faith requiring the Insured not only to disclose all material facts but also not
to suppress any material facts in response to the questions in the proposal form. If you think any fact is material,
please disclose it.
2. The Policy shall become voidable at the option of the Insurer, in the event of any untrue or incorrect statement,
misrepresentation, non-description or non-disclosure in any material particular in the proposal form/personal
statement, declaration and connected documents, or any material information has been withheld by the proposer or
any one acting on his behalf to obtain any benefit under this policy.
Note:
Coverage of risk is subject to realization of premium by the Company. Insurance coverage under the policy will
commence only on realization of full premium, receipt of complete reports (wherever applicable) and subject to
underwriting approval by the company. In case premiums not realized by the Company due to any reason, company
shall not be on cover and contract of insurance shall be treated as void ab-initio. Excess payment, if any, will be
refunded without any interest on receipt of required documents as necessary or will be utilized in future policy
issuance.

STATUTORY WARNING

PROHIBITION OF REBATES

Section 41 of the Insurance Act, 1938 as amended by the Insurance Laws (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 punishable with
)
fine which may extend to ten lac rupees.

ICICI Lombard General Insurance Company Limited

IRDA Regn. No. 115 CIN: U67200MH2000PLC129408
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
Mumbai - 400064 Mumbai - 400025 Website:www.icicilombard.com Page 5 of 5