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Certificate
For the purpose of deduction under section 80D of Income Tax amendment act, 1961 and any amendments
made thereafter.
To,
Abu Sufiyan Azad Kazi
Sehar Residency Near Bilal Hospital Kausa Mumbra
Thane,
Maharashtra 400612.
This is to certify that the company has received the premium of Rs. 29187 for Health insurance coverage under
the policy no 4128i/iH/108914412/00/000 vide Cheque/credit card dated Mar022015.
The Product is eligible for deduction u/s 80 D of the Income Tax,1961 and any amendments made there to.
For ICICI Lombard General Insurance Company Limited,IRDA Regn.No.115
Authorized Signatory
Note:
l 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.