Premium Certificate

For the purpose of deduction under section 80D of Income Tax amendment
act, 1961 and any amendments made thereafter.

To,
suman pal
1/11, Netaji Nagar. 2nd Floor

KOLKATA
WEST BENGAL
700092

This is to certify that an amount of Rs.1,72,863 has been received by the company towards premium for the
health policy no: 4063i/HAP/75936071/04/000 issued to suman pal for a period from 19 May 2022 to 18 Apr 2023

For ICICI Lombard General Insurance Company

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.
 COPY
Health Insurance Policy
Policy Number :
4063i/HAP/75936071/04/000
PREAMBLE: ICICI Lombard General Insurance Company Limited ("the Company"), having received a proposal and the premium from the
proposer named in the Schedule referred to herein below, and the said Proposal, Declaration and Annexure thereto together with any
statement, report or other document leading to the issue of this Policy and referred to therein having been accepted and agreed to by
the Company and the Proposer as the basis of this contract do, by this policy agree, in consideration of and subject to the due receipt of
the subsequent premiums, as set out in the schedule with all its parts, and further, subject to the terms and conditions contained in this
policy, as set out in the schedule with all its parts, that in proof to the satisfaction of the Company of the compensation having become
payable as set out in Part I of the schedule to the title Policy, the Sum Insured/appropriate benefit will be paid by the Company.
ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Policy Issued On 19May2022
Policy Issuing Office
Temple, Prabhadevi, Mumbai 400 025

Part 1 of Schedule
Details of the Policy Holder / Proposer:
Contact No
Policy No 4063i/HAP/75936071/04/000
(s)
Mobile No
Previous Policy No 4063i/HAP/75936071/03/000 9051099226
(s)
Period of From 00:00 hrs 19 May 2022
Name of the Proposer suman pal
Issuance to Midnight of 18 Apr 2023
1/11, Netaji Nagar. 2nd Floor Near Netaji Nagar College Email
Corresponence Address suman.pal@gmail.in
1no Play Ground, KOLKATA, 700092, WEST BENGAL Address

Details of Family Members covered under the Policy :

Benefit
Name of the Age Benefit A Additional Pre­existing Diseases/ Health Member Id
Gender Relation B
Insured SI injury No.
Years Months Hospitalization OPD

ranjit pal 75 M Father CAD IHPN­W­

4
21653019/1
1000000 0 600000
41 IHPN­W­
suman pal 11 M Self NONE
21653019/2

Premium Schedule :
1 Year
Total Premium
Plan Name Basic Premium GST(+) Discount Rider
(Rs.)
(Rs.) (Rs.) (Rs.)
Health Advantage plus 146494 26369 172863
Option 4

FOR ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED

GST Reg. No. :29AAACI7904G1ZJ
PAN Number :AAACI7904G
Category :General Insurance Business Services
Authorized Signatory

Important Note: This schedule and the attached policy shall be read together as one contract or any word or expression to which a
specific meaning has been attached in any part of this policy or of the schedule shall bear the same meaning wherever it may appear.

Agent Name : ICICI BANK LIMITED; Agent Code(ID) : 2470377; Contact No: 22­18002666 , 22­18002666 , 91­ 0018002666.

Important ::Insurance benefit shall become voidable at the option of the Company, in the event of any untrue or incorrect statement,
misrepresentation, non description or non­disclosure 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 pre­existing illness/injury/symptoms is excluded from the scope of
this policy subject to applicable terms and conditions. Refer to attached Part II and III of the schedule for the terms and conditions.All
disputes are subject to the jurisdiction of Mumbai High Court only.

The stamp duty of Rs.1(One Only) paid in cash or by demand draft or by pay order,vide Receipt/Challan no. 1000699dated 19-May-2022 ­Dec­20 1

On the happening of a claim, please call immediately at 1800 2666(Toll Free) or e­mail us at ihealthcare@icicilombard.com. You can also
write to us at ICICI Lombard GIC Ltd, ICICI Lombard Healthcare, ICICI Bank Towers, 9th FLoor,Plot No. 12, Financial District,
Nanakramguda, Gachibowli, Hyderabad­ 500034. Andhra Pradesh.
ICICI Lombard General Insurance Company Ltd
Corp Office: ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.
Mailing Address: 4th Floor, Interface 11, Off Malad Link Road, Behind Goregaon Sports Club, Malad(w),
Mumbai­ 400064.
Toll Free 24 X 7 Call Center No 1800 2666 . E­mail : customersupport@icicilombard.com