COPY

ICICI Lombard Health Care

Policy Number : 4034i/FPP/04812914/00/000
4034i/FPP/04812914/00/000

PREAMBLE :ICICI Lombard General Insurance Company Limited ("the Company"), having received a proposal and the premium from
PREAMBLE:ICICI
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.
Policy Issuing Office Zenith House, Keshavrao Khade Marg, Mahalaxmi, Mumbai - 400034 Policy Issued On 06-Jul-2009
Part I Of Schedule
Details of Policy Holder/ Proposer:
Contact No(s) (R): 2423254
Policy No 4034i/FPP/04812914/00/000
Mobile No (M1): 9898194786

Period of Issuance From 00:00 hrs 04-Jul-2009 to Midnight

(Year 1 ) of 03-Jul-2010
Name of the Proposer S M UBAIDULLA Period of Issuance
From 00:00 hrs 04-Jul-2010 to Midnight
(Year 2 Annual
of 03-Jul-2011
Autorenewal )
SULTHAN, NEW NO-52 , HABIB
NAGAR , PALLAPATTI ,
ARAVAKURICHI , PALLAPATTI-
Correspondence Address Email Address ubaidulla_sm@yahoo.com
KARUR-639207, TAMILNADU
KARUR - 639207
TamilNadu
Details of Family Members covered under the Policy :
Age
Name of the Insured(s) Gender
Gender Relati
Relation
on Sum Insure
Insured
d Pre-Ex
Pre-Exist
isting
ing illnes
illness/i
s/inju
njury
ry Health
Health Member
Member ID No.
Year Months

S U APSARA PRAVEEN 40 0F SPOUSE 300000 IHPN-05019365/01

Premium Schedule :
Year 1 Year 2

Basic Secondary and Basic Secondary and Total

Plan Name Service Education Service Education Premium
Premium Higher Education Premium Higher Education (Rs.)
Tax (Rs.) Cess (Rs.) Tax (Rs.) Cess (Rs.)
(Rs.) Cess (Rs.) (Rs.) Cess (Rs.)
Family Protect
Premier 4432.28 443.23 8.86 4.43 2954.85 295.48 5.91 2.95 8148
Inividual

For ICICI LOMBARD GENERAL

INSURANCE COMPANY LIMITED Service Tax Reg. No.: GIS/MUMBAI-I/1528/2001
Service Tax Code Number - AAACI7904GST001
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.
:Insurance benefit shall become voidable at the option of the Company, in the event of any untrue or incorrect statement,
IMPORTANT :Insurance
misrepresentation, non description or non-disclosure 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 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.62627 dated 16-Mar-2009
On the happening of a claim, please call immediately at 1800-209-8888 (Toll Free) or e-mail us at iheatlhcare@icicilombard.com
You can also write to us at ICICI Lombard GIC, i Health Care, TGV Mansion, 6th Floor, Plot No. 6-2-1012, Khairatabad, Hyderabad '
500004, Andhra Pradesh.
ICICI Lombard General Insurance Company Ltd
Corp Office: Zenith House, Keshavrao Khade Marg, Mahalaxmi, Mumbai-400034.
Mailing Address: 4th Floor, Interface 11, Off Malad Link Road, Behind Goregaon Sports Club, Malad(w), Mumbai- 400034.
Toll Free 24 X 7 Call Center No 1800-209-8888. E-mail : customersupport@icicilombard.com
 Premium Certificate
For the purpose of deduction under section 80D of Income Tax amendment act, 1961 and any amendments made thereafter.
To,
S M UBAIDULLA
SULTHAN, NEW NO-52 , HABIB NAGAR , PALLAPATTI , ARAVAKURICHI , PALLAPATTI-KARUR-639207, TAMILNADU
KARUR - 639207
TamilNadu
KARUR
639207
TamilNadu

This is to certify that the Company has received the premium as detailed below for Health Insurance Policy No :
4034i/FPP/04812914/00/000.
Premium eligible for deduction u/s 80D of the Income Tax Act, 1961 and any amendments made there to.
Financial Year 2009 - 2010
3013.64
(Rs.)
Collection
Financial Year 2010 - 2011 928106
4074 No:
(Rs.)
Collection 04-Jul-
Financial Year 2011 - 2012
1060.36 Date 2009
(Rs.)
Total Premium (Rs.) 8148
For ICICI Lombard
General Insurance Co. Ltd.

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.
l For the purpose of deduction under section 80D, the benefit shall be as per the provisions of the Income Tax Act, 1961 and any
Amendments made thereafter.
 Information Sheet
To,
S M UBAIDULLA
Date :06-Jul-2009
SULTHAN, NEW NO-52 , HABIB NAGAR , PALLAPATTI , ARAVAKURICHI , PALLAPATTI-KARUR-639207, TAMILNADU
KARUR - 639207
TamilNadu
KARUR
639207
TamilNadu

Sub : Verbal proposal for health insurance policy from ICICI Lombard GIC Ltd.

Dear S M UBAIDULLA,
Thank you for choosing ICICI Lombard Health Insurance Policy. It is a pleasure to have you as our esteemed customer. This letter is with
reference to your tele-conversation dated 05-Jul-2009 with the representative of ICICI Lombard GIC Ltd for the purchase of Health
Insurance Policy. The information provided by you has been mentioned below and the Family Protect Premier policy No :
4034i/FPP/04812914/00/000 has been issued based on the same. You are requested to kindly go through the details mentioned below vide
the tele-conversation.
In case of any discrepancy or error in the information mentioned below or in the policy copy attached, you are requested to intimate us at
our call center no 1800-209-8888 within 15 days of issue of this letter.
l Name of the Proposer : S M UBAIDULLA
l Address : SULTHAN, NEW NO-52 , HABIB NAGAR , PALLAPATTI , ARAVAKURICHI ,
PALLAPATTI-KARUR-639207, TAMILNADU
KARUR - 639207
TamilNadu
l Details of the insured:

Relationship with Name of Pre-Existing Sum

Name Sex Date of Birth Tenure
proposer illness Insured
S U APSARA PRAVEEN F 05-Jul-1969 SPOUSE 300000 2

l Premium : 8148
l Exclusions :
a. Any illness/disease/injury existing before the inception of the policy for the first
first 2 yrs for HAP and 4 yrs for the rest of the
products specifically as per the policy wordings.
b. Pregnancy and childbirth related diseases, cosmetic aesthetic & obesity related treatments and congenital diseases.
c. Any illness contracted during the first 30 days of the inception of the policy except those that are incurred as a result of
accident, the exclusion does not apply for subsequent renewals without a break of the policy with the company.
d. Non allopathic treatment, expenses arising from HIV or AIDS and related diseases, use or misuse of liquor, intoxicating
substances or drugs as well as intentional self injury/attempted suicide/suicide.
e. War, riot, strike, nuclear weapons induced hospitalization.
f. Certain ailments will be excluded from treatment for 2-years: Cataract, Hernia, Benign Prostatic Hypertrophy , Hydrocele,
Sinusitis and related disorders, Arthritis, Gastric and Duodenal ulcers etc.

Regards,

Authorized Representative
ICICI Lombard General Insurance Company Ltd.
Disclaimer:
The details mentioned herein are indicative and not exhaustive, for complete details on coverage's, exclusion, terms and conditions please
refer to policy wordings provided along with the policy kit."