Risk Assumption Letter

Date : 04­Nov­2015
Dear Sir / Madam,

We thank you for placing your confidence with ICICI Lombard for your health Insurance needs.
Please find attached herewith Policy No.: 4128i/iH/108915572/00/000 which has been issued based on the details
furnished by the applicant :
Name of the proposer: Chirag Sharma
402 D Wing Shree Sharnam Kanakia Layout Unique Garden Mira Road
Mailing Address:
(E),Thane,Maharashtra ­ 401107.
Mobile No.: 9004310607
Telephone No.:
Email ID: sharma.chirag82@gmail.com
Product Name: iHealth
No. of Members : 3
Policy Duration (years): 1
Age of the eldest member
33
(years):
Policy Period From 04­Nov­2015 To 03­Nov­2016
Insured Details
Name of the Relationship with Age P r e- Existing Annual Sum Optional Add- o n S u b- Voluntary
Insured(s) Proposer Y e a r M o n t h s illness/injury Insured Cover limit Deductible
Chirag Sharma Self 33 3 None
Sheena Sharma Spouse 29 3 None 300000 None 0
Meera Sharma Daughter 0 9 None

Please go through the details as furnished in the format and the policy document and confirm that same are in order.
In case there are any discrepancies, you are request to write back to us immediately at
customersupport@icicilombard.com or contact at 24 hour helpline number 1800 2666 for necessary
changes/rectification.
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 and as per your proposal. Thereon, any non disclosure related to
Pre­Existing illness/injury would result in rejection of claims and cancellation of policy
Thanking You,
Yours Sincerely,

Authorised Signatory
ICICI Lombard General Insurance Company Limited,IRDA Regn.No.115
 ICICI Lombard Complete Health Insurance
Policy Number : 4128i/iH/108915572/00/000
ICICI Lombard General Insurance
Company LTD., IRDA Regn. No. 115 ,
ICICI LOMBARD HOUSE , 414, Policy Issued
Policy Issuing Office 04­Nov­2015
Veer Savarkar Marg, Near Siddhi On
Vinayak Temple, Prabhadevi, Mumbai
400 025
Part I Of Schedule
Details of Policy Holder/ Proposer:
Contact No(s) (R):­
Policy No. 4128i/iH/108915572/00/000
Mobile No 9004310607
Policy From 00:00 hrs 04­Nov­2015 to
Name of the Applicant Chirag Sharma
Period Midnight of 03­Nov­2016
402 D Wing Shree Sharnam
Kanakia Layout Unique Garden
Correspondence Mira Road(E), Email Address sharma.chirag82@gmail.com
Address
Thane,
Maharashtra ­ 401107.
Relationship of Nominee
Name of Nominee ­ ­
with Proposer
Details of Family Members covered under the Policy :
Name of the Date Of Age Annual Sum Pre-Existing Health Member ID Optional Add-on Sub- Voluntary
Gender Relation
Insured(s) Joining Years Months Insured illness/injury No. Cover limit Deductible
Chirag Sharma 04-Nov-2015 33 3 M Self None 102956402
Sheena Sharma 04-Nov-2015 29 3 F Spouse 300000 None 102956403 None 0
Meera Sharma 04-Nov-2015 0 9 F Daughter None 102956404
Premium Schedule :
Secondary and
Basic Premium Service Tax Education Cess Total Premium
Plan Name Higher Education
(Rs.) (Rs.) (Rs.) (Rs.)
Cess (Rs.)
Ih_2adults_1child_1year 8058.77 1128.23 0 0 9187

For ICICI LOMBARD GENERAL INSURANCE Service Tax Registration No. : GIS/MUMBAI­
COMPANY LIMITED I/1528/2001
Service Tax Code Number : AAACI7904GST001
Category: General Insurance Business Services
Authorised Signatory 00440005.
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.
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 competent courts of INDIA.
The stamp duty of Rs 1.00 paid in cash or by demand draft or by payorder,vide Receipt/Challan no. 4063856 dated
08­oct­2015
In the event of a claim, please call our 24X7 tollfree number 1800 2666 or email us at
ihealthcare@icicilombard.com.
Please send the relevant documents to: ICICI Lombard Health Care,Plot No:12 ,ICICI Bank
Towers ,Nanakramguda ,Gachibowli, Hyderabad ­ 500032
ICICI Lombard General Insurance Company Ltd
Corp Office:ICICI Lombard General Insurance Company LTD., IRDA Regn. No. 115 , 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 1800­2666. E­mail :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,
Chirag Sharma
402 D Wing Shree Sharnam Kanakia Layout Unique Garden Mira Road(E),
Thane,
Maharashtra ­ 401107.
This is to certify that the company has received the premium of Rs. 9187 for Health insurance coverage under the
policy no 4128i/iH/108915572/00/000 vide Cheque/credit card dated Nov­04­2015.

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.