Risk Assumption Letter

Dear Sir / Madam,

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We thank you for placing your confidence with ICICI Lombard for your Health Insurance Needs.
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Please find attached herewith Policy No. 4128i/iHN/195513597/00/000 which has been issued based on the details furnished by the applicant.
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Name of Proposer VANDANA RATHEE Policy Tenure (in Years) 2
M-22, VIKAS APARTMENTS, WEST ENCLAVE, From 00:00 hrs 29-Feb-2020 To 23:59 hrs
Address Period of Insurance
PITAMPURA, NEW DELHI, DELHI - 110034 27-Feb-2022
Policy Issued On 29-Feb-2020 Email Address 5VANDANA.RATHEE@GMAIL.COM
GSTIN (Customer) Mobile No. 9958002828

Insured Details
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Name of the Date of Age Gender Relationship with Annual Sum Pre-existing Sub-limit Voluntary Optional add
insured (s) Birth Y M policy holder Insured illness / injury Deductible on cover
VANDANA
05-Oct-1976 43 4 Female SELF Hypothyroidism None
RATHEE
5000000 None 0
VANI RATHEE 14-Oct-2001 18 4 Female DAUGHTER None None
Omisha Rathee 15-Feb-2008 12 0 Female DAUGHTER None None

Please go through the details as furnished in the format and the policy document and confirm that same are order. In case there is any discrepancies / variations,
you are requested to write back to us immediately at customersupport@icicilombard.com or contact at 24 hour helpline number 1800 2666 for necessary changes
/ rectifications.

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 as per your proposal.

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE COMPANY
LIMITED
Date: 2020.03.05 08:32:24
IST
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115
Mailing Address:
ICICI Lombard General Insurance Company Limited,
Interface Building No.: 16, 601 / 602, 6th Floor, New
Link Road, Malad (West), Mumbai - 400 064.
CIN: L67200MH2000PLC129408
Registered Office:
ICICI Lombard House, 414 Veer Savarkar
Marg, Near Siddhi Vinayak Temple,
Prabhadevi, Mumbai - 400 025.
ICICI Lombard Complete Health Insurance UIN - lClHLlP20084V03l920
Toll free no.: 1800 2666
Alternate No.: +918655 222 666 (chargeable)
Email: customersupport@icicilombard.com
Website: www.icicilombard.com
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Policy Certificate
POLICY
Proposer Name VANDANA RATHEE Policy No. 4128i/iHN/195513597/00/000
Address M-22, VIKAS APARTMENTS, WEST ENCLAVE, Period of Insurance From 00:00 hrs 29-Feb-2020 To 23:59 hrs
PITAMPURA, NEW DELHI, DELHI - 110034 27-Feb-2022
Policy Tenure 2
Contact No. 9958002828 LAN No. NA
Email Address 5VANDANA.RATHEE@GMAIL.COM Policy Issuing Office Prabhadevi
Nominee Name Manoj Kumar Rathee Policy Issued On 29-Feb-2020
Relationship With SPOUSE Previous Policy No.
Policyholder
Appointee Name Nominee Age 44 Years 4 Month
GSTIN Number (Customer) Servicing Branch Name New Delhi
Servicing Branch Address Fourth Parsavnath Capital Tower Bhai Veer Invoice Number 1002202069439
Singh Marg, New Delhi New Delhi 110001

Insured's Date of Age Date of Gender Relation With Annual Sum Pre-existing Optional Permanent
Name(s) Birth Joining Proposer Insured (`) Illness/ Injury Add-on Cover* Exclusion
Y M Remarks
VANDANA
05-Oct-1976 43 4 29-Feb-2020 Female SELF Hypothyroidism None None
RATHEE
VANI
14-Oct-2001 18 4 29-Feb-2020 Female DAUGHTER 5000000 None None None
RATHEE
Omisha 15-Feb-200
12 0 29-Feb-2020 Female DAUGHTER None None None
Rathee 8
Plan Details
GSTIN Reg. No HSN/SAC code The stamp duty of ` 1 paid vide
Plan Name Additional Sum Insured Sub-limit Voluntary
deface no. 0006404850201920
(`) Deductible
dated 24-Feb-2020
9971 GENERAL
iH_1Adult_2Child_2Yea
0 None 0 07AAACI7904G1ZP INSURANCE
rs_N
SERVICES
Premium Details (`)
CGST SGST
Basic Premium Total Tax Payable Total Premium
% ` % `
32800 9 2952.00 9 2952.00 5904.00 38704

5 Agent Details
Agent Agent Agent
BABITA ARORA 8930993 9811696030
Name Code contact No.

SYSESB00102415318
Important: Insurance benefit shall become voidable at the option of the company, in the event of any untrue or incorrect statement, misrepresentation
non-description 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 i s excluded from the scope of this policy subject to applicable terms and conditions. Refer to policy wordings for the terms and conditions. All disputes
are subject to the jurisdiction of Mumbai High Court only. For claims, please call us at our toll free no. 1800 2666 or e-mail to us at ihealthcare@icicilombard.com or
write to us at ICICI Lombard GIC, ICICI Bank Tower, Plot no-12, Financial district Nanakramguda, Gachibowli, Hyderabad, Andhra Pradesh 500032.

This policy has been issued based on the details furnished by the policyholder. Please review the details furnished in the policy certificate and confirm that same
are in order. In case of any discrepancy/ variation, you are requested to call us immediately at our toll free no. 1800 2666 or write to us at
customersupport@icicilombard.com. In the absence of any communication from you within the period of 15 days of receipt of this document, the policy would be
deemed to be in order and issued as per your proposal. All refunds and claim payment will be done through NEFT only. In case of addition of member/ increase in
sum insured, fresh waiting period will be applicable to new member/ increased sum insured. This policy certificate is to be read with the policy wordings, as one
contract or any word or expression to which a specific meaning has been attached in any part of this policy shall bear the same meaning wherever it may appear.

Scan QR Code for Customer Information Sheet and Policy Wordings

109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115
Mailing Address:
ICICI Lombard General Insurance Company Limited,
Interface Building No.: 16, 601 / 602, 6th Floor, New
Link Road, Malad (West), Mumbai - 400 064.
CIN: L67200MH2000PLC129408
Registered Office:
ICICI Lombard House, 414 Veer Savarkar
Marg, Near Siddhi Vinayak Temple,
Prabhadevi, Mumbai - 400 025.
ICICI Lombard Complete Health Insurance UIN - lClHLlP20084V03l920
Toll free no.: 1800 2666
Alternate No.: +918655 222 666 (chargeable)
Email: customersupport@icicilombard.com
Website: www.icicilombard.com
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