(A) Policy Schedule (Policy Certificate) : Policyall 5 5 4 4

(a) Policy Schedule (Policy Certificate)
POLICYALL 5 5 4 4
PREAMBLE
yes
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 and Declaration together with any statement, report or other document leading to the issuance 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 on proof to the satisfaction of the Company of the compensation having become payable as set out
in Part I of Policy to the title of the said person or persons claiming payment or upon the happening of an event upon which one or more benefits become payable
under this Policy, the Sum Insured/appropriate benefit will be paid by the Company.
Part I of Policy: Policy Schedule

ICICI Lombard Group Health Policy no. 4177i/MSTR/291415383/00/000 has been issued at Mumbai, by ICICI Lombard General Insurance Company Limited to
the Policyholder, for covering its members as specified in the policy and is governed by, and is subject to, the terms, conditions & exclusions therein contained or
otherwise expressed in the said policy, but not exceeding the sum insured as specified forming Part I of the schedule to the said policy.
Proposer Name LUB BIRLA Product name Health Shield 360

Address PAKKI GALI,MOHALLA NATTHU Plan Name ICICI_HS360_OPTA_10LTO50L
RAM,,KASGANJ,INDIA,UTTAR PRADESH,
ETAH, UTTAR PRADESH - 207123 Policy No. 4177i/IBANK/320131753/00/000
Contact No. 98******38 Period of Insurance From 00:00 hrs 11-Dec-2023 To 23:59 hrs
10-Dec-2024
Email Address LU******@YAHOO.COM Policy Tenure 1
Nominee Name Kush birla Alternate Policy No.
LAN No. NA
Relationship With BROTHER Policy Issuing Office Prabhadevi
Policyholder
Appointee Name Policy Issued On 11-Dec-2023
Nominee Age 35 Years 6 Month Previous Policy No.
GSTIN No. (Customer) 09APNPB7114A1ZB Invoice No. 101223963486
Servicing Branch Address Summit Building B-503 To B- 508, Fifth Floor, Plot Servicing Branch Name Lucknow
No Tcg 3/3, Vibhutikhand Gomti Nagar, Lucknow
Uttar Pradesh-226010
Politically Exposed Person (PEP)/close relative of PEP: No
Insured's Date of Age Date of Gender Relation With Annual Sum Pre-existing Illness/ Special
0
Name(s) Birth Y M Joining Proposer Insured (`) Injury Condition
LUB BIRLA 01-Apr-1987 36 8 11-Dec-2023 Male SELF None None
Pratibha 02-Feb-1988 35 10 11-Dec-2023 Female SPOUSE None None
2500000
Rudra 16-May-2018 5 6 11-Dec-2023 Male SON None None
Vaishnavi 24-Mar-2020 3 8 11-Dec-2023 Female DAUGHTER None None
Plan Details
The stamp duty of ` 0.5 paid
Plan Name Additional Sum Sub-limit Voluntary GSTIN Reg. No HSN/SAC code
vide deface no.
Insured (`) Deductible (`) CSD6920232872 dated
997133 GENERAL 14-Jun-2023
ICICI_HS360_OPTA_
0 None 0 09AAACI7904G1ZL
INSURANCE
10LTO50L_2A + 2K
SERVICES
We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under
sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.
Premium Details (`)
CGST SGST
Basic Premium Total Tax Payable Total Premium
% ` % `
12221.19 9 1099.91 9 1099.91 2199.81 14421
Signature Not Verified
5 Agent Details Digitally signed by DS ICICI
Agent ICICI BANK Agent AgentLOMBARD GENERAL
CA0112 0018002666
INSURANCE CO LTD 1
Name LIMITED Code contact No.
Date: 2024.01.18 14:03:05
IST
GSTIN Reg. No HSN/SAC code The stamp duty of ` 0.5 paid vide deface no. CSD6920232872
109/20150914/284
ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Health Shield 360 UIN - ICIHLGP22083V022122
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, P Balu Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Off Veer Savarkar Road, Near Email: customersupport@icicilombard.com
Link Road, Malad (West), Mumbai - 400 064. Siddhi Vinayak Temple, Prabhadevi, Website: www.icicilombard.com 1/6
Mumbai -400025.
The stamp duty of ` 0.5 paid vide deface no. CSD6920232872
997133 GENERAL INSURANCE dated 14-Jun-2023
09AAACI7904G1ZL
SERVICES
We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under
sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.
SYSESB00172313746
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, 1st, 4th (Half), 5th and 6th floors, Varun Towers- II, Opp. Hyderabad Public school, Begumpet, Hyderabad District Hyderabad,Pin
code -500016 Telangana.
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.
Click or Scan QR Code for Policy Wordings
109/20150914/284

Mumbai -400025.
Tax Certificate
5
To
LUB BIRLA
PAKKI GALI,MOHALLA NATTHU RAM,,KASGANJ,INDIA,UTTAR
PRADESH
ETAH
UTTAR PRADESH - 207123
ANNUAL
Subject: Premium certificate for the purpose of deduction under section 80D of Income Tax
Act, 1961 and any amendments made thereafter.
Dear LUB BIRLA,
This is to certify that the Company has received the premium dated Dec 11, 2023 for Health
insurance coverage under "Health Insurance Policy" with the following details.
Policyholder's LUB BIRLA 4177i/IBANK/320131753/0 Policy Number

Name 0/000
Policy Start DateDec 11, 2023 Policy End Date Dec 10, 2024
Plan Name ICICI_HS360_OPTA_10LT Total Premium Paid 14421
O50L_2A + 2K (`)
GSTIN Number 09APNPB7114A1ZB GSTIN Reg.No (ICICI 09AAACI7904G1ZL
(Customer) Lombard)
Servicing Branch Lucknow Servicing Branch Summit Building B-503 To
Name Address B- 508, Fifth Floor, Plot No
Tcg 3/3, Vibhutikhand
Gomti Nagar, Lucknow
Uttar Pradesh-226010
Premium Details (`)

CGST SGST
Basic Premium Total Tax Payable Total Premium
% ` % `
12221.19 9 1099.91 9 1099.91 2199.81 14421
Financial Year Amount (`)
2023-2024 14421.00
The product is eligible for deduction u/s 80D of the Income Tax, 1961 and any amendments
made there to.
Sincerely,
For ICICI Lombard General Insurance Company Ltd.
Authorised Signatory
Note: 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.
In case You find any variations against Your proposal or any discrepancy in the Policy, please
contact Us immediately on the numbers available on our website www.icicilombard.com Or call
on our toll free no. 1800 2666
109/20150914/284

Mumbai -400025.
Name : LUB BIRLA
Policy No. : 4177i/IBANK/320131753/00/000
Card No. : 138643569
Gender : Male Age : 36 DOB : 01-Apr-1987
Valid Upto : 10-Dec-2024
Name : Pratibha
Policy No. : 4177i/IBANK/320131753/00/000
Card No. : 138643570
Gender : Female Age : 35 DOB : 02-Feb-1988
109/20150914/284

Mumbai -400025.
Name : Rudra
Policy No. : 4177i/IBANK/320131753/00/000
Card No. : 138643571
Gender : Male Age : 5 DOB : 16-May-2018
Name : Vaishnavi
Policy No. : 4177i/IBANK/320131753/00/000
Card No. : 138643572
Gender : Female Age : 3 DOB : 24-Mar-2020
109/20150914/284

Mumbai -400025.
109/20150914/284

Mumbai -400025.

(A) Policy Schedule (Policy Certificate) : Policyall 5 5 4 4

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(A) Policy Schedule (Policy Certificate) : Policyall 5 5 4 4

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(a) Policy Schedule (Policy Certificate)

Part I of Policy: Policy Schedule

Proposer Name LUB BIRLA Product name Health Shield 360

Politically Exposed Person (PEP)/close relative of PEP: No

ICICI Lombard General Insurance Company Limited

Click or Scan QR Code for Policy Wordings

ICICI Lombard General Insurance Company Limited

Dear LUB BIRLA,

Policyholder's LUB BIRLA 4177i/IBANK/320131753/0 Policy Number

Premium Details (`)

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

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