Risk Assumption Letter

Dear Sir / Madam,

We thank you for placing your confidence with ICICI Lombard for your Health Insurance Needs.
2
Please find attached herewith Policy No. 4128i/HP/150189966/00/000 which has been issued based on the details furnished by the applicant.
2
Name of Proposer AJAY ROY Policy Tenure (in Years) 1
FORT GLOSTER , E BLOCK STREET NO 7 H-NO 298
From 00:00 hrs 16-Jun-2018 To 23:59 hrs
Address BAURIA , HOWRAH,WBL-711310 -, HOWRAH, Period of Insurance
15-Jun-2019
WEST BENGAL - 711310
Policy Issued On 20-Jun-2018 Email Address AJAYROY@LIVE.COM
GSTIN (Customer) Mobile No. 9464101737

Insured Details
2
Name of the Date of Birth Age Gender Relationship with Annual Sum Pre-existing illness / Sub-limit Voluntary Optional add on
insured (s) Y M policy holder Insured injury Deductible cover

AJAY ROY 06-May-1985 33 1 Male SELF None None

500000 None 0
NITU ROY 28-Dec-1994 23 5 Female SISTER 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
SANJAY DATTA
Date: 2019.02.01
16:44:02 IST
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP10001V020910
Mailing Address: Registered Office: Toll free no.: 1800 2666
401 & 402, 4th Floor, Interface 11, ICICI Lombard House, 414 Veer Savarkar Marg, Alternate No.: +9186552 22666
New Linking Road, Malad (West), Near Siddhi Vinayak Temple, Prabhadevi, (chargeable) 1/4
Mumbai - 400 064. Mumbai - 400 025. Email: customersupport@icicilombard.com
Policy Certificate
POLICYALL
Proposer Name AJAY ROY Policy No. 4128i/HP/150189966/00/000
Address FORT GLOSTER , E BLOCK STREET NO 7 H-NO 298 Period of Insurance From 00:00 hrs 16-Jun-2018 To 23:59 hrs
BAURIA , HOWRAH,WBL-711310 -, HOWRAH, 15-Jun-2019
WEST BENGAL - 711310 Policy Tenure 1
Contact No. 9464101737 LAN No. NA
Email Address AJAYROY@LIVE.COM Policy Issuing Office Prabhadevi
Nominee Name CHANDRAMA ROY Policy Issued On 20-Jun-2018
Relationship With Policyholder FATHER Previous Policy No.
Appointee Name Nominee Age NA
GSTIN Number (Customer) Servicing Branch Name Mumbai
Servicing Branch Address 414, ICICI LOMBARD HOUSE, VEER SAVARKAR Invoice Number 100618359664
MARG, NEAR SIDDHI VINAYAK TEMPLE MAIN GATE,
PRABHADEVI, MUMBAI, 400025, MAHARASHTRA

Insured's Date of Birth Age Date of Gender Relation With Annual Sum Insured (`) Pre-existing Illness/ Optional Add-on
Name(s) Y M Joining Proposer Injury Cover*

AJAY ROY 06-May-1985 33 1 16-Jun-2018 Male SELF None None

500000
NITU ROY 28-Dec-1994 23 5 16-Jun-2018 Female SISTER None None
Plan Details
Plan Name Additional Sum Insured Sub-limit Voluntary GSTIN Reg. No HSN/SAC code The stamp duty of ` 1 paid vide deface no.
(`) Deductible MH001629654201819M dated 17-May-2018
9971 GENERAL
HP_2Adults_1Year 0 None 0 27AAACI7904G1ZN
INSURANCE SERVICES
Premium Details (`)
IGST
Basic Premium Total Tax Payable Total Premium
% `
8294.92 18 1493.08 1493.08 9788

2 Agent Details
Agent ICICI BANK Agent Agent
2470377 8871978067
Name CSPB Code contact No.

SYSESB0010511015
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 is 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.
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP10001V020910
Mailing Address: Registered Office: Toll free no.: 1800 2666
401 & 402, 4th Floor, Interface 11, ICICI Lombard House, 414 Veer Savarkar Marg, Alternate No.: +9186552 22666
New Linking Road, Malad (West), Near Siddhi Vinayak Temple, Prabhadevi, (chargeable) 2/4
Mumbai - 400 064. Mumbai - 400 025. Email: customersupport@icicilombard.com
 Tax Certificate
2

To
AJAY ROY
FORT GLOSTER , E BLOCK STREET NO 7 H-NO 298 BAURIA ,
HOWRAH,WBL-711310 -
HOWRAH
WEST BENGAL - 711310

Subject: Premium certificate for the purpose of deduction under section 80D of Income Tax Act, 1961 and any
amendments made thereafter.

Dear AJAY ROY,

This is to certify that the Company has received the premium dated Jun 16, 2018 for Health insurance coverage
under "Health Insurance Policy" with the following details.

Policyholder's Name AJAY ROY Policy Number 4128i/HP/150189966/00/000

Policy Start Date Jun 16, 2018 Policy End Date Jun 15, 2019
Plan Name HP_2Adults_1Year Total Premium Paid (`) 9788
GSTIN Number GSTIN Reg.No (ICICI 27AAACI7904G1ZN
(Customer) Lombard)
Servicing Branch Mumbai Servicing Branch 414, ICICI LOMBARD HOUSE,
Name Address VEER SAVARKAR MARG, NEAR
SIDDHI VINAYAK TEMPLE MAIN
GATE, PRABHADEVI, MUMBAI,
400025, MAHARASHTRA
Premium Details (`)
IGST
Basic Premium Total Tax Payable Total Premium
% `
8294.92 18 1493.08 1493.08 9788

The product is eligible for deduction u/s 80D of the Income Tax, 1961 and any amendments made there to.

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.

109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP10001V020910
Mailing Address: Registered Office: Toll free no.: 1800 2666
401 & 402, 4th Floor, Interface 11, ICICI Lombard House, 414 Veer Savarkar Marg, Alternate No.: +9186552 22666
New Linking Road, Malad (West), Near Siddhi Vinayak Temple, Prabhadevi, (chargeable) 3/4
Mumbai - 400 064. Mumbai - 400 025. Email: customersupport@icicilombard.com
Name : AJAY ROY
Policy No. : 4128i/HP/150189966/00/000
Card No. : 109891018
Gender : Male Age : 33 Dob : 06-May-1985
Valid Upto : 15-Jun-2019

Name : NITU ROY

Policy No. : 4128i/HP/150189966/00/000
Card No. : 109891019
Gender : Female Age : 23 Dob : 28-Dec-1994
Valid Upto : 15-Jun-2019
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP10001V020910
Mailing Address: Registered Office: Toll free no.: 1800 2666
401 & 402, 4th Floor, Interface 11, ICICI Lombard House, 414 Veer Savarkar Marg, Alternate No.: +9186552 22666
New Linking Road, Malad (West), Near Siddhi Vinayak Temple, Prabhadevi, (chargeable) 4/4
Mumbai - 400 064. Mumbai - 400 025. Email: customersupport@icicilombard.com