(a) Policy Schedule (Policy Certificate)

POLICYALL 3 3 2 2
Proposer Name GANDE MADHU Policy No. 4128i/iHPA/272706190/00/000
Address FLAT NO 201 SRI SAI TEJA RESIDENCY, Period of Insurance From 00:00 hrs 14-Dec-2022 To 23:59 hrs
ROAD NO 3 DD COLONY BANDLAGUDA 13-Dec-2023
JAGIR, HYDERABAD, TELANGANA - 500086 Policy Tenure 1
Contact No. 9676849587 LAN No. NA
Email Address GANDHEMADHU@GMAIL.COM Policy Issuing Office Prabhadevi
Nominee Name A Bhagyasree Policy Issued On 14-Dec-2022
Relationship With SPOUSE Previous Policy No.
Policyholder
Appointee Name Nominee Age 27 Years 6 Month
GSTIN Number (Customer) Servicing Branch Name Mumbai
Servicing Branch Address 414, ICICI LOMBARD HOUSE, VEER Invoice Number 1012221779105
SAVARKAR MARG, NEAR SIDDHI VINAYAK
TEMPLE MAIN GATE, PRABHADEVI, MUMBAI,
400025, MAHARASHTRA

Insured's Date of Age Date of Gender Relation With Annual Sum Pre-existing Optional Special
Name(s) Birth Y M Joining Proposer Insured (`) Illness/ Injury Add-on Cover* Condition
11-Feb-199
Gande Madhu 28 10 14-Dec-2022 Male SELF None None None
4 1000000
A Bhagyasree 06-Jun-1995 27 6 14-Dec-2022 Male SPOUSE None None None
Plan Details
The stamp duty of ` 1 paid
Plan Name Additional Sum Insured Sub-limit Voluntary Deductible GSTIN Reg. No HSN/SAC code
vide deface no.
(`) (`) CSD36420222395 dated
997133 03-Jun-2022
GENERAL
iHP_2Adults_1Year_A 0 None 0 27AAACI7904G1ZN
INSURANCE
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 (`)
IGST
Basic Premium Total Tax Payable Total Premium
% `
19751.69 18 3555.31 3555.31 23307

SYSESB00172313341
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.

Signature Not Verified

Digitally signed by DS ICICI
Click or Scan QR Code for Customer Information Sheet and Policy Wordings LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2022.12.14 17:11:50
IST
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP22096V062122
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Savarkar Marg, Near Siddhi Vinayak Email: customersupport@icicilombard.com
Link Road, Malad (West), Mumbai - 400 064. Temple, Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com 1/4
 Tax Certificate
3

To
GANDE MADHU
FLAT NO 201 SRI SAI TEJA RESIDENCY, ROAD NO 3 DD
COLONY BANDLAGUDA JAGIR
HYDERABAD
TELANGANA - 500086
ANNUAL
Subject: Premium certificate for the purpose of deduction under section 80D of Income Tax
Act, 1961 and any amendments made thereafter.

Dear GANDE MADHU,

This is to certify that the Company has received the premium dated Dec 14, 2022 for Health
insurance coverage under "Health Insurance Policy" with the following details.

Policyholder's GANDE MADHU Policy Number 4128i/iHPA/272706190/00

Name /000
Policy Start Date Dec 14, 2022 Policy End Date Dec 13, 2023
Plan Name iHP_2Adults_1Year_A Total Premium Paid 23307
(`)
GSTIN Number GSTIN Reg.No (ICICI 27AAACI7904G1ZN
(Customer) Lombard)
Servicing Branch Mumbai Servicing Branch 414, ICICI LOMBARD
Name Address HOUSE, VEER
SAVARKAR MARG, NEAR
SIDDHI VINAYAK
TEMPLE MAIN GATE,
PRABHADEVI, MUMBAI,
400025, MAHARASHTRA

Premium Details (`)

IGST
Basic Premium Total Tax Payable Total Premium
% `
19751.69 18 3555.31 3555.31 23307
Financial Year Amount (`)
2022-2023 23307.00
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: L67200MH2000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP22096V062122
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Savarkar Marg, Near Siddhi Vinayak Email: customersupport@icicilombard.com
Link Road, Malad (West), Mumbai - 400 064. Temple, Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com 2/4
Name : Gande Madhu
Policy No. : 4128i/iHPA/272706190/00/000
Card No. : 153595348
Gender : Male Age : 28 DOB : 11-Feb-1994
Valid Upto : 13-Dec-2023

Name : A Bhagyasree
Policy No. : 4128i/iHPA/272706190/00/000
Card No. : 153595349
Gender : Male Age : 27 DOB : 06-Jun-1995
Valid Upto : 13-Dec-2023
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP22096V062122
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Savarkar Marg, Near Siddhi Vinayak Email: customersupport@icicilombard.com
Link Road, Malad (West), Mumbai - 400 064. Temple, Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com 3/4
 109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP22096V062122
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Savarkar Marg, Near Siddhi Vinayak Email: customersupport@icicilombard.com
Link Road, Malad (West), Mumbai - 400 064. Temple, Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com 4/4