Ref. No.

: W306162341 Policy 4111/EPP/340242145/00/0

Number: 00
Date: 23-Apr-2024

DEVESH KUMAR
DURGA MANDIR KE PEECHHTHARPUTHA,

SYSESB00172313744
ETAWAHFIROZABAD
FIROZABAD
UTTAR PRADESH - 283203
Phone: 97******75

Dear Customer,

Subject: Risk Assumption Letter

We thank you for placing your confidence with ICICI Lombard for your Insurance needs.

Please find enclosed herewith Policy No. : 4111/EPP/340242145/00/000 which has been issued
based on the details furnished by the applicant.

Details are:

Name of the Insured Devesh Kumar Product Name PERSONAL PROTECT

Relationship with SELF LAN No NA
Applicant
Date of Birth XX-XX-1993 Policy Duration 1 Years
(Years)
Sum Insured 300000 Period of From: 23-Apr-2024 00:00
Insurance To 22-Apr-2025 23:59
Please go through the details as furnished in the format and the policy document. Please confirm
that same are in 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/ 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.

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2024.04.22 15:38:16
IST
102/20170517/754

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Toll free no.: 1800 2666 UIN -
ICIPAIP22076V042122
Mailing Address: Registered Office: Alternate No.: +918655 222 666
(chargeable)
1 / 10
401 & 402, 4th Floor, Interface 11, New ICICI Lombard House, 414 Veer Savarkar Marg, Email: customersupport@icicilombard.com
Linking Road, Malad (West), Mumbai - 400 Near Siddhi Vinayak Temple, Prabhadevi, Mumbai
 Policy Certificate

PERSONAL PROTECT
PREAMBLE: ICICI Lombard General Insurance Company Limited ("the Company"), having received a Proposal and the
premium from the Policy holder 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 issue of this Policy and referred to therein having been accepted
and agreed to by the Company and the Policy holder 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 the Schedule 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 amount will be paid by the Company.

Part I of Policy Schedule

2

Proposer Name DEVESH KUMAR Policy No. 4111/EPP/340242145/00/000

DURGA MANDIR KE Period of From: 23-Apr-2024 00:00 To
PEECHHTHARPUTHA, Insurance 22-Apr-2025 23:59
Address
ETAWAHFIROZABAD, FIROZABAD, Policy Tenure 1 Years
UTTAR PRADESH - 283203
Contact No. 97******75 LAN No. NA
Email Address YO*****@GMAIL.COM Policy Issuing MUMBAI - CO
Office
Nominee Name Jyoti Savita Policy Issued On 22-Apr-2024
Relationship With SELF Previous Policy NA
Policyholder No.
Appointee Name Nominee Age 27 years
GSTIN Number Servicing Branch Mumbai
(Customer) Name
Servicing Branch 414, ICICI LOMBARD HOUSE, VEER Invoice Number 1004242140174
Address SAVARKAR MARG, NEAR SIDDHI
VINAYAK TEMPLE MAIN GATE,
PRABHADEVI, MUMBAI, 400025,
MAHARASHTRA
Date of Joining

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

Relation of
Insured Date of Risk Relationship Beneficiary /
Age Gender Occupation Nominee with the
Name Birth Category with Proposer Nominee
Insured
Devesh
XX-XX-1993 31 M OTHERS I SELF Jyoti Savita SPOUSE
Kumar
Benefit & Extension Table 2
Section Benefit Cover Benefit Amount Sum Insured (Rs.)
Benefit 1 Death resulting from Accident 100% of the Sum Insured
Section A 300000
Benefit 2 Permanent Total Disablement resulting from Accident 100% of the Sum Insured

Premium Details (` )
IGST
Basic Premium Total Tax Payable Total Premium
% `
326 18 58.68 59.00 385
Place of Supply UTTAR PRADESH
102/20170517/754

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Toll free no.: 1800 2666 UIN -
ICIPAIP22076V042122
Mailing Address: Registered Office: Alternate No.: +918655 222 666
(chargeable)
2 / 10
401 & 402, 4th Floor, Interface 11, New ICICI Lombard House, 414 Veer Savarkar Marg, Email: customersupport@icicilombard.com
Linking Road, Malad (West), Mumbai - 400 Near Siddhi Vinayak Temple, Prabhadevi, Mumbai
 GSTIN Reg.No HSN/SAC code
The stamp duty of ` 15 paid vide deface no.
997133 / GENERAL INSURANCE CSD4520241123 dated 30-Jan-2024
27AAACI7904G1ZN
SERVICES
414, ICICI LOMBARD HOUSE, VEER SAVARKAR MARG, NEAR SIDDHI VINAYAK
GSTIN Address
TEMPLE MAIN GATE, PRABHADEVI, MUMBAI, 400025, MAHARASHTRA
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.

For ICICI Lombard General Insurance Important: Insurance benefit shall become voidable at the option of the company, in the event of any untrue or incorrect
Company ltd. 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
Authorised Signatory claims, please call us at our toll free no. 1800 2666 or e-mail to us at customersupport@icicilombard.com or write to us
at ICICI Lombard GIC, ICICI Bank Tower, Plot no-12, Financial district Nanakramguda, Gachibowli, Hyderabad, Andhra
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. 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

102/20170517/754

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Toll free no.: 1800 2666 UIN -
ICIPAIP22076V042122
Mailing Address: Registered Office: Alternate No.: +918655 222 666
(chargeable)
3 / 10
401 & 402, 4th Floor, Interface 11, New ICICI Lombard House, 414 Veer Savarkar Marg, Email: customersupport@icicilombard.com
Linking Road, Malad (West), Mumbai - 400 Near Siddhi Vinayak Temple, Prabhadevi, Mumbai
 PERSONAL PROTECT POLICY
Customer Information Sheet/ Know Your Policy

This document provides key information about your policy. You are advised to go through your policy document.

SI.No. Title Description Policy Clause

Number
Name of Insurance Personal Protect Policy
1.
Product/Policy
4111/EPP/340242145/00/000
2. Policy Number

Both Indemnity and benefit-

Indemnity (Where insured losses are covered up to the sum insured
under the policy)
Type of insurance
3. Benefit (Where an Insurance Policy pays a fixed amount under the
Product/Policy
policy on the occurance of a covered event)
Both Indemnity and Benefit (where policy has elements of both the
above)
Sum insured (Basis) Individual Sum Insured
4. (Along with Amount) Individual Sum Insured -Where each member has a separate sum
insured under the policy),
5. BENEFITS COVERED UNDER THE POLICY SECTION A -

Cover Name Payout Policy

Clause
No.

Benefit 1: Insured Event - Death resulting from Accident III.A.1

Policy Coverage (what Benefit 2: Insured Event - Permanent Total Disablement (PTD)
the policy Covers?) resulting from Accident III.A.2
(Policy Clause
Number/s) Benefit 3: Insured Event - Permanent Partial Disablement (PPD)
resulting from Accident III.A.3

Benefit 4: Insured Event - Temporary Total Disablement (TTD)

resulting from Accident III.A.4

Extensions Under Section A :

Extension 1: Carriage of Dead Body III.A.1

Extension 2: Medical Benefits Extension III.A.2

Extension 3: Hospital Daily Allowance Extension III.A.3

Extension 4: Permanent Total Disablement Improvement Benefit III.A.4

102/20170517/754

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Toll free no.: 1800 2666 UIN -
ICIPAIP22076V042122
Mailing Address: Registered Office: Alternate No.: +918655 222 666
(chargeable)
4 / 10
401 & 402, 4th Floor, Interface 11, New ICICI Lombard House, 414 Veer Savarkar Marg, Email: customersupport@icicilombard.com
Linking Road, Malad (West), Mumbai - 400 Near Siddhi Vinayak Temple, Prabhadevi, Mumbai
 Extension 4: Permanent Total Disablement Improvement Benefit
Extension

Extension 5: Permanent Partial Disablement Improvement Benefit III.A.5

Extension 6: Children's Education Grant Extension III.A.6

Extension 7: Ambulance Charges Extension III.A.7

Extension 8: Funeral Expenses Extension III.A.8

Extension 9: Repatriation of Remains Extension III.A.9

Benefits under Section B -

Payout Policy
Cover Name Clause
No.

Benefit 5: Accidental Hospital Confinement Allowance Benefit III.B.5

Benefit 6: Accidental Hospitalization Expenses Reimbursement III.B.6

Benefit 7: Convalescence Benefit III.B.7

Benefit 8: Double Benefit Accident resulting in such Injury. III.B.8

6. Exclusions (what the IV. EXCLUSIONS AND LIMITATIONS IV.

policy does not cover)
A.STANDARD EXCLUSIONS
For Extension 2 & 3 of Section A following exclusions shall apply
1. Maternity (Code – Excl 18
2. Breach of law (Code – Excl 10)
3. Change of Gender Treatments (Code – Excl 07) -
4. Cosmetic or Plastic Surgery (Code – Excl 08) -
5. Treatments received in health hydros, nature cure clinics, spas or similar
establishments or private beds registered as a nursing home attached to
such establishments or where admission is arranged wholly or partly for
domestic reasons (Code – Excl 13) 6. Use of intoxicating drugs, liquors or
any diseases, Injury, death or disablement directly or indirectly due to any
one or more of them.
7. Treatment for, Alcoholism, drug or substance abuse or any addictive
condition and consequences thereof (Code – Excl 12) 8. Dental treatment,
eye treatment unless necessitated as a consequence of an Injury.
9. Refractive error (Code – Excl 15)
10. Investigation & Evaluation (Code – Excl 04) - i.
B. SPECIFIC EXCLUSIONS
102/20170517/754

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Toll free no.: 1800 2666 UIN -
ICIPAIP22076V042122
Mailing Address: Registered Office: Alternate No.: +918655 222 666
(chargeable)
5 / 10
401 & 402, 4th Floor, Interface 11, New ICICI Lombard House, 414 Veer Savarkar Marg, Email: customersupport@icicilombard.com
Linking Road, Malad (West), Mumbai - 400 Near Siddhi Vinayak Temple, Prabhadevi, Mumbai
 The Company shall not be liable for: i) Any other payment to the Insured
Person after a claim under Benefit 1 Section A of Part I of the Schedule to
this Policy has been admitted and become payable. However, amounts
relating to Extensions under Section - A viz. Carriage of Dead Body,
Medical Benefits, Children's Education Grant, Ambulance Charges, Funeral
Expenses and Repatriation of Remains, if applicable would be payable in
addition.

ii) Payment of compensation relating to Medical Expenses unless covered

by way of appropriate extensions.
iii) Payment of any claim for Hospitalization where such Hospitalization
does not commence within 7 days of Accident, provided that the Accident
occurs within the Policy Period/Policy Year
iv) Payment of compensation in respect of death, disablement (whether of
a permanent nature or of a temporary nature), Injury, disease, illness,
Hospitalization of Insured Person a. from intentional self-injury, suicide or
attempted suicide; b. whilst under the influence of intoxicating liquor or
drugs; c. While in air carrier other than as passenger in common carrier d.
directly or indirectly caused by venereal disease e. arising or resulting
from the Insured Person committing any breach of law. v) Payment of
compensation in respect of death, disablement (whether of a permanent
nature or of a temporary nature), Injury, disease, illness, Hospitalization of
Insured Person a. from Participation in adventure sports/professional
sports as per policy wordings vi) Payment of compensation in respect of
death, disablement (whether of a permanent nature or of a temporary
nature), Injury, disease, illness, Hospitalization of Insured Person due to, or
arising out of, or directly or indirectly connected with or traceable to, War,
invasion, act of foreign enemy, hostilities (whether war be declared or not)
civil war, rebellion, revolution, insurrection, mutiny, military or usurped
power, seizure, capture, arrests, restraints and detainment of all kinds.

vii) Radioactivity, nuclear weapons etc as per policy wordings. c. Whilst

working in underground mines or explosives magazines, or involving
electrical installation with high tension supply, or as jockeys or circus
personnel, or engaged in activities like racing on wheels or horseback, big
game hunting, mountaineering, winter sports, rock climbing, pot holing,
bungee jumping, skiing, ice hockey, ballooning, hang gliding, river rafting,
polo and persons whilst engaged in occupation / activities of similar hazard
viii) Claim due to childbirth or pregnancy or in consequence thereof as per
policy wordings
ix) Nuclear, Chemical, Biological Terrorism Exclusion as per policy wordings
x) Payment of compensation in respect of death, disablement (whether of
a permanent nature or of a temporary nature), Injury, disease, illness,
Hospitalization of Insured Person while serving in any branch of the
military or armed forces of any country during War or warlike operations.
xi) Claim beyond SI limit as per policy.
xii) If the Company alleges that by reason of any of the above exclusions
i.e. any loss, cost or expenses is not covered by this Policy, the onus of
proving the contrary shall be upon the Insured Person/ or any such person
acting on behalf of the Insured Person, as the case may be.
102/20170517/754

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Toll free no.: 1800 2666 UIN -
ICIPAIP22076V042122
Mailing Address: Registered Office: Alternate No.: +918655 222 666
(chargeable)
6 / 10
401 & 402, 4th Floor, Interface 11, New ICICI Lombard House, 414 Veer Savarkar Marg, Email: customersupport@icicilombard.com
Linking Road, Malad (West), Mumbai - 400 Near Siddhi Vinayak Temple, Prabhadevi, Mumbai
 xiii) For Extension 2 & 3 of Section A, the following exclusions shall applya.
disease, Injury, death or disablement directly or indirectly due to War,
invasion, act of foreign enemy hostilities or warlike operations (whether
War be declared or not) or civil commotion or rebellion, military, naval or air
service b. hunting, steeple chasing, revolution, insurrection, mutiny,
engaging in aviation other than as a passenger (fare paying or otherwise) in
any licensed standard type of aircraft. c. Circumcision or strictures,
vaccination, inoculation, intentional self-injury, (which expression shall
cover also general debility, 'run down' conditions), venereal disease, d. Use
of intoxicating drugs, liquors or any diseases, Injury, death or disablement
directly or indirectly due to any one or more of them. e. Dental treatment,
eye treatment unless necessitated as a consequence of an Injury. f. Any
Injury present prior to the commencement of Policy Period. Any Injury
existing before the Policy Start Date as stated in Part I of the Schedule to
this Policy, whether or not if the same has been treated, or for which
medical advice, diagnosis, care or treatment has been sought before the
commencement of this Policy. Any illness, complication or ailment arising
out of or connected to such Injury. g. Any Hospitalization not arising out of
an Injury. h. Payment of compensation relating to Medical Expenses not
incurred in a Hospital.

The above is indicative list of exclusions, please refer policy wordings for
detailed description

7 Waiting period Waiting period is not applicable, limits are as per the covers opted in the
policy.
• Time period during
which specified
diseases/treatments
are not covered

• It is counted from the

beginning of the policy
coverage.

8 Financial limits of
coverage

Sub-limit (It is a
predefined limit and
the insurance
company will not pay
any amount in excess
of this limit)
• Co-payment (It is a
specified
amount/percentage of
the admissible claim
amount to be paid by
policyholder/insured).
102/20170517/754

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Toll free no.: 1800 2666 UIN -
ICIPAIP22076V042122
Mailing Address: Registered Office: Alternate No.: +918655 222 666
(chargeable)
7 / 10
401 & 402, 4th Floor, Interface 11, New ICICI Lombard House, 414 Veer Savarkar Marg, Email: customersupport@icicilombard.com
Linking Road, Malad (West), Mumbai - 400 Near Siddhi Vinayak Temple, Prabhadevi, Mumbai
 Deductible (It is a
specified amount: up
to which an insurance
company will not pay
any claim, and which
will be deducted from
total claim amount
claim amount is more
than the specified
amount) iv. Any other
limit (as applicable)

Claims / Claims Upon the happening of any event giving rise or likely to give rise to a claim V.A.
9
procedure under this Policy:

• Barring exceptional circumstances where a reasonable cause is shown

and the Company is satisfied with such reasons, the Company should
be immediately notified in writing of such event.

• The Insured Person or any such person acting on behalf of the Insured
Person, as the case may be, shall deliver to the Company, within
30days of the date on which the event shall have come to his
knowledge, a detailed statement in writing as per the claim form, and
any other material particular, relevant to the making of such claim.

• The Insured Person or any such person acting on behalf of the Insured
Person, as the case may be, shall tender to the Company all
reasonable information, assistance and proofs in connection with any
claim hereunder.

• Customer to send documents to Company at :- ICICI Lombard General

Insurance Company Limited

1st, 4th (Half) , 5th and 6th floors, Varun Towers- II , Opp. Hyderabad
Public school , Begumpet, Hyderabad District Hyderabad , Pin code
-500016

Download the Claim Form here

https://www.icicilombard.com/downloads

Find our extensive list of hospitals providing services on our website

https://www.icicilombard.com/health-insurance/health-claim/partner-
hospital
or on the IL TakeCare App.

List of excluded providers/delisted hospitals is available on our website

https://www.icicilombard.com/docs/default-source/apps/healthclaims/
assets/files/delisted-hospital-list.pdf
102/20170517/754

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Toll free no.: 1800 2666 UIN -
ICIPAIP22076V042122
Mailing Address: Registered Office: Alternate No.: +918655 222 666
(chargeable)
8 / 10
401 & 402, 4th Floor, Interface 11, New ICICI Lombard House, 414 Veer Savarkar Marg, Email: customersupport@icicilombard.com
Linking Road, Malad (West), Mumbai - 400 Near Siddhi Vinayak Temple, Prabhadevi, Mumbai
 10 Policy Servicing • You may contact us on our Toll Free no: 1800 2666, or email
to customersupport@icicilombard.com or use our IL TakeCare App
or send a Hi to RIA, our Responsive Intelligent Assistant on
WhatsApp (7738282666) for policy services

For details of Company officials kindly visit our

website https://www.icicilombard.com/customer-support.

11 Grievances/Complaints ln case of any grievance the insured person may contact the company Part III 21.
through Website: www. icicilombard.com (Customer Support section). Toll
Free: 1800 2666 (Senior Citizen Included) E-mail:
customersupport@icicilombard.com

There is an interactive voice response (IVR) facility for senior citizens’

grievance redressal for easy and faster resolution.

lnsured person may also approach the grievance cell at any of the
company's branches with the details of grievance. lf lnsured person is not
satisfied with the redressal of grievance through one of the above
methods, insured person may contact the grievance officer at

Manager- Service Quality, Corporate Manager- Service Quality, National

Manager- Operations & finally Director-services and Business development

at the following address: ICICI Lombard General Insurance Company

Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi
Vinayak Temple, Prabhadevi, Mumbai 400025

For updated details of grievance officer, kindly refer the link

https://www.icicilombard.com/grievance-redressal

lf lnsured person is not satisfied with the redressal of grievance through

above methods, the insured person may also approach the office of
lnsurance ombudsman of the respective area/region for redressal of
grievance as per lnsurance Ombudsman Rules 2017

The updated details of Insurance Ombudsman are also available on IRDA

website: www.irdaindia.org , on the website of General Insurance Council:

www.generalinsurancecouncil.org.in website of the company

www.icicilombard.com or from any of the offices of the company.

Grievance may also be lodged at IRDAI lntegrated Grievance Management

System - https:/ligms. irda.qov. in/
12 Things to remember • Free look period: You will be given a period of 15 days or 30 days (only
if the Policy Tenure is 3 years or more and is sold through distance
marketing) from the date of receipt of the Policy document to review its
terms and conditions. Where if you disagree to any of the terms or
conditions of the Policy, you have the option to return the Policy stating
the reasons for your objection, when you will be entitled to
a.)Refund of the premium paid, subject only to a deduction of the
102/20170517/754

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Toll free no.: 1800 2666 UIN -
ICIPAIP22076V042122
Mailing Address: Registered Office: Alternate No.: +918655 222 666
(chargeable)
9 / 10
401 & 402, 4th Floor, Interface 11, New ICICI Lombard House, 414 Veer Savarkar Marg, Email: customersupport@icicilombard.com
Linking Road, Malad (West), Mumbai - 400 Near Siddhi Vinayak Temple, Prabhadevi, Mumbai
 a.)Refund of the premium paid, subject only to a deduction of the
expenses incurred by the Company on medical examination of the Insured

b.) where the risk is already commenced and the option of return of the
policy is exercised by the Policyholder, a deduction towards the
proportionate premium for period on cover.
c.) Where only a part of the insurance coverage has commenced, such
• Benefits payable under this policy will be paid within 30 days of the
receipt of last necessary documents required for the settlement of the
claim.
• The Policy may be renewed by mutual consent and in such event the
Renewal premium should be paid to Us before the Grace Period of 30 days
from the expiry of the Policy.
• The Policy can be renewed or migrated, wherever applicable, under the
then prevailing Product or its nearest substitute (in case of withdrawal of
the prevailing Product) approved by IRDAI.
Migration and Portability: When your policy is due for renewal, you may
migrate to another policy with us or port your policy to another insurer.

Change in Sum Insured: Sum Insured can be changed

(increased/decreased) only at the time of renewal or at any time, subject
to underwriting by the company. For increase in Sl, the waiting period if
any shall start afresh only for the enhanced portion of the sum insured

Moratorium Period: After completion of eight continuous years under the

policy no look back to be applied. This period of eight years is called as
moratorium period. The moratorium would be applicable for the sums
insured of the first policy and subsequently completion of eight continuous
years would be applicable from date of enhancement o sums insured only
on the enhanced limits.

After the expiry of Moratorium Period no health insurance policy shall be

contestable except for proven fraud and permanent exclusions specified in
the policy contract.

13 Your Obligations • Please disclose all material information (Including Pre-Existing Diseases,
Annual income and other relevant details asked at the time of enrollment)
before buying the policy.
• Cooperation from the Insured/claimant is solicited in providing all or
sufficient documents as per the claims procedure in support of claim.

Declaration by the Policy Holder:

I have read the above and confirm having noted the details.

Place:

Date:
Signature of the Policy Holder

NOTE:

In case of any conflict, the terms and conditions mentioned in the policy document shall prevail.
102/20170517/754

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Toll free no.: 1800 2666 UIN -
ICIPAIP22076V042122
Mailing Address: Registered Office: Alternate No.: +918655 222 666
(chargeable)
10 / 10
401 & 402, 4th Floor, Interface 11, New ICICI Lombard House, 414 Veer Savarkar Marg, Email: customersupport@icicilombard.com
Linking Road, Malad (West), Mumbai - 400 Near Siddhi Vinayak Temple, Prabhadevi, Mumbai