4128i HP 90979507 03 000

Risk Assumption Letter
Dear Sir / Madam,

2
We thank you for placing your confidence with ICICI Lombard for your Health Insurance Needs.
2
Please find attached herewith Policy No. 4128i/HP/90979507/03/000 which has been issued based on the details furnished by the applicant.
2
Name of Proposer SUKHDEV OSHAN Policy Tenure (in Years) 1
202/B BHAGWATI APARTMENT 2ND FLOOR B-WIND
DOCTOR CHARTAT COLONY ANDHERI EAST, DR From 00:00 hrs 13-Jun-2017 To 23:59 hrs
Address Period of Insurance
CHARAT SINGH COLONY ,, MUMBAI, 12-Jun-2018
MAHARASHTRA - 400093
Policy Issued On 03-Jun-2017 Email Address SUKHDEVOSHAN@YAHOO.COM
GSTIN (Customer) Mobile No. 9833209511
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
SUKHDEV OSHAN 06-Mar-1957 60 3 Male SELF None None

400000 None 0
RITA OSHAN 24-Dec-1960 56 5 Female SPOUSE 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: 2019.05.19 16:54:40
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.: +918655 222 666 (chargeable)
New Linking Road, Malad (West), Near Siddhi Vinayak Temple, Prabhadevi, Email: customersupport@icicilombard.com 1/4
Mumbai - 400 064. Mumbai - 400 025. Website: www.icicilombard.com
Policy Certificate
POLICYALL
Proposer Name SUKHDEV OSHAN Policy No. 4128i/HP/90979507/03/000
Address 202/B BHAGWATI APARTMENT 2ND FLOOR B-WIND Period of Insurance From 00:00 hrs 13-Jun-2017 To 23:59 hrs
DOCTOR CHARTAT COLONY ANDHERI EAST, DR 12-Jun-2018
CHARAT SINGH COLONY ,, MUMBAI, Policy Tenure 1
Contact No. 9833209511 LAN No. NA

Email Address SUKHDEVOSHAN@YAHOO.COM Policy Issuing Office Prabhadevi
Nominee Name Policy Issued On 03-Jun-2017
Relationship With Policyholder Previous Policy No. 4128i/HP/90979507/02/000
Appointee Name Nominee Age NA
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*
SUKHDEV
06-Mar-1957 60 3 13-Jun-2009 Male SELF None None
OSHAN 400000
RITA OSHAN 24-Dec-1960 56 5 13-Jun-2009 Female SPOUSE None None
Plan Details Premium Details (`) no
Plan Name Additional Sum Sub-limit Voluntary Basic Premium Service Tax Swachh Bharat Krishi Kalyan Total Premium
Insured (`) Deductible Cess Cess
HP_2Adults_1Ye 200000 None 0 30840.87 4317.72 154.2 154.2 35467
ar
Service Tax Reg. No Service Tax Code Category The stamp duty of ` 1 paid vide deface no. 1574749 dated
25-May-2017
GIS/Mumbai-I/1528/2001 AAACI7904GST001 General Business Services 00440005
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

Tax Certificate
2
To
SUKHDEV OSHAN
202/B BHAGWATI APARTMENT 2ND FLOOR B-WIND DOCTOR CHARTAT
COLONY ANDHERI EAST
DR CHARAT SINGH COLONY ,
MUMBAI
Subject: Premium certificate for the purpose of deduction under section 80D of Income Tax Act, 1961 and any
amendments made thereafter.
Dear SUKHDEV OSHAN,
This is to certify that the Company has received the premium dated Jun 13, 2017 for Health insurance coverage
under "Health Insurance Policy" with the following details.
Policyholder's Name SUKHDEV OSHAN Policy Number 4128i/HP/90979507/03/000

Policy Start Date Jun 13, 2017 Policy End Date Jun 12, 2018
Plan Name HP_2Adults_1Year Total Premium Paid (`) 35467
The product is eligible for deduction u/s 80D of the Income Tax, 1961 and any amendments made there to.
Service tax registration number: GIS/MUMBAI-I/1528/2001
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

Name : SUKHDEV OSHAN
Policy No. : 4128i/HP/90979507/03/000
Card No. : 100247094
Gender : Male Age : 60 Dob : 06-Mar-1957
Valid Upto : 12-Jun-2018
Name : RITA OSHAN

Policy No. : 4128i/HP/90979507/03/000
Card No. : 100247097
Gender : Female Age : 56 Dob : 24-Dec-1960
Valid Upto : 12-Jun-2018
109/20150914/284


4128i HP 90979507 03 000

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Risk Assumption Letter

Dear Sir / Madam,

SUKHDEV OSHAN 06-Mar-1957 60 3 Male SELF None None

Signature Not Verified

ICICI Lombard General Insurance Company Limited

Contact No. 9833209511 LAN No. NA

ICICI Lombard General Insurance Company Limited

Dear SUKHDEV OSHAN,

Policyholder's Name SUKHDEV OSHAN Policy Number 4128i/HP/90979507/03/000

Service tax registration number: GIS/MUMBAI-I/1528/2001

ICICI Lombard General Insurance Company Limited

Name : RITA OSHAN

ICICI Lombard General Insurance Company Limited

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