Off Malad Link Road,

Behind Goregaon
Sports Club, Malad(w),
Mumbai- 400034.Toll
Free 24 X 7 Call
Center No 1800-209-
8888. E-mail
:customersupport@icici
lombard.com
Premium
CertificateFor the
purpose of deduction
under section 80D of
Income Tax
amendment act, 1961
and any amendments
made thereafter.
To,S
M UBAIDULLASULT
HAN, NEW NO-52 ,
HABIB NAGAR ,
PALLAPATTI
, ARAVAKURICHI
, PALLAPATTI-
KARUR-639207,
TAMILNADUKARUR
-
639207TamilNaduKA
RUR639207TamilNad
uThis is to certify that
the Company has
received the premium
as detailed below for
Health Insurance
Policy No
:4034i/FPP/04812914/0
0/000.Premium eligible
for deduction u/s 80D of
the Income Tax Act,
1961 and any
amendments made there
to.Financial Year 2009 -
2010(Rs.)3013.64Finan
cial Year 2010 -
2011(Rs.)4074Financial
Year 2011 -
2012(Rs.)1060.36Total
Premium (Rs.) 8148Co
llection No:928106Coll
ectionDate04-Jul-2009
For ICICI
LombardGeneral
Insurance Co. Ltd.

Authorized
SignatoryNote:
l
 This certificate must
be surrendered to the
Insurance Company in
case of Cancellation of
the policy.
In the event of
incorrectrepresentation
of this declaration, the
liability shall be
upon the policyholder.
l

For the purpose of

deduction under
section 80D, the benefit
shall be as per the
provisions of the
Income Tax Act, 1961
and anyAmendments
made thereafter.
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Information Sheet
To,S
M UBAIDULLADate :
06-Jul-
2009SULTHAN, NEW
NO-52 , HABIB
NAGAR
, PALLAPATTI
, ARAVAKURICHI
, PALLAPATTI-
KARUR-639207,
TAMILNADUKARUR
-
639207TamilNaduKAR
UR639207TamilNaduS
ub : Verbal proposal
for health insurance
policy from ICICI
Lombard GIC Ltd.Dear
SM
UBAIDULLA,Thank
you for choosing ICICI
Lombard Health
Insurance Policy. It is
a pleasure to have you
as our esteemed
customer. This letter
is withreference to your
tele-conversation dated
05-Jul-2009
with the representative
of ICICI Lombard GIC
Ltd for the purchase of
HealthInsurance Policy.
The information
provided by you has
been mentioned below
and the
Family Protect
Premier
policy No :
4034i/FPP/04812914/00
/000
 has been issued based
on the same. You are
requested to kindly go
through the details
mentioned below
videthe tele-
conversation.In case of
any discrepancy or error
in the information
mentioned below or in
the policy copy
attached, you are
requested to intimate us
atour call center no
1800-209-8888 within
15 days of issue of this
letter.
l

Name of the Proposer :

S M UBAIDULLA
l

Address :
SULTHAN, NEW
NO-52 , HABIB
NAGAR ,
PALLAPATTI
, ARAVAKURICHI
,PALLAPATTI-
KARUR-
639207, TAMILNAD
UKARUR -
639207TamilNadu
l

Details of the insured:

Name

Sex
Date of Birth

Relationship withprop
oser

Name of Pre-
Existingillness

SumInsured

Tenure
 S U APSARA PRAVE
EN F 05-Jul-
1969 SPOUSE 300000
2
l

Premium :
8148
l

Exclusions :
a.Any
illness/disease/injury
existing before the
inception of the policy
for the first 2 yrs
for HAP and 4 yrs for
the rest of the products
specifically as per the
policy
wordings. b.Pregnancy
and childbirth related
diseases, cosmetic
aesthetic & obesity
related treatments and
congenital
diseases.c.Any illness
contracted during the
first 30 days of the
inception of the policy
except those that are
incurred as a result
ofaccident, the
exclusion does not
apply for subsequent
renewals without a
break of the policy with
the company.d.Non
allopathic treatment,
expenses arising from
HIV or AIDS and
related diseases, use or
misuse of liquor,
intoxicatingsubstances
or drugs as well as
intentional self
injury/attempted
suicide/suicide.e.War,
riot, strike, nuclear
weapons induced
hospitalization.f.Certai
n ailments will be
excluded from
treatment for 2-years:
Cataract, Hernia,
Benign Prostatic
Hypertrophy ,
Hydrocele,Sinusitis
and related disorders,
Arthritis, Gastric and
Duodenal ulcers
etc.Regards,
Authorized
Representative

ICICI Lombard
General Insurance
Company Ltd.

Disclaimer:
The details mentioned
herein are indicative and
not exhaustive, for
complete details on
coverage's, exclusion,
terms and conditions
pleaserefer to policy
wordings provided
along with the policy
kit."

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