(a) Policy Schedule (Policy Certificate)

POLICYALLCOUPON 8 8 3 3
PREAMBLE
yes
ICICI Lombard General Insurance Company Limited ("the Company"), having received a Proposal and the premium from the Proposer 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 issuance of this policy and
referred to therein having been accepted and agreed to by the Company and the Proposer 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 Policy 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 will be paid by the Company.

Part I of Policy: Policy Schedule

ICICI Lombard Group Health Policy no. 4177i/MSTR/232059116/00/000 has been issued at Mumbai, by ICICI Lombard General Insurance Company Limited to
the Policyholder, for covering its members as specified in the policy and is governed by, and is subject to, the terms, conditions & exclusions therein contained or
otherwise expressed in the said policy, but not exceeding the sum insured as specified forming Part I of the schedule to the said policy.

Proposer Name HUDDARSINH BHARATSINH GOHIL Policy No. 4177i/IHOME/253894581/00/000

Address GOHIL FALIYU GLENDA SAMANTPOR Period of Insurance From 00:00 hrs 26-Jul-2022 To 23:59 hrs
GALENDA BHARUCH, BHARUCH, GUJARAT 25-Jul-2027
- 392130 Policy Tenure 5
Contact No. 9825065124 LAN No. LBBRD00006075783
Email Address HUDDAR_GOHIL@YAHOO.COM Policy Issuing Office Prabhadevi
Nominee Name NIPURNA PATEL Policy Issued On 29-Jul-2022
Relationship With SPOUSE Previous Policy No.
Policyholder
Appointee Name Nominee Age 36 Years 3 Month
GSTIN Number (Customer) Servicing Branch Name Ahmedabad
Servicing Branch Address Third Zodiac Square S G road Ahmedabad Invoice Number 1007221997876
Gujarat 380054
Insured's Name(s) Date of Age Date of Gender Relation With Annual Sum Pre-existing Optional Special
Birth Y M Joining Proposer Insured (`) Illness/ Injury Add-on Cover* Condition
HUDDARSINH
07-Nov-198
BHARATSINH 36 8 26-Jul-2022 Male SELF None None None
5
GOHIL
25-Apr-198 1000000
NIPURNA PATEL 36 3 26-Jul-2022 Female SPOUSE None None None
6
MOKSHITSINH 26-Sep-201
2 10 26-Jul-2022 Male SON None None None
GOHIL 9
Plan Details
The stamp duty of ` 0.5 paid
Plan Name Additional Sum Sub-limit Voluntary Deductible GSTIN Reg. No HSN/SAC code
vide deface no.
Insured (`) (`) CSD232202184 dated
997133 GENERAL 06-Jan-2022
ICICIMOR_HS360_10L_
0 None 0 24AAACI7904G1ZT INSURANCE
25L_50L_5YR_2A + 1K
SERVICES
Premium Details (`)
CGST SGST
Basic Premium Total Tax Payable Total Premium
% ` % `
38050.85 9 3424.58 9 3424.58 6849.15 44900

8 Agent Details
Agent ICICI BANK Agent Agent
2470377 0018002666
Name LIMITED Code contact No. Signature Not Verified
Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2022.07.29 22:39:03
IST
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Health Shield 360 UIN - ICIHLGP22083V022122
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 1/6
 SYSESB00172313343
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.

Click or Scan QR Code for Customer Information Sheet and Policy Wordings

109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Health Shield 360 UIN - ICIHLGP22083V022122
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 2/6
 Tax Certificate
8

To
HUDDARSINH BHARATSINH GOHIL
GOHIL FALIYU GLENDA SAMANTPOR GALENDA BHARUCH
BHARUCH
GUJARAT - 392130
ANNUAL
Subject: Premium certificate for the purpose of deduction under section 80D of Income Tax
Act, 1961 and any amendments made thereafter.

Dear HUDDARSINH BHARATSINH GOHIL,

This is to certify that the Company has received the premium dated Jul 26, 2022 for Health
insurance coverage under "Health Insurance Policy" with the following details.

Policyholder's HUDDARSINH Policy Number 4177i/IHOME/253894581/

Name BHARATSINH GOHIL 00/000
Policy Start Date Jul 26, 2022 Policy End Date Jul 25, 2027
Plan Name ICICIMOR_HS360_10L_25 Total Premium Paid 44900
L_50L_5YR_2A + 1K (`)
GSTIN Number GSTIN Reg.No (ICICI 24AAACI7904G1ZT
(Customer) Lombard)
Servicing Branch Ahmedabad Servicing Branch Third Zodiac Square S G
Name Address road Ahmedabad Gujarat
380054
Premium Details (` )
CGST SGST
Basic Premium Total Tax Payable Total Premium
% ` % `
38050.85 9 3424.58 9 3424.58 6849.15 44900
Financial Year Amount (` )
2022-2023 8980.00
2023-2024 8980.00
2024-2025 8980.00
2025-2026 8980.00
2026-2027 8980.00
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 Health Shield 360 UIN - ICIHLGP22083V022122
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 3/6
Name : HUDDARSINH BHARATSINH GOHIL
Policy No. : 4177i/IHOME/253894581/00/000
Card No. : 120755784
Gender : Male Age : 36 DOB : 07-Nov-1985
Valid Upto : 25-Jul-2027

Name : NIPURNA PATEL

Policy No. : 4177i/IHOME/253894581/00/000
Card No. : 145638493
Gender : Female Age : 36 DOB : 25-Apr-1986
Valid Upto : 25-Jul-2027
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Health Shield 360 UIN - ICIHLGP22083V022122
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 4/6
Name : MOKSHITSINH GOHIL
Policy No. : 4177i/IHOME/253894581/00/000
Card No. : 145638494
Gender : Male Age : 2 DOB : 26-Sep-2019
Valid Upto : 25-Jul-2027

Health Coupon 0 3

109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Health Shield 360 UIN - ICIHLGP22083V022122
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 5/6
 109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Health Shield 360 UIN - ICIHLGP22083V022122
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 6/6