(A) Policy Schedule (Policy Certificate) : Policyall 4 4 3 3

(a) Policy Schedule (Policy Certificate)
POLICYALL 4 4 3 3
Proposer Name SANJEEV AGARWAL Product name ICICI Lombard Complete Health Insurance
Address FLAT NO D-001, BLUEMOON HOMES Plan Name Health_Shield_R
RAJNAGAR EXTENSION, GHAZIABAD,
UTTAR PRADESH - 201017 Policy No. 4128i/HSRN/240375030/01/000
Contact No. 9837089579 Period of Insurance From 00:00 hrs 26-Feb-2023 To 23:59 hrs
25-Feb-2024
Email Address AGARWALRKE@GMAIL.COM Policy Tenure 1
Nominee Name MONA AGARWAL Alternate Policy No. 4128i/iHAR/240375030/01/000
LAN No. NA
Relationship With SPOUSE Policy Issuing Office Prabhadevi
Policyholder
Appointee Name Policy Issued On 25-Feb-2023
Nominee Age 49 Years 3 Month Previous Policy No. 4128i/iHA/240375030/00/000
GSTIN No. (Customer) Invoice No. 1002232516695
Servicing Branch Address 414, ICICI LOMBARD HOUSE, VEER Servicing Branch Name Mumbai
SAVARKAR MARG, NEAR SIDDHI VINAYAK
TEMPLE MAIN GATE, PRABHADEVI, MUMBAI,
400025, MAHARASHTRA
Are you or any of the proposed applicants a PEP* or a close relative of a PEP*? No
Insured's Name(s) Date of Birth Age Date of Joining Gender Relation With Proposer
Y M
MONA AGARWAL 15-Nov-1973 49 3 26-Feb-2011 Female SPOUSE
SANJEEV AGARWAL 16-Apr-1974 48 10 26-Feb-2011 Male SELF
SANCHAY AGARWAL 03-Oct-2006 16 4 26-Feb-2011 Male SON
Insured's Name(s) Pre-existing Illness/ Optional Add-on Pneumococcal vaccine Special nn
Annual Sum Insured (`)
oo
Injury Cover* taken Condition
MONA AGARWAL None None NO None
SANJEEV AGARWAL None None NO None
500000
SANCHAY
None None NO None
AGARWAL
Plan Details
Plan Name Voluntary co-payment Zone opted Guaranteed Cumulative Bonus [GCB]
HSRN_2Adult_1Child_1Year 0% Zone A 680000
Premium Details (`)

IGST
Basic Premium Total Tax Payable Total Premium
% `
23884.75 18 4299.25 4299.25 28184
Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2023.02.25 15:48:05
IST
109/20150914/284
ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP23144V072223
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, P Balu Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Off Veer Savarkar Road, Near Email: customersupport@icicilombard.com
Link Road, Malad (West), Mumbai - 400 064. Siddhi Vinayak Temple, Prabhadevi, Website: www.icicilombard.com 1/5
Mumbai -400025.
Table of Benefits
Covers Benefits
Upto Annual Sum Insured
In Patient Treatment
No room rent capping
Daycare procedures/treatment All procedures covered up to Annual Sum Insured
Coverage for modern treatments Upto Annual Sum Insured
Pre Hospitalisation Medical Expenses 30 days
Post Hospitalisation Medical Expenses 60 days
In Patient AYUSH hospitalisation Upto Annual Sum Insured
Reset benefit Unlimited times for different illness and once for same illness
Cashless: Actuals; Reimbursement: 1% of Sum Insured ; maximum up to ₹ 10,000,
Domestic road ambulance
within annual sum insured
Air Ambulance Cover Upto Annual Sum Insured
Donor expenses Upto Annual Sum Insured
Domicillary hospitalisation Upto Annual Sum Insured
Home Care Treatment 5% of Annual Sum Insured ; maximum upto ₹ 25,000
• Includes wellness program, health assistance, ambulance assistance and discounts
on services and products
Wellness Program
• Redemption of points will be through utilisation of services on our mobile application
20% for every claim free year maximum up to 100% of Annual Sum Insured ; no
Guaranteed Cumulative Bonus [GCB]
reduction in case of claims
Preventive Health check up As per annual sum insured package eligibility
Tele consultations Unlimited
2.5% discount on premium if all adults in the policy have been vaccinated with
Incentives associated with vaccination against Pneumococcal disease
pneumococcal vaccine
GSTIN Reg. No HSN/SAC code The stamp duty of ` 1 paid vide deface no. CSD45120223802
997133 GENERAL INSURANCE dated 05-Sep-2022
27AAACI7904G1ZN
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.
SYSESB00172313737
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

Mumbai -400025.
Tax Certificate
4
To
SANJEEV AGARWAL
FLAT NO D-001
BLUEMOON HOMES RAJNAGAR EXTENSION
GHAZIABAD
UTTAR PRADESH - 201017
ANNUAL
Subject: Premium certificate for the purpose of deduction under section 80D of Income Tax
Act, 1961 and any amendments made thereafter.
Dear SANJEEV AGARWAL,
This is to certify that the Company has received the premium dated Feb 26, 2023 for Health
insurance coverage under "Health Insurance Policy" with the following details.
Policyholder's SANJEEV AGARWAL 4128i/HSRN/240375030/0 Policy Number

Name 1/000
Policy Start DateFeb 26, 2023 Policy End Date Feb 25, 2024
Plan Name HSRN_2Adult_1Child_1Ye Total Premium Paid 28184
ar (`)
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
% `
23884.75 18 4299.25 4299.25 28184
Financial Year Amount (`)
2022-2023 28184.00
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

Mumbai -400025.
Name : MONA AGARWAL
Policy No. : 4128i/HSRN/240375030/01/000
Card No. : 139993858
Gender : Female Age : 49 DOB : 15-Nov-1973
Valid Upto : 25-Feb-2024
Name : SANJEEV AGARWAL

Policy No. : 4128i/HSRN/240375030/01/000
Card No. : 139993859
Gender : Male Age : 48 DOB : 16-Apr-1974
109/20150914/284

Mumbai -400025.
Name : SANCHAY AGARWAL
Policy No. : 4128i/HSRN/240375030/01/000
Card No. : 139993860
Gender : Male Age : 16 DOB : 03-Oct-2006
109/20150914/284

Mumbai -400025.

(A) Policy Schedule (Policy Certificate) : Policyall 4 4 3 3

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(A) Policy Schedule (Policy Certificate) : Policyall 4 4 3 3

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Premium Details (`)

Signature Not Verified

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

Dear SANJEEV AGARWAL,

Policyholder's SANJEEV AGARWAL 4128i/HSRN/240375030/0 Policy Number

Premium Details (`)

ICICI Lombard General Insurance Company Limited

Name : SANJEEV AGARWAL

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

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