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RISK ASSUMPTION LETTER

Dear Sir / Madam,
We thank you for placing your confidence with ICICI Lombard for your Health Insurance Needs.

Please find attached here with Alternate Policy IB360HS1000157306 which has been issued based on the details furnished by the
No.
applicant.

ICICI Lombard Health Shield 360 Master Policy no. 4177i/MSTR/291415383/00/000 has been issued to ICICI Bank Limited at
Mumbai, by ICICI Lombard General Insurance Company Limited, 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 in the said policy.

Name of the Policy Holder NITHIN WILSON Policy Tenure (in Years) 1

Address KARUNA,B-150,MANGAD NAGAR,MANGAD,,NEAR HOLY CROSS CHURCH,KOLLAM,INDIA,KERALA

City KOLLAM State KERALA Pincode 6 9 1 0 1 5

Period of Insurance From 07/06/2023 To 06/06/2024

Email ID nithinwilson.es@gmail.com

Mobile No. 9 0 4 8 6 2 6 6 5 5

Insured Details
Age
Name of the insured (s) Date of Birth Gender Relationship with Sum Pre-existing
Y M policy holder Insured illness /injury
NITHIN WILSON 2 8 1 2 1 9 8 7 35 5 Male Self NA
BHAVANA JOY 3 1 0 3 1 9 8 6 37 2 Female Spouse NA
1000000
NADEIN ELIZEBETH NITHIN 1 7 0 2 2 0 1 3 10 3 Female Daughter NA
ROZANNE MIRIAH NITHIN 2 3 0 1 2 0 2 0 3 4 Female Daughter NA

Premium Details
Basic Premium Total Tax Payable Total Premium
9760 1757 11517
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
/ varia ons, 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 communica on from you in this connec on within a period of 15 days of receipt of this le er, we would take it that the issued
policy is in order as per your proposal.
ICICI Lombard General Insurance Company Limited
MailingAddress: InterfaceBuildingNo.16,601-602,6thFloor,NewLinkRoad,Malad(West),Mumbai-400064
Registered Office Address: : ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025
Visitusatwww.icicilombard.com•Mailusatcustomersupport@icicilombard.com•TollFreeNo.: 18002666 •ChargableNo.: +918655222666
Insurance is the subject matter of solicitation. IRDA Reg. No. 115. CIN: L67200MH2000PLC129408 UIN: ICIHLGP22083V022122.