ADDITIONAL INFORMATION REQUEST FORM

Ref : IHPN-05821873 Date: 29-DEC-11

To, KANDULA RAMACHANDRA REDDY HOUSE NO 25-242 ,SANJEEVA NAGAR, N/A Nandyal,Andhra Pradesh-518501 Dear Sir/Madam, Claim Number Claim of UHID Policy Number Coverage Period Date of Admission Date of Discharge Diagnosis Hospital Name AL Number

220100171769 KANDULA RAMACHANDRA REDDY IHPN-05821873/01 4034I/CHC/05588151/00/000 18-OCT-10 to 17-OCT-11 05-OCT-11 20-OCT-11 Superficial injury of head;Fracture of coccyx S G R HOSPITALS

On behalf of ICICI Lombard General Insurance Co. Ltd, we thank you for preferring ICICI Lombard as your health insurance partner.With reference to your claim intimated in our office we request you to send the following documents for further processing of your claim.

Sr No 1

Query Documents Not Received

Investigation Reports Not Received

Payment Receipts Not Received

Remarks Kindly furnish the details of the incident leading to the injury including the time, date and place on a treating doctor's letter head along with a copy of MLC as it is mandatory to process the claim as this is a case of RTA. Kindly submit all the X-Ray and other investigation reports IN ORIGINAL supporting the diagnosis as well as towards the bills furnished as the same are not furnished. Kindly furnish the original payment receipt for the final hospital duly stamped and signed by the hospital authorities FOR RS.51050/-(ADVANCE), RS.47200/(BALANCE) as mentioned on final bill as it is mandatory to process the claim.

ALL ABOVE MENTIONED DOCUMENTS TO BE SUBMITTED IN ORIGINAL Please submit the documents to us within 15 days from the date of receipt of this letter at the below mentioned address to ensure speedy service. Please note that the conclusion regarding the eligibility of coverage /admissible amount can only be arrived on submission of the above mentioned documents. In case of any further clarification, please feel free to write to us at the below mentioned address. Please quote our claim number as mentioned above in all your claim correspondences. We look forward to your co-operation in helping us serve you better. P.S.: Effective June 01, 2011 ICICI Lombard Health Care office would be shifted to new location, please find communication address details below.

Head Customer Service For ICICI Lombard General Insurance Company Ltd ICICI LOMBARD HEALTH CARE Address: Old Address: ICICI Lombard GIC, ICICI Lombard Health Care, TGV Mansion, 6th Floor, New Address: ICICI Lombard GIC, ICICI Lombard Health Care, ICICI Bank Tower, Email: ihealthcare@icicilombard.com Contact Us

1800 209 8888 Toll Free Fax No.: 1800 209 8880
Toll Free Helpline No.:

Plot No. 6-2- 1012 Khairatabad, Hyderabad - 500004, Andhra Pradesh

Plot No 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad 500032, Andhra Pradesh

Fax No. Line 1: Fax No. Line 2:

040-66989160 040-66989161

i Health Care is now ICICI Lombard Health Care"

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