Risk Assumption Letter
Date :23-Mar-2010
Dear Sir / Madam,
We thank you for placing your confidence with ICICI Lombard for your health insurance needs.
Please find attached herewith Policy No. :4034i/FPT/05217048/00/000, which has been issued based on the details furnished by the
applicant.
Name of the Proposer : SHASHI KAPUR
2E-21 B P HINDUSTAN VACCUM
GLASS COLONY NIT
FARIDABAD NEAR PANCKULIA
Mailing Address :
ROAD
FARIDABAD - 121001
HARYANA
Mobile No. : 9312285177
Telephone No. : (R): 1292415828, (O): 1292415828
Email ID : [email protected]
Product Name : Family Protect 2007
No. of Members : 2
Policy Duration (years) : 2
Age of the eldest member (years) : 54
Period of Insurance
From 20-Mar-2010 to 19-Mar-2011
(Year 1 )
Period of Insurance
From 20-Mar-2011 to 19-Mar-2012
(Year 2 Annual Autorenewal )
Insured Details
Age
Name of the Insured(s) Relationship with Proposer Pre-Existing illness/injury Sum Insured
Year Months
NEELAM KAPUR SPOUSE 49 6 NONE
300000
SHASHI KAPUR SELF 54 3 NONE
Please go through the details as furnished in the format and the policy document. Please confirm that same are in order.In case there is any
discrepancies / variations, you are requested to write back to us immediately at [email protected] or contact at 24
hour helpline number 1800 209 8888 for necessary changes / rectification.
In the absence of any communication from you in this connection within a period of 15 days of receipt of this letter, We would take it that
the issued policy is in order and as per your proposal.
Thanking You,
Yours Sincerely,
Authorized Signatory
For ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED
COPY
ICICI Lombard Health Care
Policy Number : 4034i/FPT/05217048/00/000
PREAMBLE: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, Declaration and Annexure thereto together with any
statement, report or other document leading to the issue 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 in proof to the satisfaction of the Company of the compensation having become payable as
set out in Part I of the schedule to the title Policy, the Sum Insured/appropriate benefit will be paid by the Company.
Policy Issuing Office Zenith House, Keshavrao Khade Marg, Mahalaxmi, Mumbai - 400034 Policy Issued On 23-Mar-2010
Part I Of Schedule
Details of Policy Holder/ Proposer:
Contact No(s) (R): 1292415828, (O): 1292415828
Policy No 4034i/FPT/05217048/00/000
Mobile No 9312285177
Period of Issuance From 00:00 hrs 20-Mar-2010 to
(Year 1 ) Midnight of 19-Mar-2011
Name of the Proposer SHASHI KAPUR Period of Issuance
From 00:00 hrs 20-Mar-2011 to
(Year 2 Annual
Midnight of 19-Mar-2012
Autorenewal )
2E-21 B P HINDUSTAN VACCUM
GLASS COLONY NIT FARIDABAD
Correspondence Address NEAR PANCKULIA ROAD Email Address [email protected]
FARIDABAD - 121001
HARYANA
Details of Family Members covered under the Policy :
Age
Name of the Insured(s) Gender Relation Sum Insured Pre-Existing illness/injury Health Member ID No.
Year Months
NEELAM KAPUR 49 6F SPOUSE NONE IHPN-05437511/01
300000
SHASHI KAPUR 54 3M SELF NONE IHPN-05437511/02
Premium Schedule :
Year 1 Year 2
Basic Secondary and Basic Secondary and Total
Plan Name Service Education Service Education Premium
Premium Higher Education Premium Higher Education (Rs.)
Tax (Rs.) Cess (Rs.) Tax (Rs.) Cess (Rs.)
(Rs.) Cess (Rs.) (Rs.) Cess (Rs.)
FPR 2007 2
Adults 2 11378.24 1137.82 22.76 11.38 7585.49 758.55 15.17 7.59 20917
Years
For ICICI LOMBARD GENERAL
INSURANCE COMPANY LIMITED Service Tax Reg. No.: GIS/MUMBAI-I/1528/2001
Service Tax Code Number - AAACI7904GST001
Category : General Insurance Business Services
Authorized Signatory
Important Note :
l This schedule and the attached policy shall be read together as one contract or any word or expression to which a specific meaning has
been attached in any part of this policy or of the schedule shall bear the same meaning wherever it may appear.
l Please note that you have availed for auto renewal option against this policy, for complete details please refer to the enclosed letter.
IMPORTANT :Insurance benefit shall become voidable at the option of the Company, in the event of any untrue or incorrect statement,
misrepresentation, non description or non-disclosure 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 is excluded from the scope of this policy
subject to applicable terms and conditions. Refer to attached Part II and III of the schedule for the terms and conditions.All disputes are
subject to the jurisdiction of Mumbai High Court only.
The stamp duty of Rs.1 (One Only) paid in cash or by demand draft or by pay order,vide Receipt/Challan no.38201 dated 12-Jan-2010
On the happening of a claim, please call immediately at 1800-209-8888 (Toll Free) or e-mail us at [email protected]
You can also write to us at ICICI Lombard GIC, ICICI Lombard Health Care, TGV Mansion, 6th Floor, Plot No. 6-2-1012, Khairatabad,
Hyderabad ' 500004, Andhra Pradesh.
ICICI Lombard General Insurance Company Ltd
Corp Office: Zenith House, Keshavrao Khade Marg, Mahalaxmi, Mumbai-400034.
Mailing Address: 4th Floor, Interface 11, Off Malad Link Road, Behind Goregaon Sports Club, Malad(w), Mumbai- 400064.
Toll Free 24 X 7 Call Center No 1800-209-8888. E-mail : [email protected]
Premium Certificate
For the purpose of deduction under section 80D of Income Tax amendment act, 1961 and any amendments made thereafter.
To,
SHASHI KAPUR
2E-21 B P HINDUSTAN VACCUM GLASS COLONY NIT FARIDABAD NEAR PANCKULIA ROAD
FARIDABAD - 121001
HARYANA
FARIDABAD
121001
HARYANA
This is to certify that the Company has received the premium of Rs. 20917 for Health insurance coverage under the "Health Insurance
Policy" policy no 4034i/FPT/05217048/00/000.
The Product is eligible for deduction u/s 80 D of the Income Tax,1961 and any amendments made there to.
Financial Year 2009 - 2010
314.76
(Rs.)
Collection
Financial Year 2010 - 2011 191820
10444.19 No:
(Rs.)
Collection 20-Mar-
Financial Year 2011 - 2012
10158.05 Date 2010
(Rs.)
Total Premium (Rs.) 20917
For ICICI Lombard
General Insurance Co. Ltd.
Authorized Signatory
Note:
l 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.
Information Sheet
To,
SHASHI KAPUR
Date :22-Mar-2010
2E-21 B P HINDUSTAN VACCUM GLASS COLONY NIT FARIDABAD NEAR PANCKULIA ROAD
FARIDABAD - 121001
HARYANA
FARIDABAD
121001
HARYANA
Sub : Verbal proposal for health insurance policy from ICICI Lombard GIC Ltd.
Dear SHASHI KAPUR,
Thank you for choosing ICICI Lombard Health Insurance Policy. It is a pleasure to have you as our esteemed customer. This letter is with
reference to your tele-conversation dated 21-Mar-2010 with the representative of ICICI Lombard GIC Ltd for the purchase of Health
Insurance Policy. The information provided by you has been mentioned below and the Family Protect 2007 policy No :
4034i/FPT/05217048/00/000 has been issued based on the same. You are requested to kindly go through the details mentioned below vide
the 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 at
our call center no 1800-209-8888 within 15 days of issue of this letter.
l Name of the Proposer : SHASHI KAPUR
l Address : 2E-21 B P HINDUSTAN VACCUM GLASS COLONY NIT FARIDABAD NEAR
PANCKULIA ROAD
FARIDABAD - 121001
HARYANA
l Details of the insured:
Relationship with Name of Pre-Existing Sum
Name Sex Date of Birth Tenure
proposer illness Insured
NEELAM KAPUR F 19-Sep-1960 SPOUSE NONE
300000 2
SHASHI KAPUR M 10-Dec-1955 SELF NONE
l Premium : 20917
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 of
accident, 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, intoxicating
substances or drugs as well as intentional self injury/attempted suicide/suicide.
e. War, riot, strike, nuclear weapons induced hospitalization.
f. Certain 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 please
refer to policy wordings provided along with the policy kit."
Reference No: IHPN-05437511
Sr. No. Insured Name Age Health Checkup Date Authorization No. Card No.
1 NEELAM KAPUR 49 IHPN-05437511/01
2 SHASHI KAPUR 54 IHPN-05437511/02
Policy No.: 4034i/FPT/05217048/00/000 Valid up to: 19-Mar-2012
Name : NEELAM KAPUR
Policy No. : 4034i/FPT/05217048/00/000
Card No. : IHPN-05437511/01
Gender : Female Age : 49 Dob : 19-Sep-1960
Valid Upto : 19-Mar-2012
Name : SHASHI KAPUR
Policy No. : 4034i/FPT/05217048/00/000
Card No. : IHPN-05437511/02
Gender : Male Age : 54 Dob : 10-Dec-1955
Valid Upto : 19-Mar-2012
