(a) Policy Schedule (Policy Certificate)

POLICYALL 2 2 1 1
Proposer Name VEMURI VIJAYA KUMAR Policy No. 4128i/HSHA/100257428/05/000
Address PLOT NO. 23, PHASE-1, SANCHARPURI Period of Insurance From 00:00 hrs 07-Mar-2022 To 23:59 hrs
COLONY,NEW BOWENPALLY, HYDERABAD, 06-Mar-2023
TELANGANA - 500011 Policy Tenure 1
Contact No. 8008989037 LAN No. NA
Email Address VEMURIVIJAY@GMAIL.COM Policy Issuing Office Prabhadevi
Nominee Name Policy Issued On 19-Feb-2022
Relationship With Previous Policy No. 4128i/iHA/100257428/04/000
Policyholder
Appointee Name Nominee Age NA
GSTIN Number (Customer) Servicing Branch Name Mumbai
Servicing Branch Address 414, ICICI LOMBARD HOUSE, VEER Invoice Number 1002221326646
SAVARKAR MARG, NEAR SIDDHI VINAYAK
TEMPLE MAIN GATE, PRABHADEVI, MUMBAI,
400025, MAHARASHTRA

Insured's Date of Age Date of Gender Relation With Annual Sum Pre-existing Optional Special
Name(s) Birth Y M Joining Proposer Insured (`) Illness/ Injury Add-on Cover* Condition
VEMURI VIJAYA
31-Oct-1968 53 4 03-Mar-2010 Male SELF 700000 None None None
KUMAR
Plan Details
The stamp duty of ` 1 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
HSH_Individual_Adult_
350000 None 0 27AAACI7904G1ZN INSURANCE
1Year
SERVICES
Premium Details (`)
IGST
Basic Premium Total Tax Payable Total Premium
% `
18121.19 18 3261.81 3261.81 21383

SYSESB00172313346
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

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE COMPANY
LIMITED
Date: 2022.02.19 11:15:29
IST
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP22096V062122
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 1/3
 Tax Certificate
2

To
VEMURI VIJAYA KUMAR
PLOT NO. 23, PHASE-1, SANCHARPURI COLONY,NEW
BOWENPALLY
HYDERABAD
TELANGANA - 500011
ANNUAL
Subject: Premium certificate for the purpose of deduction under section 80D of Income Tax
Act, 1961 and any amendments made thereafter.

Dear VEMURI VIJAYA KUMAR,

This is to certify that the Company has received the premium dated Mar 07, 2022 for Health
insurance coverage under "Health Insurance Policy" with the following details.

Policyholder's VEMURI VIJAYA KUMAR Policy Number 4128i/HSHA/100257428/0

Name 5/000
Policy Start Date Mar 07, 2022 Policy End Date Mar 06, 2023
Plan Name HSH_Individual_Adult_1Y Total Premium Paid 21383
ear (`)
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
% `
18121.19 18 3261.81 3261.81 21383
Financial Year Amount (`)
2021-2022 21383.00
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 ICICI Lombard Complete Health Insurance UIN - ICIHLIP22096V062122
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 2/3
Name : VEMURI VIJAYA KUMAR
Policy No. : 4128i/HSHA/100257428/05/000
Card No. : 100185581
Gender : Male Age : 53 DOB : 31-Oct-1968
Valid Upto : 06-Mar-2023

109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP22096V062122
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 3/3