(a) Policy Schedule (Policy Certificate)

POLICYALL 2 2 1 1
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 and Declaration together with any statement, report or other document leading to the issuance 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 on proof to the satisfaction of the Company of the compensation having become payable as set out
in Part I of Policy to the title of the said person or persons claiming payment or upon the happening of an event upon which one or more benefits become payable
under this Policy, the Sum Insured/appropriate benefit will be paid by the Company.

Part I of Policy: Policy Schedule

ICICI Lombard Group Health Policy no. 4177i/MSTR/291415383/00/000 has been issued at Mumbai, by ICICI Lombard General Insurance Company Limited to
the Policyholder, 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 forming Part I of the schedule to the said policy.

Proposer Name 34162 SANJEEV KUMAR Product name Health Shield 360
Address G BLOCK G PKT SEC ROHINI DELHI Plan Name ICICI_HS360_OPTA_10LTO50L
INDIA DELHI, DELHI, DELHI - 110085 Policy No. 4177i/IBANK/305095570/00/000
Contact No. 9810044103 Period of Insurance From 00:00 hrs 02-Sep-2023 To 23:59 hrs
01-Sep-2024
Email Address SANJEEV.VALECHA@RELIANCEADA.COM Policy Tenure 1
Nominee Name DINESH VALECHA Alternate Policy No.
LAN No. NA
Relationship With MOTHER Policy Issuing Office Prabhadevi
Policyholder
Appointee Name Policy Issued On 02-Sep-2023
Nominee Age 49 Years 0 Month Previous Policy No.
GSTIN No. (Customer) Invoice No. 10092364372
Servicing Branch Address 414, ICICI LOMBARD HOUSE, VEER Servicing Branch Name Mumbai
SAVARKAR MARG, NEAR SIDDHI VINAYAK
TEMPLE MAIN GATE, PRABHADEVI, MUMBAI,
400025, MAHARASHTRA

Politically Exposed Person (PEP)/close relative of PEP: No

Insured's Date of Age Date of Gender Relation With Annual Sum Insured Pre-existing Illness/ Special
0
Name(s) Birth Y M Joining Proposer (` ) Injury Condition
KUNAL
07-Sep-1998 24 11 02-Sep-2023 Male SON 1000000 None None
VALECHA
Plan Details
The stamp duty of ` 0.5 paid
Plan Name Additional Sum Sub-limit Voluntary GSTIN Reg. No HSN/SAC code
vide deface no.
Insured (`) Deductible (`) CSD6142023662 dated
997133 GENERAL 20-Feb-2023
ICICI_HS360_OPTA
0 None 0 27AAACI7904G1ZN
INSURANCE
_10LTO50L_1A
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.
Premium Details (` )
IGST
Basic Premium Total Tax Payable Total Premium
% `
3444.92 18 620.08 620.08 4065

2 Agent Details
Signature Not Verified
Agent ICICI BANK Agent Agent
CA0112 0018002666
Name LIMITED Code contact No.
Digitally signed
LOMBARD GENERAL
by DS ICICI
INSURANCE CO LTD 1
GSTIN Reg. No HSN/SAC code Date: 2023.09.02 15:43:20
The stamp duty of ` 0.5 paid IST
vide deface no. CSD6142023662
997133 GENERAL INSURANCE dated 20-Feb-2023
27AAACI7904G1ZN
SERVICES
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Health Shield 360 UIN - ICIHLGP22083V022122
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 1/4
Mumbai -400025.
 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.

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, 1st, 4th (Half), 5th and 6th floors, Varun Towers- II, Opp. Hyderabad Public school, Begumpet, Hyderabad District Hyderabad,Pin
code -500016 Telangana.

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

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Health Shield 360 UIN - ICIHLGP22083V022122
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 2/4
Mumbai -400025.
 Tax Certificate
2

To
34162 SANJEEV KUMAR
G BLOCK G PKT SEC ROHINI DELHI INDIA DELHI
DELHI
DELHI - 110085
ANNUAL
Subject: Premium certificate for the purpose of deduction under section 80D of Income Tax
Act, 1961 and any amendments made thereafter.

Dear 34162 SANJEEV KUMAR,

This is to certify that the Company has received the premium dated Sep 02, 2023 for Health
insurance coverage under "Health Insurance Policy" with the following details.

Policyholder's 34162 SANJEEV KUMAR 4177i/IBANK/305095570/0 Policy Number

Name 0/000
Policy Start DateSep 02, 2023 Policy End Date Sep 01, 2024
Plan Name ICICI_HS360_OPTA_10LT Total Premium Paid 4065
O50L_1A (`)
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
% `
3444.92 18 620.08 620.08 4065
Financial Year Amount (`)
2023-2024 4065.00
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.
In case You find any variations against Your proposal or any discrepancy in the Policy, please
contact Us immediately on the numbers available on our website www.icicilombard.com Or call
on our toll free no. 1800 2666
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Health Shield 360 UIN - ICIHLGP22083V022122
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 3/4
Mumbai -400025.
Name : KUNAL VALECHA
Policy No. : 4177i/IBANK/305095570/00/000
Card No. : 169531880
Gender : Male Age : 24 DOB : 07-Sep-1998
Valid Upto : 01-Sep-2024

109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Health Shield 360 UIN - ICIHLGP22083V022122
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 4/4
Mumbai -400025.