Risk Assumption Letter

Ref. No. : W337810131

02-Aug-2024

Dear Customer,

We value your relationship with ICICI Lombard General Insurance Company Limited and thank you for choosing us as
your preferred service partner.

Please find enclosed herewith your policy having policy number 4129/354811711/00/000 which has been issued based
on the details furnished to us by the insured:-

Insured Name SAPNA DEB Policy No. 4129/354811711/00/000 WORLD WID

Mailing Address A 7 RAMGARH AMBE TOWER, Period of Insurance / From : 14-Aug-2024
NAKTALA|||,KOLKATA,WEST Trip Particulars To : 09-Feb-2025 ,
BENGAL,INDIA - 700047 Days : 180
Contact Number 98******23 / 98******29 Geographical Scope WORLD WIDE
Email Id no********@gmail.com Plan Type GOLD_W_250
Nominee Name Novarun Deb Visa Type Non Immigrant
Insured Age 67.0 Alternative Policy No. 4129/W-187062140/00/000
Product Code / 4129 - Internationaltravel UIN No. ICITIOP22093V032122
Product Name
DOB 09-Jan-1957 Passport No Z7585782

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

Note:
Medical expenses due to Covid-19 is covered if contracted during the travel period as per policy terms and
conditions

This policy does not cover any injury/illness and complications arising out of pre-existing condition whether declared or
undeclared.

Pre-existing Condition shall mean and include any condition, ailment or injury or related condition(s) for which you had
signs or symptoms, and/ or were diagnosed, and/ or received medical advice/ treatment within 48 months prior to the
first policy issued by the insurer.

Important:This policy has been issued based on the details furnished by the policyholder. Please review the details
furnished in the policy certificate cum information sheet and confirm that same are in order. In case of any
discrepancy / variation, you are requested to write back to us immediately at customersupport@icicilombard.com or
contact our toll free no. 1800 2666 for necessary changes / rectifications. In the absence of any communication from
you with in period of 15 days of receipt of this document, the policy would be deemed to be in order and issued as per
your proposal. 102/20141021/66

SYSESB00172313344 02-Aug-2024 1 / 12
 Part 1 of the schedule - International Travel Insurance
Policy No. 4129/354811711/00/000 Travel Days 180
Period of Insurance From : 14-Aug-2024 Geographical Scope WORLD WIDE
To : 09-Feb-2025
GSTIN Number (Customer) - Invoice number 10082492681

Insured Name SAPNA DEB Date of Birth 09-Jan-1957

Mailing Address A 7 RAMGARH AMBE TOWER, Gender female
NAKTALA|||,KOLKATA,WEST
BENGAL,INDIA - 700047 Nominee Name Novarun Deb
Contact Number 98******23 / 98******29 Relationship with Son
Nominee
Email Id no********@gmail.com Passport No Z7585782
Sum Insured (USD) 250000 IL ID 160020788
Medical Treatment History NA Pre-Existing Disease None-None
Family Doctor Name & -
Address
Servicing Branch Mumbai Servicing Branch 414, ICICI LOMBARD
Address HOUSE, VEER SAVARKAR
MARG, NEAR SIDDHI
VINAYAK TEMPLE MAIN
GATE, PRABHADEVI,
MUMBAI, 400025,
MAHARASHTRA
ABHA No. -

Please Note: Any claim due to or arising out of pre-existing disease/ailment whether declared or
undeclared is not covered under the policy
The above records details given by the insured pursuant to Clause 8(2) of the IRDA (Protection of policy holder's
interest) Regulations, 2017. If the information shown above is found to be either incomplete or incorrect at the time of
claim, the same shall be construed as non disclosure of material information

Plan Name : GOLD_W_250

Benefits Sum Insured Deductibles
Accidental Death (Common Carrier) USD 5000 NA
Delay of Checked-In Baggage USD 100 6 Hours
Dental Expenses USD 300 USD 100
Emergency Cash Advance USD 1000 NA
Hijack Distress Allowance USD 125 per day for max 7 days 12 Hours
Loss of Passport USD 300 USD 50
Medical Cover(Includes Medical USD 100 (Total amount applicable for
Evacuation cost, Sublimit applicable Medical Expenses alongwith the
USD 250,000
for age 51 yrs and above. Please applicable extensions under Medical
refer policy wordings for details) Expenses)
Missed Flight Connection USD 500 3 Hours
Personal Accident USD 15000 NA
Personal Liability USD 100,000 5% of Actuals
Political Risk and Catastrophe
USD 7500 NA
Evacuation
Repatriation of Remains(Included in
USD 7500 NA
Medical Expenses)
Total Loss of Checked-In Baggage USD 500 NA
Trip Cancellation and Interruption USD 500 NA
Trip Delay Upto USD 500 6 Hours
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 Premium Details (`)
Basic Premium IGST Total Tax Payable Total Premium
% `
33860.02 18 6094.8 6094.80 39955
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.

GSTIN Reg.No HSN/SAC code The stamp duty of `1 paid vide deface no. CSD0220242018 dated
997136 GENERAL 10-Apr-2024 .
27AAACI7904G1ZN
INSURANCE SERVICES
Note: Sub-limits are not applicable for Schengen Countries

Date of Issue : 02-Aug-2024

Place of Issuance : MUMBAI

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 behalf of the beneficiary to obtain insurance benefit.
Please visit our website www.icicilombard.com for branch office address
Please refer to Part II and Part III of the policy schedule for detailed terms and conditions of the covers described
above.
Claims Procedure:
In the event of an accident or sudden illness or any other claim (cashless or reimbursement) caused by a contingency
covered under the insurance policy, immediately contact the helpline number stating the necessary details.
For claim intimation request to log in to the link below or Scan the QR Shared Below.
URL Link: https://fgaindia.com/FalckMLink/Register.aspx

Contact the ICICI Lombard 24hr Help Line number for assistance and registering your claim:
From USA and Canada: +18448711200 (Toll Free)
From Rest of the World: +91 124 4498778 (Call back facility)
In India: 1800 102 5721 (Toll free and accessible in India (available from Mon-Fri between 9am- 6pm))
Fax: + 91 124 4006674
E-mail: icicilombard@falck.com
Website : www.falck.com
Failure to send immediate notice on the happening of a loss resulting in a claim may prejudice the insured's claim under
the policy. The documents required in support of the claim shall be forwarded to the Company at the address
mentioned below immediately upon return of the Insured to the Republic of India and in no case beyond a period of 30
days from the date of return of the Insured to the Republic of India.
CLAIMS DEPARTMENT
ICICI LOMBARD
C/O Falck India Pvt Ltd
Upper Floor
The Peach Tree, Block - C
Sushantlok-I, Sector 43,Gurgaon,
Haryana-122015 (India)
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 IMPORTANT NOTE: This certificate has to be read in conjunction with the Terms & Conditions, coverage and
exclusions, which is available with ICICI Lombard. Kindly acknowledge receipt of this policy. In case you find any
variation against your proposal or any discrepancy in the policy, kindly contact us immediately. You may email us at
customersupport@icicilombard.com. In cases of any product related query, please call us at 1800 2666 (Toll Free and
accessible in India only).

Disclaimer: Insurance is the subject matter of solicitation. Please refer to policy wordings for terms and conditions,
coverage and exclusions.

ICICI Lombard General Insurance Company Limited

ICICI Lombard House,414,Veer Savarkar Marg,Near Siddhi Vinayak Temple,Prabhadevi,Mumbai 400 025.
IRDA Reg. No.115, CIN L67200MH2000PLC129408, Misc 129, www.icicilombard.com

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 INTERNATIONAL TRAVEL INSURANCE
Customer Information Sheet/ Know Your Policy

This document provides key information about your policy. You are advised to go through your policy document.
Description Policy Clause
S.No
(Please refer to applicable Policy Clause Number in next column) Number
1. Name of Insurance Product/Policy
INTERNATIONAL TRAVEL INSURANCE – Gold Plan
2. Policy Number
4129/354811711/00/000
3. Type of insurance Product/Policy
Both Indemnity and Benefit
4. Sum Insured (Basis)
Individual Sum Insured USD 250000 - where each member has a separate sum insured under
the policy
5. Expenses in respect of:
BENEFIT 1: MEDICAL COVER INCLUDING MEDICAL EVACUATION
• Reimbursement of expenses incurred in case of hospitalization due to an accidental Injury Benefit 1
or illness contracted or for emergency transportation and evacuation services necessitated
during the policy period.

Repatriation of Remains-
• In the unfortunate event of the death of the insured, reimbursement of expenses incurred Extension 2
for transporting the remains of the deceased Insured back to the Country/Place of
Residence or for a local burial or cremation in the country/place where death has occurred.

BENEFIT 2: DENTAL TREATMENT

• Reimbursement of expenses incurred for emergency dental treatment towards relief from Benefit 2
sudden acute pain and/or due to an accident during the policy period

BENEFIT 3: TOTAL LOSS OF CHECKED IN BAGAGGE

• Refund determined by market value, excluding Valuables, on the expected delivery date at Benefit 3
the destination port. In cases of multiple losses, the liability for each bag is limited to 50%
of the specified maximum liability specified in the Part I of policy schedule.

BENEFIT 4: Delay of Checked-In Baggage

• Fixed payout in case the checked-in baggage is delayed beyond the period specified in Benefit 4
policy certificate.

BENEFIT 5: LOSS OF PASSPORT

• Reimbursement for the prescribed fee and incidental expenses related to an emergency Benefit 5
certificate if the original passport is lost during the covered trip.

BENEFIT 6: PERSONAL LIABILITY

• Reimbursement of expenses towards payment of legal liability to a third party during the Benefit 6
covered trip arising out of accidental death, bodily injury or property damages to third party.

BENEFIT 7 - PERSONAL ACCIDENT

• We shall pay a lump sum payout in case of death or permanent total disablement or Benefit 7
permanent partial disablement of the insured during the policy period

BENEFIT 8 - HIJACK DISTRESS COMPENSATION

• Per day payout payable in the event of an Hijack of the Common Carrier/Public Carrier in Benefit 8
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 Per day payout payable in the event of an Hijack of the Common Carrier/Public Carrier in
which the insured is travelling as a fare paying passenger.

BENEFIT 9- EMERGENCY CASH ADVANCE

• Lump sum payout in case you are left with no travel funds following an incident of theft, Benefit 9
robbery, larceny etc. during the policy period

BENEFIT 12 - TRIP CANCELLATION AND INTERRUPTION Benefit 12

• Indemnification for financial loss incurred on cancellation of trip due to unexpected events
e.g. sickness, natural calamities, terrorist attack etc.

BENEFIT 13 - MISSED (FLIGHT) CONNECTIONS

• Payment of fixed amount in case you fail to access a connecting flight due to a delayed Benefit 13
arrival of the earlier flight for reasons beyond your control.

BENEFIT 14 - TRIP DELAY

• Payment of a specified sum per day for trip delays caused by specified contingencies, Benefit 14
including natural disasters, terrorism etc.

BENEFIT 20 - POLITICAL RISK AND CATASTROPHE EVACUATION EXPENSES Benefit 20

Reimbursement of expenses incurred for your return to your place of residence or the nearest
place of safety in such situations.

BENEFIT 21- ACCIDENTAL DEATH (COMMON CARRIER)- If the insured dies due to an injury Benefit 21
while boarding, disembarking or travelling as a passenger in any common carrier, payment is
provided to the nominee or legal heir as per policy schedule.

6. GENERAL EXCLUSIONS (APPLICABLE TO ALL COVERS UNDER THE POLICY): Section 3

• No compensation for events before or after the covered trip.
• Excludes fraudulent claims, intentional acts, or connivance by the insured.
• Restrictions on benefits related to medical, dental, personal liability, accident, trip
cancellation, interruption, delay, compassionate visit, and emergency hotel extension if:
• Traveling against medical advice.
• Receiving or waiting for specified medical treatment.
• Terminal prognosis received.
• Traveling for treatment.
• Participating in military operations.
• Involvement in intentional self-injury, suicide, intoxication, criminal acts, murder, or assault.
• Claims related to venereal disease or mutant derivatives.
• Excludes war-related events, confiscation, and nuclear incidents.
• Excludes claims related to professional or semi-professional sports activities unless
declared and agreed upon.
• No claims related to hazardous activities unless specifically covered.
• No claims for contingencies occurring after 90 days from the start of cover for immigrant
visa travelers.
• Excludes compensation for illness or injury resulting from the insured's criminal intent

Cover specific exclusions-

Exclusion applicable to benefit 1 and extensions therein-
• No coverage for pre-existing medical conditions/ailments, whether declared or undeclared. Benefit 1
• Exclusion of orthopedic, degenerative, and oncological diseases, except for
Life-Threatening Medical Conditions.
• No coverage for dental illness or injury, cosmetic treatments, and reconstructive plastic
surgery.
• Excludes treatment for general debility, convalescence, spa, health resort, or similar
institutions.
• Pregnancy, childbirth, voluntary termination, miscarriage, fertility treatment not covered.
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 • Routine physical tests not related to illness or injury are not covered.
• Vaccination unless post-animal bite and excludes rehabilitation, physiotherapy, prosthetics.
• Self-inflicted illness or injury is not covered.
• Excludes costs of spectacles, contact lenses, hearing aids.
• Donor hospitalization expenses not covered.
• Excludes naturopathy, ayurvedic, homeopathic, unani medicine, and other alternative
therapies.
• Circumcision covered only if necessary for illness or due to an accident.
• Weight management services, vitamins, and tonics for weight reduction programs not
covered.
• No coverage for sex change treatment, surgery, or related complications.
• Personal comfort, convenience, hygiene items, and services are excluded.
• Alternative treatments are not covered.

Dental Treatment
• Excludes payment for any deductible mentioned in the Policy Schedule.
• No coverage for treatment of pre-existing conditions under this benefit.
• Excludes cementing or fixation of tooth or teeth bridges.
Benefit 2
• Dental treatment does not cover orthopedic, degenerative, or oncological diseases.
• No coverage for beauty, cosmetic treatment, or reconstructive plastic surgery.
• Excludes rest or recuperation at spas, health resorts, sanatoriums, or similar institutions.

Total Loss of Checked-In Baggage

• Excludes any deductible amount mentioned in the Policy Schedule for the specified benefit.
• No liability for losses related to valuables.
Benefit 3
• Does not cover partial loss of contents in checked-in baggage.
• Excludes losses from delay, detention, or confiscation by customs or other authorities.
• No coverage for loss due to total or partial damage to the contents of checked-in baggage.

Delay of Checked-In Baggage

• No payment for delay if it doesn't exceed the deductible time specified in Part I of the
Policy.
• Excludes delay for part of total checked-in baggage related to the insured trip ticket.
• No coverage for delay due to detention, confiscation by common carriers, customs, Benefit 4
government agencies, or other authorities.
• Delay attributable to damage requiring examined delivery by the common carrier is not
covered.

Personal Liability Benefit 6

• Excludes any deductible amount specified in the Policy Schedule for Benefit 6.
• No coverage for legal liability related to professional services rendered by the insured.
• Excludes liability for injury or damage during business activities or in the course of
business by the insured.
• Liability assumed by agreement, not present without such agreement, is not covered.
• Excludes liability from acts of nature and atmospheric disturbances, intentional or illegal
acts by the insured.
• Does not cover fines, penalties, punitive, or exemplary damages.
• No coverage for liability arising from the use of vehicles, aircraft, watercraft, or specific
insurance elsewhere.
• Liability for personnel engaged by the insured, personal liability toward family, relations,
and traveling companions is excluded.
• Excludes liability for transmission of illness, personal injuries, mental anguish, or shock.
• No coverage for infringement of intellectual property rights, possession of animals, or
ownership of vehicles involving specific activities.
• Liability arising from alcohol/drug use (except as medically prescribed) or addiction is not
covered.
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 • Excludes liability from the supply of goods/services, ownership/occupation of land or
buildings, and contingencies in the country of residence.

Personal Accident
• No compensation under multiple benefit categories for one accident/event. Benefit 7
• Excludes medical expenses and compensation for death or disability from intentional
self-injury, suicide, or illness-related incidents.
• No coverage under the influence of intoxicating substances.
• Excludes coverage while engaging in aviation, ballooning, or traveling in a balloon or aircraft
(except as a passenger).
• Does not cover events directly or indirectly caused by war, invasion, hostilities, civil war,
rebellion, revolution, or nuclear-related incidents.

Hijack Distress compensation

• If you are in any way involved principally or as an accessory in causing or planning the Benefit 8
hijack

Trip Cancellation & interruption

• Losses due to actions by Common carrier, travel agent, air transport authority, Benefit 12
Government or attributed to perils are not covered.

Missed (Flight) Connection

• No claim is payable if the time gap between the scheduled arrival of the previous flight and Benefit 13
the departure of the next flight is less than 3 hours, except for reimbursing cancellation
charges and additional transportation costs for the missed flight, or if the flight is missed
due to the insured's deviation from the originally scheduled route or advance intimation of a
possible delay

Political Risk and Catastrophe Evacuation

• Insured violating the laws or regulations of the country from which he is to be evacuated. Benefit 20
• Failure to produce or maintain immigration, work, residence or similar visas, permits or
other documentation.
• Failure to honour any contractual obligation or bond or to obey any conditions in a license
• Insured being a national of the country from which he is to be evacuated.
• Circumstances that resulted in the Insured's evacuation being in existence prior to the
Insured entering the country or their occurrence being foreseeable to a reasonable person
before the Insured entered the country.

Accidental Death (Common carrier)

• Amounts related to medical expenses. Benefit 21
• Payment of compensation in respect of death.
• Arising from intentional self-Injury/ suicide/ attempted suicide.
• Whilst the Insured is under the influence of intoxicating liquor/ drugs.

7. Waiting period
• Time period during which specified diseases/treatments are not covered
• It is counted from the beginning of the policy coverage.

Initial waiting Period: Not Applicable

Specific Waiting periods (Not applicable for claims arising due to an accident):
Not Applicable
Pre-existing diseases: Not Applicable
8. Financial limits of coverage Benefit 1
Extension 3
Sub-limit(It is a pre- defined limit and the insurance company will not pay any amount
in excess of this limit)
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 The policy will pay only up to the limits specified against the covers in Part 1 of the policy
schedule.

Co-payment (It is the specified amount/percentage of the admissible claim amount to

be paid by policyholder/insured)
Not applicable

Deductible (It is a specified amount:

• Up to which an insurance company will not pay any claim, and
• Which will be deducted from total claim amount (if claim amount is more than the
specified amount)
Deductible is specific to each coverage and is outlined in Part 1 of the policy schedule.

Any other limit as applicable

• Sub-limit A - For policies with sum insured over US$ 100,000, the benefit of medical
expenses is restricted to US$ 100,000 per sickness or accident leading to one or more
hospitalizations
• Sub-limit B - For persons aged 51 years and above, maximum eligible medical expenses
are as follows:
o Hospital Room and boarding, and Hospital Misc. Expenses* – maximum US$ 1,800 per
day up to 30 days.
o Intensive Care Unit/Emergency Department - maximum US$ 3,250 per day up to 7
days.
o Surgical treatment – maximum up to US$ 15,000
o Anaesthetist services – up to 25% of surgical treatment.
o Physician’s visit – maximum US$ 100 per day up to 10 visits.
o Diagnostic and pre-admission testing – maximum US$ 1000.
o Ambulance services – maximum US$ 500.
*Miscellaneous expenses: Includes but not limited to cost of medicines/ Pharmacy/ Drugs/
Supplies, nursing charges, external medical appliances as prescribed in writing by a registered
Medical Practitioner as necessary and essential as part of the treatment on actual, Blood
storage & processing charges, other services which are not part of any other above given heads

9. Claims/Claims Procedure
Claims (if approved) shall be paid through Cashless facility or Reimbursement of benefits, up
to an amount as specified for said cover

Claim section-
Turn Around Time(TAT) for claim settlements- Claim Procedure-
Claims will be settled within 30 days from the receipt of last necessary documents. Reasons General –
for rejections (if any) will be provided. Settlement/
Rejection of
Claims Procedure- claims
Network hospital details
Claims will be settled within 30 days from the receipt of last necessary documents. Reasons
for rejections (if any) will be provided.

HELPLINE NUMBERS- Claims- Claims

In USA and Canada: + 1 844 871 1200(Toll-free) Procedure general
From the rest of the world: +91 124 4498778 (With Call back facility)
In India: 1800 102 5721 (Toll-free and accessible in India only)
Fax: +91 124 4006674
E-mail: icicilombard@falck.com
E-claim web link: https://fgaindia.com/FalckMLink/

Customer needs to reach out to Falck for assistance. Once the necessary details are
obtained, Falck will provide the claim form & procedure to the customer.
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 10. Policy Servicing Part III of policy
• You may contact us through our website www.icicilombard.com (Customer Support section) schedule-
or call on our toll Free no: 1800 2666, or email us at customersupport@icicilombard.com. Grievances
11. Grievances/Complaints

In case the Insured is aggrieved in any way, the Insured should do the following:
• For resolution of any query or grievance, Insured may contact the respective branch Part III of policy
office of The Company or may call on our toll free no. 1800 2666 or email us at schedule-
customersupport@icicilombard.com or write to us at ICICI Lombard General Insurance Grievances
Company Ltd. ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak
Temple, Prabhadevi, Mumbai- 400025.
• There is an interactive voice response (IVR) facility for senior citizens’ grievance redressal
for easy and faster resolution.
• If you are not satisfied with the resolution provided, you may approach us at the
subsection “Grievance Redressal “on our website www.icicilombard.com (Customer Support
section).
• In case your complaint is not fully addressed by the insurer, you may use the Integrated
Grievance Management System (IGMS) for escalating the complaint to IRDAI. Through
IGMS you can register your complain online and track its status. For registration please
visit IRDAI website www.irda.gov.in.
• If the issue still remains unresolved, you may, subject to vested jurisdiction, approach
Insurance Ombudsman for the redressal of the grievance.
12. Things to remember
Free Look cancellation: You may cancel the insurance policy if you do not want it, within 15
days from the beginning of the policy by giving Us 15 days’ written notice for the cancellation
by registered post, and then We shall refund premium on short term rates for the unexpired
Policy Period. Not applicable for policies with less than 1 year tenure. (Please refer to the
Part III of policy
Policy Wordings and the Prospectus for more details)
schedule

If you wish to cancel the Policy, you may contact us through Our website www.icicilombard.
com (Customer Support section) or call us at toll Free no: 1800 2666, or email to
customersupport@icicilombard.com.

Policy renewal: Except on grounds of fraud, moral hazard or misrepresentation or

Part III of policy
non-cooperation, renewal of your policy shall not be denied, provided the policy is not
schedule
withdrawn.
13. Your Obligations
Disclosure to information norm- The Policy shall be void and all premium paid hereon shall be
General conditions
forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure
of any material fact

Declaration by the policy holder:

I have read the above and confirm having noted the details

Place:

Dated: Signature:

NOTE: In case of any conflict, the terms and conditions mentioned in the policy document shall prevail.
Global Assistance E-Card

Name : SAPNA DEB

Policy No. : 4129/354811711/00/000

Date of Birth : 09-Jan-1957

Valid From : 14-Aug-2024

Valid To : 09-Feb-2025