Risk Assumption Letter
Date :02• May•2024
Dear Sir / Madam,
We thank you for placing your confidence with ICICI Lombard for your health Insurance needs.
Please find attached herewith Policy No.: 4128i/iH/1089144241/00/000 which has been issued based on the
details furnished by the applicant
Name of the proposer: Hilki Bharat Choragudi
Mailing Address: Flat 103, A01 Tower, Sahabhavana Township, GSI Road,
Bandlaguda, Hyderabad, 500068
Mobile No.:
Telephone No.: 7981160147
Email ID: [email protected]
Product Name: iHealth
No. of Members : 3
Policy Duration (years): 1
Age of the eldest member 67
(years):
From 02• May •2024 7 R 01• May •2025
Policy Period
Insured Details
Name of the Relationship with Age Pr e- Existing Annual Sum Optional Add- on Su b- Vo lun ta ry
Insured( s) Proposer Y e a r Mont hs i l lness / injury Insured C ove r l imit D e duct ible
Rajasree Ch Mother 61 4 NA
Madhuri Peiyanka Spouse 35 3 NA 1000000 None 0
Hilki Bharat Choragudi Self 37 5 NA
Please go through the details as furnished in the format and the policy document and confirm that same are in order.
In case there are any discrepancies, you are request to write back to us immediately at
[email protected] or contact at 24 hour helpline number 1800 2666 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. Thereon, any non disclosure related to
PreExisting illness/injury would result in rejection of claims and cancellation of policy
Thanking You,
Yours Sincerely,
Authorised Signatory
ICICI Lombard General Insurance Company Limited,IRDA Regn.No.115
ICICI Lombard Complete Health Insurance
Policy Number : 4128i/iH/108915572/00/000
ICICI Lombard General Insurance
Company LTD., IRDA Regn. No. 115 ,
ICICI LOMBARD HOUSE , 414, Policy Issued
Policy Issuing Office 02May2024
Veer Savarkar Marg, Near Siddhi On
Vinayak Temple, Prabhadevi, Mumbai
400 025
Part I Of Schedule
Details of Policy Holder/ Proposer:
Contact No(s) (R):
Policy No. 4128i/iH/1089144241/00/000
Mobile No 8939742475
Policy From 00:00 hrs 02May •2024 to
Name of the Applicant Hilki Bharat Choragudi
Period Midnight of 01May2025
103, A01 Tower, Sahabhavana
Township, GSI Road, Bandlaguda,
Nagole
Correspondence
Hyderabad Email Address [email protected]
Address
Telangana • 500068
Relationship of Nominee
Name of Nominee
with Proposer
Details of Family Members covered under the Policy :
Name of the Date Of Age Annual Sum Pre-Existing Health Member ID Optional Add-on Sub- Voluntary
Gender Relation
Insured(s) Joining Years Months Insured illness/injury No. Cover limit Deductible
Hilki Bharat Ch 02May2024 36 6 M Self None 102965007
Madhuri Priyanka 02May2024 35 5 F Spouse 1000000 None 102965008 None 0
Rajasree Ch 02May2024 60 10 F Mother 102965009
Premium Schedule :
Secondary and
Basic Premium Service Tax Education Cess Total Premium
Plan Name Higher Education
(Rs.) (Rs.) (Rs.) (Rs.)
Cess (Rs.)
Senior Health i Health 65015.38 11702.76 0 0 76,718.14
For ICICI LOMBARD GENERAL INSURANCE Service Tax Registration No. : GIS/MUMBAI
COMPANY LIMITED I/1528/2001
Service Tax Code Number : AAACI7904GST001
Category: General Insurance Business Services
Authorised Signatory 00440005.
Important Note :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.
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 nondisclosure 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 preexisting 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 competent courts of INDIA
The stamp duty of Rs 1.00 paid in cash or by demand draft or by payorder,vide Receipt/Challan no. 4063856
In the event of a claim, please call our 24X7 tollfree number 1800 2666 or email us at
[email protected].
Please send the relevant documents to: ICICI Lombard Health Care,Plot No:12 ,ICICI Bank
Towers ,Nanakramguda ,Gachibowli, Hyderabad 500032
ICICI Lombard General Insurance Company Ltd
Corp Office:ICICI Lombard General Insurance Company LTD., IRDA Regn. No. 115 , ICICI
LOMBARD HOUSE , 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025
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 18002666. Email :[email protected]
Premium Certificate
For the purpose of deduction under section 80D of Income Tax amendment act, 1961 and any amendments
made thereafter.
To,
Hilki Bharat Choragudi,
Flat No:103, A01 Tower, Rajiv Swagruha Sahabhavana Township, GSI Road, Bandlaguda,Nagole
Hyderabad,
Telangana • 500068.
This is to certify that the company has received the premium of Rs. 76,718.14 for Health insurance coverage
under the policy no 4128i/iH/1089144241/00/000 vide Cheque/credit card dated May022024.
The Product is eligible for deduction u/s 80 D of the Income Tax,1961 ad any amendments made there to.
For ICICI Lombard General Insurance Company Limited,IRDA Regn.No.115
Authorized Signatory
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.
