Risk Assumption Letter

RISK ASSUMPTION LETTER
Ref No.:
Date: 10-May-2022
Dear Sir / Madam
We thank you for placing your confidence with ICICI Lombard for your Insurance needs.
Please find attached herewith Policy No. : 18621774971, which has been issued based on the details furnished by the applicant.
Name of the applicant Chandrashekhar sadashiv shimpi

Address Flat no 201 building no 2 B wing, Cosmos Paradise near tata housing betegaon boisar, Tarapur Maharashtra -
Mobile No. 9273476482
Product Name GROUP PERSONAL ACCIDENT
Policy Start Date 13-May-2022
Policy End Date 13-May-2023
Insured Details
Name of the Insured Relationship with Applicant Date of Birth Age in Years Sum Insured
Chandrashekhar sadashiv Self 28-08-1988 33 100000
shimpi
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 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.
ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Group Personal Accident UIN: ICIPAGP22077V062122
Mailing Address: Registered Office Address: Toll free no. 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Savarkar Marg, Near Alternate No.: 86552 22666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor Siddhi Vinayak Temple, Email [email protected]
New Link Road, Malad (West), Mumbai - 400 064Prabhadevi, Mumbai - 400 025. Website www.icicilombard.com
Policy Certificate - Group Personal Accident
ICICI Lombard Group Personal Accident Policy no. 4005/M/244422733/00/000 dated 01-Apr-2022 has been issued at Mumbai, by ICICI
Lombard General Insurance Company Limited to the Policyholder ONE97 COMMUNICATION LIMITED, 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 in Part I of the schedule to the said policy.
This certificate, issued under the signature of an authorized signatory of the Company represents the availability of benefit to the insured
named below, Customers of ONE97 COMMUNICATION LIMITED subject to the terms, conditions and exclusions contained or otherwise
expressed in the said Policy to the extent of sum insured mentioned as maximum liability, but not exceeding the Sum Insured as specified
below.
Applicant Name Chandrashekhar sadashiv shimpi Policy No. 18621774971

Address Flat no 201 building no 2 B wing, Period of Insurance From 00:00 hrs 13-May-2022 To
Cosmos Paradise near tata 23:59 hrs 13-May-2023
housing betegaon boisar, Tarapur
Maharashtra - 401501
Contact No. 9273476482 Policy Tenure (in Years) 1
Email Address [email protected] Policy Issuing Office Prabhadevi, Mumbai
Previous Policy No. Policy Issued On 10-May-2022
GSTIN Number (Customer) Service Branch Name IL Branch New Delhi
Servicing Branch Address Fourth Parsavnath Capital Tower Invoice Number 18041867547
Bhai Veer Singh Marg, New Delhi
New Delhi 110001.
PREAMBLE
ICICI Lombard General Insurance Company Limited ("the Company"), having received a Proposal and the premium from the Policy holder
named in the Schedule referred to here in below, and the said Proposal and Declaration 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 Policy
holder 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 the Schedule 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 amount will be paid by the Company.
Insured Details
Name in Full Date of Gender Age in Years Relationship Occupation Beneficiary / Relation of
Birth with Proposer Nominee Nominee with the
Insured
Chandrashekhar 28-08-1988 33 Self
sadashiv shimpi
Benefits & Extension Table
Benefit Cover Benefit Amount Sum Insured (Rs.)
Benefit 1 Death resulting from Accident 100% of Sum Insured
Benefit 2 Permanent Total Disablement resulting from Accident 100% of Sum Insured 100000
Premium Details
Basic Premium 16.95 Stamp Duty 5
CGST % 9 CGST Amount 1.53
SGST % 9 SGST Amount 1.53
Total Tax Payable 3.05 Total Premium 20
Place of Supply MAHARASHTRA

IL GSTIN Registration No. Category The stamp duty of 5 paid vide receipt/ challan no. CSD232202184 dated 06-
Jan-2022
27AAAC17904G1ZN General Business Services
997133
Agent/Broker Details
Agent Name Agent Code Agent Contact No.
Important Notes:
1. Insurance cover will start only on receipt of complete premium by ICICI Lombard General Insurance Company Limited
2. Insurance cover is subject to the terms and conditions mentioned in the Policy wordings provided to you with this Certificate
3. On renewal of policy benefits and terms & conditions of policy including premium may be subject to change.
4. The above covers would not be applicable for persons occupied in underground mines, explosives and electrical installations on high
tension lines
5. Major exclusions: Intentional self-injury, suicide or attempted suicide whilst under the influence of intoxicating liquor or drugs, Any loss
arising from an act made in breach of law with or without criminal intent
6. The claimant can contact us at Toll Free Number 1800-2-666 or Email us at [email protected] for lodging the claim.
7. Claim Notification address: IL Health Care, Secure Mind Claims, ICICI LOMBARD HEALTHCARE ICICI BANK TOWER, PLOT NO.12
FINANCIAL DISTRICT, NANAKRAM GUDA, GACHIBOWLI, HYDERABAD
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 [email protected]. 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.
GROUP PERSONAL ACCIDENT

KEY INFORMATION SHEET
DISCLAIMER NOTE : The information mentioned below is illustrative and not exhaustive . The information must be read in conjunction with
the policy wordings. In case of any conflict between the Key Information Sheet and the policy wordings, the terms and conditions mentioned in
the policy wordings shall prevail.
S. no. Title Description Refer to Policy

Wordings
1 Product Name Group Personal Accident
2 What is covered The policy covers the Insured Person (or his Nominee/ legal heir, as the case Part I of the Policy
under the Policy may be) for the occurrence of any Insured Event, as specifically described,
under different Benefit(s) (and Extensions - if any) arising due to an Injury
sustained by the Insured Person during the Policy Period but not exceeding the
Sum Insured as specified under the respective Benefits (and Extensions - if any)
under Policy Schedule. The cover is for 24 hours or as mentioned in Part 1 of the
policy and on a worldwide basis.
3 Coverage and Benefits : Part II of the policy
Optional Add-ons Death Clause No. 2
Permanent Total Disablement (Benefits) and Clause
Permanent Partial Disablement No. 3 (Extensions)
Temporary Total Disablement
Extensions :
Cover for Expenses related to Burns
Modification of residential accommodation & vehicle
Repatriation of Mortal Remains
Ambulance Charges
Transportation Allowance (Compassionate visit)
Travel Expenses for Medical Treatment

Catastrophe Evacuation
Cost of Clothing Damage
Loss of Job Cover
Improved Disability Benefit/ Dismemberment
Daily Cash Allowance :
Carriage of Dead Body
On Duty Cover
Children’s Education Grant
Accidental Hospitalization Expenses
Mysterious disappearance
Treatment outside India (along with travelling cost & boarding & lodging of the
attendant)
Medical Expenses
Out Patient Department (OPD) expenses
Loss/damage to School Bag/Books
Widowhood Cover
Purchase of Blood
Prosthesis & Artificial Limbs
Broken Bones
Legal Expenses
4 What are the major Suicide, attempt to Suicide or intentionally self- inflicted injury sexually Part I and Part II
Exclusions in the transmitted conditions. (Clause 4) of the
Policy Being under influence of drugs, alcohol, or other intoxication or hallucinogens policy Indicative list of
Participation in actual or attempted felony, riot, civil commotion,crime Exclusions
misdemeanor
Committing any breach of law of land with criminal intent.
Death or disablement resulting from Pregnancy or childbirth
Professional sports team in respect of specific benefit for inability to perform
Participation in any kind of motor speed contest
While engaged in aviation, or whilst mounting or dismounting from or traveling in
any aircraft. ( Not applicable for fare Paying Passengers)
Underground mining & contractor specializing in tunneling
Naval, military or air force personnel
Radioactivity, Nuclear risks, ionizing radiation
5 Payout Basis Reimbursement claims of covered benefits upto specified sum insured as per Part II of the policy
the scope of cover clause 4 (i, ii, iii and iv)-
Claim Administration
6 Terms of Renewal The Policy can be renewed as a separate contract under the then prevailing Part II of the policy
ICICI Lombard Group Personal Accident Insurance product or its nearest Clause 10-Terms of
substitute (in case the product ICICI Lombard Group Personal Accident renewal
Insurance is withdrawn by the Company) approved by IRDA.
The policy shall ordinarily be renewable except on grounds of fraud, moral
hazard or misrepresentation or non- cooperation by the insured.
7 Cancellation The Policy shall be void and all premium paid hereon shall be forfeited to the Part III of the policy
Company, in the event of misrepresentation, mis-description or non-disclosure of Clause 9 -
any material fact. Cancellation/

Insured or the Company may cancel this Policy by giving the Company or the Termination
insured, as the case may be, 15 days written notice for the cancellation of the
Policy, and then the Company shall refund premium on short term rates (if
initiated by the insured) or pro rata rates (if initiated by the Company) for the
unexpired Policy Period. The Company shall follow the short period scale unless
otherwise mutually agreed


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RISK ASSUMPTION LETTER

Dear Sir / Madam

Name of the applicant Chandrashekhar sadashiv shimpi

ICICI Lombard General Insurance Company Limited

Applicant Name Chandrashekhar sadashiv shimpi Policy No. 18621774971

ICICI Lombard General Insurance Company Limited

GROUP PERSONAL ACCIDENT

S. no. Title Description Refer to Policy

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

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