Medical Insurance Premium Receipt 2019 20
Medical Insurance Premium Receipt 2019 20
Medical Insurance Premium Receipt 2019 20
Date : 02May2019
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
Mailing Address: Flat 219 Mahaveer Lakes Dr Vishnuvardhan Road Uttarahalli Main Road
KengeriBengalu 9844729394
Mobile No.:
Telephone No.:
Email ID: [email protected]
Product Name: iHealth
No. of Members : 2
Policy Duration (years): 2
Age of the eldest member
(years): 27
Name of the Relationship with Age Pre- Existing Annual Sum Optional Add- on Sub- Voluntary
Insured(s) Proposer Year Months illness/injury Insured Cover limit Deductible
Abu Sufiyan Kazi Self 27 4 NA
Farah Kazi Spouse
Please go through the details as furnished in the format and the policy 1000000
27 3 NA
document and confirm that same are in
None 0
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 02-Mar-2015
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 7738407457
Policy From 00:00 hrs 02-Mar2015 to
Name of the Applicant Abu Sufiyan Azad Kazi
Period Midnight of 01-Mar-2016
104 Sehar Residency,
Near Bilal Hospital
Kausa Mumbra
Correspondence
Thane Email Address [email protected]
Address
Maharashtra 400612
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 Optional Add-on Sub- Voluntary
Gender Relation
Insured(s) Joining Years Months Insured illness/injury ID No. Cover limit Deductible
Abu Sufiyan Kazi 02-Mar-2015 27 4 M Self None 102965007
Farah Kazi 02-Mar-2015 27 3 F Spouse 1000000 None 102965008 None 0
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 15015.38 738.62 0 0 15754
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 spec
IMPORTANT :Insurance benefit shall become voidable at the option of the Company, in the event of any untrue or incorrect statemen
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
Please send the relevant documents to: ICICI Lombard Health Care,Plot No:12 ,ICICI Bank Towers ,Nanakramguda ,Gachi
ICICI Lombard General Insurance Company Ltd
Corp Office:ICICI Lombard General Insurance Company LTD., IRDA Regn. No. 115 , ICICI LOMBARD HOUSE , 414,
Mailing Address:4th Floor, Interface 11, Off Malad Link Road, Behind Goregaon Sports Club, Malad(w), Mumbai400064
Toll Free 24 X 7 Call Center No 18002666. Email
To,
Abu Sufiyan Azad Kazi
Sehar Residency Near Bilal Hospital Kausa Mumbra
Thane,
Maharashtra 400612.
This is to certify that the company has received the premium of Rs. 15754 for Health insurance coverage
under the policy no 4128i/iH/1089144241/00/000 vide Cheque/credit card dated Mar022015.
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.