COMPLETE HEALTH INSURANCE Proposal Form

FOR OFFICE USE ONLY

Intermediary Id:
Intermediary Name: WEBSITE DIRECT ICICI LOMBARD
Deal no: DL-4128/1410867
Branch Name: MUMBAI - CO
Proposal no: 1754901206

PROPOSER / CUSTOMER INFORMATION

Proposer Name: Mr/Mrs/Miss INDRANATH MISHRA
Date of Birth: 17-Dec-1973 Gender: Male Marital Single
Status:
Occupation:
Annual Income(Rs):
Nationality:
Residential Status:
PAN No: Passport Aadhar No:
No:
GSTIN No.
Customer:
Correspondence Address:
ASTU MISHRA 3RD FLOOR S57 SUNDAR BLOCK SHAKARPUR DELHI
Landmark:
City/Town: DELHI State: DELHI Pin Code: 110092
Landline Number (with STD Code): Mobile No*: 7303169978
Email Address: INDRANATH_MISHRA@YAHOO.COM
Permanent Residence Address:
ASTU MISHRA 3RD FLOOR S57 SUNDAR BLOCK SHAKARPUR DELHI
Landmark:
City/Town: DELHI State: DELHI Pin Code: 110092
Landline Number (with STD Code): Mobile No*:
Email Address:
*Kindly provide the details to enable us to serve you better
DETAILS OF PERSONS TO BE INSURED:
Full Name Height
Insured No Gender Date of Birth Relationship with Proposer Add on Covers Weight (KGs)
Title Name Feet Inches
0 DURGA DEVI Female 02-Mar-1955 MOTHER None 5' 1" 65

DETAILS OF PERSONS TO BE INSURED:

Insured No Existing Health Insurance Policy Policy No Policy Period (Years) Insurance Company Sum Insured
Attention! 80D Alert - Please note that for the premium paid towards health policy, the maximum eligible tax benefit under Section 80D of Income Tax Act, 1961 is
Rs. 25,000 (for Self, Spouse and dependent children) and Rs. 30,000 (for Parents or Senior Citizen Members (Self/Spouse)

DETAILS OF INSURANCE
Sub Product Name iHealth N Sum Insured 500000
Plan Name iH_Individual_Adult_1Year_N Deductible SI NA
Tenure (Years) 1 Premium 36659 Voluntary
Deductible
Please Note: Insured(s) will have to undergo medical underwriting before policy issuance at designated diagnostic centersSignature
empanelled by Not Verified
ICICI Lombard GIC
Ltd in case:
Digitally signed by DS ICICI
1. Individual(s) applying for policy are aged 46 years & above irrespective of the sum insured. LOMBARD GENERAL
2. Both the members applying for policy with Annual Sum Insured greater than 10 Lcs irrespective of age INSURANCE COMPANY
3. Cost of Pre Policy Medical Check-up for policy issuance: 100% of the pre policy medical test cost will be paid LIMITEDby the Company. In case the health
Date: 2020.02.29 18:04:24
proposal is declined, medical cost will be deducted from the premium and the balance would be refunded. IST
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 ICICI Lombard Complete Health Insurance UIN - lClHLlP20084V03l920
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Savarkar Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Near Siddhi Vinayak Temple, Email: customersupport@icicilombard.com
Link Road, Malad (West), Mumbai - 400 064. Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com
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 NOMINEE DETAILS: APPOINTEE DETAILS: (IF NOMINEE MINOR)
Nominee Mr/Mrs/Miss Mr/Mrs/Miss
Name:
Date of Birth: Relationship with Relationship with
proposer: proposer:
Signature: Place:
Any of the above insured members already have health policy with ICICI Lombard General Insurance Company - NULL.
Terms and Conditions
• Initial waiting period of 30 days for all illnesses (except Hospitalization due to injury)*.
• Specific waiting period of first two years for specific illnesses and treatments (mentioned in the policy wording)*.
• Pre-existing conditions/diseases declared and accepted by us will be covered after expiry of the pre existing disease waiting period (as per plan)
• Sum Insured can be changed at the time of renewal only. Company reserves right to approve/ reject the change in Sum Insured. Fresh waiting period as per
the terms of the policy will be applicable to the enhanced limit from the effective date of such enhancement.
• Factors determining the renewal premium are:
(i) Age slab of the senior most insured member at the time of renewal.
(ii) Any change in the renewing policy.
• The liability of the Company does not commence until this Proposal has been accepted by the Company and premium realised.
Disclaimer: Insurance is a contract of Utmost Good Faith requiring the Insured not only to disclose all material facts but also not to suppress any material facts in
response to the questions in the proposal form.
• Applicable for new insured.

IMPORTANT NOTES
1. The information that you give to us on this proposal form or in any supplementary Information form or documentation supplied by you or on your behalf will
influence our decision to offer insurance and the terms upon which to offer it. Further, any policy we issue will be based on what you have communicated to
us. It is therefore important that your answer are complete and accurate in all respect.
2. The question in this proposal are indicative rather then exhaustive. You must provide us with all information relevant to the risk to be insured, even if it is not
the subject of a question in this proposal. If you are in any doubt as to what information should be given, you should liaise with your insurance advisor/
company.
3. Acceptance of your proposal would be subject to receipt of complete medical reports(wherever applicable), medical underwriting and realization of full
premium amount by the company and the insurance coverage will commence from the date of underwriting by the company.
4. The list of exclusions/ inclusions and other policy details are indicative, for complete list and comprehensive details kindly refer policy wordings.
5. The Policy 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 material particulars in the Proposal Form/ personal statement, declaration and connected documents, or any material fact* information has
been withheld by beneficiary or anyone acting on beneficiary's behalf to obtain insurance.
*A material fact will mean and include all important, essential and relevant information, pertaining to the questions made in this proposal form, that are likely to
influence company's acceptance or assessment of the proposal.
MEDICAL AND LIFESTYLE INFORMATION

Declared are the medical conditions/disease and lifestyles details of the new insured members.

Medical and lifestyle details of insured (s). DURGA

DEVI
Hypertension (Blood Pressure) History Y
Diabetes History N
Any Heart related Or Circulatory Conditions Disorders N
Kidney Failure, Stone, Dialysis Or Any Other Kidney/Urinary Tract Or Prostate Disease N
Arthritis, Spondylosis, Joint Replacement Or Any Other Disorder of Joint/ ligaments N
Tuberculosis, Asthma, Bronchitis Or Any Other Lung / Respiratory Disease N
Liver Disease Or Any Other Gastro Intestinal Or Gallbladder Disease N
Cancer or Tumor of any kind N
Stroke, Epilepsy, Paralysis, Or Any Other Brain/ Nervous System Disease N
Any Gynecological / Breast Disorder N
Use tobacco products /cigarettes or drinks alcohol? N
Have you or any other member proposed to be insured under this policy sought medical advice or been
advised or awaiting any treatment medical or surgical due to any of the diseases / condition listed above N
or otherwise attend follow up for any diseases / condition / ailment / injury / addiction

Remarks
109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 ICICI Lombard Complete Health Insurance UIN - lClHLlP20084V03l920
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Savarkar Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Near Siddhi Vinayak Temple, Email: customersupport@icicilombard.com
Link Road, Malad (West), Mumbai - 400 064. Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com
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 PAYMENT DETAILS
Payment Option: Debit Cheque/DD Number: Premium Amount: 36659 Cheque/DD Date/Transaction
Authorization 1110121822 Date: 29/02/2020
Amount In Words: Thirty Six Thousand Six Hundred Fifty Nine
Bank Name: ICICI BANK Branch: NA
Account Number: MICR:
Account Type: IFSC:
DECLARATION
I/We hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are
true and complete in all respects to the best of my knowledge and that I/We am/are authorized to propose on behalf of these other persons.
I understand that the information provided by me will form the basis of the insurance policy, is subject to the board approved underwriting policy of the insurance
company and that the policy will come into force only after full receipt of the premium chargeable.
I/We further declare that I/we will notify in writing any change occurring in the occupation or general health of the life to be insured/proposal after the proposal has
been submitted but before communication of the risk acceptance by the company.
I/We declare and consent to the company seeking medical information from any doctor or from a hospital who at any time has attended on the life to be
insured/proposed or from any past or Present employer concerning anything which affects the physical or mental health of the life to be assured/Proposer and
seeking information from any insurance company to which an application for insurance on the life to be assured/Proposer has been made for the purpose of
underwriting the proposal and/or claim settlement.
I/We authorize the company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or
claims settlement and with any Government and /or Regulatory authority.
STATUTORY WARNING
PROHIBITION OF REBATES
(Under Section 41 of Insurance Act 1938)
1. No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of
any kind of risk relating to lives or property, in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the
policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the
published prospectuses or tables of the Insurer.
2. Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to ten thousand rupees.

"This is an e-proposal form. This doesn't require customer signature. The information captured as per the details
provided during the first proposal of the policy or any changes (if any) in the subsequent renewals."

109/20150914/284

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 ICICI Lombard Complete Health Insurance UIN - lClHLlP20084V03l920
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414 Veer Savarkar Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Near Siddhi Vinayak Temple, Email: customersupport@icicilombard.com
Link Road, Malad (West), Mumbai - 400 064. Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com
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