Premium Certificate

For the purpose of deduction under section 80D of Income Tax amendment
act, 1961 and any amendments made thereafter.

To,
CHAKALA ANJANEYULU
12-1-717 Ashok Nagar

ANANTAPUR
ANDHRA PRADESH
515001

This is to certify that the company has received a premium of Rs. 6 740 for health insurance coverage under the health policy
no. 4034i/FPP/W-8732417/00/000 vide EMI dated 02- -201 .

The product is eligible for deduction u/s 80D of the Income Tax Act, 1961 and any amendments made there to.

For ICICI Lombard General Insurance Company

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.
 For the purpose of deduction under section 80D, the benefit shall be as per the provisions of the Income Tax Act, 1961
and any amendments made thereafter.

Claim Procedure Before going to the hospital please call ICICI Lombard Health Care Services for complete assistance
& guidance
ICICI Lombard Health Care Services Number
Toll Free Phone Number 1800 2666(Accessible even from your Mobile Phone)
Toll Free Fax Number 1800 208 8880
Email: ihealthcare@icicilombard.com Web Site: http://www.icicilombard.com

Emergency or planned hospitalization :

Simply use our Health ID card at our Health Care network hospitals (Refer www.icicilombard.com for updated list) and
avail of cashless service.Call our Health Cares 24 hour-toll-free number 1800 2666for claims registration.

Treatment in non-network hospitals :

The claim form (available at www.icicilombard.com) must be filled fully after discharge from hospital and sent to ICICI
Lombard Health Care office along with the original documents.

 Claim form duly filled & signed by the insured.

 Original discharge card & Final bill.
 All investigation reports in originals.
 All medicines /lab/ hospital bill in original.
 All payments receipts in original.
 Any other required documents depending upon the case.

Note:Please refer to the policy wordings for complete information on Coverage & Exclusions.
For more information on our product, Log on to
E-Mail ID : ipartnersupport@icicilombard.com
www.icicilombard.com