Pol Ict
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Risk Assumption Letter
Dear Sir / Madam, We thank you for placing this Insurance busi ness with us. Please find attached herewith Policy No.:
500065170 , which has been issued based on the details furnished to us by
insured: 1. Name of the Insured : DIKSHIT DHARMENDRA 2. Mailing Address : SKF INDIA MGM BLDG NS RD CHARNI RD, MUMBAI MAHARASHTRA 3. Risk Address :
,
4. Telephone No. : 000 -000 -66337777 5. Mobile No. : 000 6. E-mail Id :
10. Visa Type : no n-immigrant 11. Period of Insurance / Trip Particulars : From: 21-Jul-2009 To: 27-Jul-2009 Days: 7 12. Geographical Scope : EXCLUSCANADA 13. Plan Type : GOLD X100 14. Pre-existing Diseases : NA 15. Medical Treatment History : NA 16. Family Doctor’s Details : Please go through the de tails as furn ished in th e format and a lso a s p rovided in the policy document and confirm that they are in order. Sh oul d you feel that there are any discrepancies/variations, you are requested to write back to us immediately at [email protected] for necessary changes/rectification. In the absence of any communication from you with in 15 days or before the risk inception date of the policy in this connection, we would take it that you have accepted the contents and the coverage to be confirming to your proposal. It brings us pleasure in announcing that our operations function has been ISO 9001:2000 certified with effect from 7th September 2004. The certifying agency was De t Norske Veritas (DNV). This would mean that we would meet the service related promises that we make to our custome rs. Thanking you,
Authorised Signatory ICICI Lombard General Insurance Company Limited
PART 1 OF INSURANCE
THE SCHEDULE
-
OVERSEAS
Agent Location:
MUMBAI
INDIVIDUAL
TRAVEL
POLICY DETAILS Policy No.:
500065170
Agent:
CUST-510870
Period of Insurance/Trip Particulars : From: 22-Aug-2009 To: 28-Aug-2009 Midnight(Single Trip) or actual date of arrival whichever is earlier Insured no of travel days : 7 Geographical Scope : EXCLUSCANADA
DETAILS INSURED
OF
THE
PLAN NAME : GOLD X100 Benefits Deductibles
Name PENDSEABHIJIT S MR
Sum
Insured
Personal Accident USD 15,000 -
Mailing Address SKF INDIA MGM BLDG NS RD CHARNI RD, MUMBAI , MAHARASHTRA
Medical Cover (includes medical evacuation *USD 100,000 US D 100 cost). Dental Treatment USD 250 US D 100
Pin Code 400002 Telephone No. 000 -000 -66337777 Mobile No. 000
Repatriation of Remains under Medica... USD 7000 (Included
E-mail Id
Loss of Passport USD 200 US D 50
Date Of Birth 11-May-1975
Total Loss of Checked Baggage USD 500 -
Passport No. G8112390
Delay of Checked Baggage USD 100 12 Hrs
Nominee Name SMITA
Personal Liability USD 100,000 -
Visa Type non-immigrant
Financial Emergency USD 300 -
Special Terms & Conditions :
Hijack Distress Allowance USD 125 for max 7 days 12 Hrs
Pre-existing Ailments History : NA
Hospitalisation / Medical Treatment History NA
:
Family doctor's Name ,Address and Contact No.:
The above records the information of pre-existing illnesses / hospitalization etc. details given by the insured pursuant to Clause 4 (4) of the IRDA (Policyholder's interest) Regulations, 2002. If the information shown above is found to be either incomplete or incorrect at the time of claim, the same shall be construed as non disclosure of material information.
Start Date Education
End Date
Premium Service Tax
Cess
Higher Education Cess
Net Premium
Claim Amount Details (Rs.)
Original Details 22-Aug-2009 28-Aug-2009 624.00 62.40 1.25 0.62 688.00 - -
For ICICI LOMBARD GENERAL INSURANCE CO. LTD.
Authorised Signatory
Date of Issue :24-Aug-200 9 Place of issuance: Mumbai
Service tax registration number-GIS/Mumbai-I/1528/2001. Service tax Code number-AAACI7904GST001. Category : General Insurance Business Services - 00440005 The stamp duty of Rs. 1 (Rupee One only) paid in cash or by demand draft or by pay order,vide Receipt/Challan no. 9955 dated 09-Jun-2009.” Contact the ICICI Lombard 24hr Help Line number for assistance and registering your claim: In USA & Canada: +1866 625 8529 (Toll Free), From the rest of the world: +91 11 4189 8868 (Call Back Facility), In India: 1800 113 666 (Toll Free & Accessible only in India), Fax: +91 11 4189 8801, and E-Mail: [email protected]. Failure to call this number and register your claim as soon as the loss occurs shall invalidate your claim Now you can call on 1800-209-8888 ( Toll Free : Also accessible from your mobile phone ) To Buy /Extend policy or any other customer service. *Subject to sub-limits provided in the terms of cover incorporated in the Part II of the policy. Please ensure that the you have received, read and understood the terms and conditions as contained in Part II and III of the Policy. Kindly acknowledge receipt of this policy. In case you find any variations against your proposal or any discrepancy in the policy, kindly contact us immediately or have not received Part II and Part III of the Policy, please email at [email protected] In the event of an accident or sudden illness or any other claim caused by a contingency covered under the insurance policy, immediately contact the Help Line number stating the necessary details. If a
claim is not registered with the Help Line number and prior authorization is not taken from the claims assistance company before making the expense, the company will be relieved of its liability to pay the claim. Even if no assistance is required and no expenses are incurred, please contact the Help Line number while abroad, and inform the claims assistance company of the claim that will be lodged on the company on return back to the Republic of India. If this is not done, then the company will be relieved of its liability to pay the claim. Policy extension is valid only if all claims that are put up / that will be put up by the insured on return back to the Republic of India, for the original policy duration have been informed as soon as they occur and well in advance to the extension request to the Help Line Number stated below; and that you are unaware today of any health condition that might lead to claims in the extended policy duration. The multi trip (Annual Cover) insurance is valid in respect of trips undertaken during the 12 months of policy period as specified in PART 1 OF THE SCHEDULE, subject to the duration of any one trip not exceeding the 'Maximum Trip Duration', as specified in PART 1 OF THE SCHEDULE. Please note, the first US$100 of your medical expenses is deductible, and must be borne by you. Note:Kindly acknowledge receipt of this policy. In case you find any variations against your proposal or any discrepancy in the policy , kindly contact us immediately. ICICI Lombard General Insurance Company Limited Zenith House, Keshavrao Khadye Marg, Opp. Race Cource, Mahalaxmi, Mumbai - 400 034
Dear Sir / Madam, We thank you for placing this Insurance busi ness with us. Please find attached herewith Policy No.:
500065170 , which has been issued based on the details furnished to us by
insured: 1. Name of the Insured : DIKSHIT DHARMENDRA 2. Mailing Address : SKF INDIA MGM BLDG NS RD CHARNI RD, MUMBAI MAHARASHTRA 3. Risk Address :
,
4. Telephone No. : 000 -000 -66337777 5. Mobile No. : 000 6. E-mail Id :
10. Visa Type : no n-immigrant 11. Period of Insurance / Trip Particulars : From: 21-Jul-2009 To: 27-Jul-2009 Days: 7 12. Geographical Scope : EXCLUSCANADA 13. Plan Type : GOLD X100 14. Pre-existing Diseases : NA 15. Medical Treatment History : NA 16. Family Doctor’s Details : Please go through the de tails as furn ished in th e format and a lso a s p rovided in the policy document and confirm that they are in order. Sh oul d you feel that there are any discrepancies/variations, you are requested to write back to us immediately at [email protected] for necessary changes/rectification. In the absence of any communication from you with in 15 days or before the risk inception date of the policy in this connection, we would take it that you have accepted the contents and the coverage to be confirming to your proposal. It brings us pleasure in announcing that our operations function has been ISO 9001:2000 certified with effect from 7th September 2004. The certifying agency was De t Norske Veritas (DNV). This would mean that we would meet the service related promises that we make to our custome rs. Thanking you,
Authorised Signatory ICICI Lombard General Insurance Company Limited
PART 1 OF INSURANCE
THE SCHEDULE
-
OVERSEAS
Agent Location:
MUMBAI
INDIVIDUAL
TRAVEL
POLICY DETAILS Policy No.:
500065170
Agent:
CUST-510870
Period of Insurance/Trip Particulars : From: 22-Aug-2009 To: 28-Aug-2009 Midnight(Single Trip) or actual date of arrival whichever is earlier Insured no of travel days : 7 Geographical Scope : EXCLUSCANADA
DETAILS INSURED
OF
THE
PLAN NAME : GOLD X100 Benefits Deductibles
Name PENDSEABHIJIT S MR
Sum
Insured
Personal Accident USD 15,000 -
Mailing Address SKF INDIA MGM BLDG NS RD CHARNI RD, MUMBAI , MAHARASHTRA
Medical Cover (includes medical evacuation *USD 100,000 US D 100 cost). Dental Treatment USD 250 US D 100
Pin Code 400002 Telephone No. 000 -000 -66337777 Mobile No. 000
Repatriation of Remains under Medica... USD 7000 (Included
E-mail Id
Loss of Passport USD 200 US D 50
Date Of Birth 11-May-1975
Total Loss of Checked Baggage USD 500 -
Passport No. G8112390
Delay of Checked Baggage USD 100 12 Hrs
Nominee Name SMITA
Personal Liability USD 100,000 -
Visa Type non-immigrant
Financial Emergency USD 300 -
Special Terms & Conditions :
Hijack Distress Allowance USD 125 for max 7 days 12 Hrs
Pre-existing Ailments History : NA
Hospitalisation / Medical Treatment History NA
:
Family doctor's Name ,Address and Contact No.:
The above records the information of pre-existing illnesses / hospitalization etc. details given by the insured pursuant to Clause 4 (4) of the IRDA (Policyholder's interest) Regulations, 2002. If the information shown above is found to be either incomplete or incorrect at the time of claim, the same shall be construed as non disclosure of material information.
Start Date Education
End Date
Premium Service Tax
Cess
Higher Education Cess
Net Premium
Claim Amount Details (Rs.)
Original Details 22-Aug-2009 28-Aug-2009 624.00 62.40 1.25 0.62 688.00 - -
For ICICI LOMBARD GENERAL INSURANCE CO. LTD.
Authorised Signatory
Date of Issue :24-Aug-200 9 Place of issuance: Mumbai
Service tax registration number-GIS/Mumbai-I/1528/2001. Service tax Code number-AAACI7904GST001. Category : General Insurance Business Services - 00440005 The stamp duty of Rs. 1 (Rupee One only) paid in cash or by demand draft or by pay order,vide Receipt/Challan no. 9955 dated 09-Jun-2009.” Contact the ICICI Lombard 24hr Help Line number for assistance and registering your claim: In USA & Canada: +1866 625 8529 (Toll Free), From the rest of the world: +91 11 4189 8868 (Call Back Facility), In India: 1800 113 666 (Toll Free & Accessible only in India), Fax: +91 11 4189 8801, and E-Mail: [email protected]. Failure to call this number and register your claim as soon as the loss occurs shall invalidate your claim Now you can call on 1800-209-8888 ( Toll Free : Also accessible from your mobile phone ) To Buy /Extend policy or any other customer service. *Subject to sub-limits provided in the terms of cover incorporated in the Part II of the policy. Please ensure that the you have received, read and understood the terms and conditions as contained in Part II and III of the Policy. Kindly acknowledge receipt of this policy. In case you find any variations against your proposal or any discrepancy in the policy, kindly contact us immediately or have not received Part II and Part III of the Policy, please email at [email protected] In the event of an accident or sudden illness or any other claim caused by a contingency covered under the insurance policy, immediately contact the Help Line number stating the necessary details. If a
claim is not registered with the Help Line number and prior authorization is not taken from the claims assistance company before making the expense, the company will be relieved of its liability to pay the claim. Even if no assistance is required and no expenses are incurred, please contact the Help Line number while abroad, and inform the claims assistance company of the claim that will be lodged on the company on return back to the Republic of India. If this is not done, then the company will be relieved of its liability to pay the claim. Policy extension is valid only if all claims that are put up / that will be put up by the insured on return back to the Republic of India, for the original policy duration have been informed as soon as they occur and well in advance to the extension request to the Help Line Number stated below; and that you are unaware today of any health condition that might lead to claims in the extended policy duration. The multi trip (Annual Cover) insurance is valid in respect of trips undertaken during the 12 months of policy period as specified in PART 1 OF THE SCHEDULE, subject to the duration of any one trip not exceeding the 'Maximum Trip Duration', as specified in PART 1 OF THE SCHEDULE. Please note, the first US$100 of your medical expenses is deductible, and must be borne by you. Note:Kindly acknowledge receipt of this policy. In case you find any variations against your proposal or any discrepancy in the policy , kindly contact us immediately. ICICI Lombard General Insurance Company Limited Zenith House, Keshavrao Khadye Marg, Opp. Race Cource, Mahalaxmi, Mumbai - 400 034
