Ref. No.

: W27923248 LAN Number: 19020618531140

Policy Number: 4111/EPP/164559158/00/000
Date: 06-Feb-2019

NAVEEN KUMAR KODURU

HNO 3 938/A,OLD COURT LANE,PARKAL,WARANGAL, TELENGANA

SYSESB0010511015
,
WARANGAL
ANDHRA PRADESH - 506164
Phone: 9848043826

Dear Customer,

Subject: Risk Assumption Letter

We thank you for placing your confidence with ICICI Lombard for your Insurance needs.

Please find enclosed herewith Policy No. : 4111/EPP/164559158/00/000 which has been issued based on the details
furnished by the applicant.

Details are:

Name of the Insured NAVEEN KUMAR KODURU Product Name PERSONAL PROTECT
Relationship with Applicant SELF LAN No 19020618531140
Date of Birth 10/10/1972 Policy Duration (Years) 3 Years
Sum Insured 2500000 Period of Insurance From: 06-Feb-2019 00:00 To
05-Feb-2022 23:59
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.

Signature Not Verified

Digitally signed by
SANJAY DATTA
Date: 2019.02.06
19:21:19 IST
102/20170517/754

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Toll free no.: 1800 2666 UIN - ICIPAIP06001V020506
Mailing Address: Registered Office: Alternate No.: +9186552 22666
(chargeable)
401 & 402, 4th Floor, Interface 11, New Linking ICICI Lombard House, 414 Veer Savarkar Marg, Near Email: [email protected]
Road, Malad (West), Mumbai - 400 064. Siddhi Vinayak Temple, Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com
 Policy Certificate

PERSONAL PROTECT
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 herein 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.

Part I of Policy Schedule

2

Proposer Name NAVEEN KUMAR KODURU Policy No. 4111/EPP/164559158/00/000

HNO 3 938/A,OLD COURT Period of Insurance From: 06-Feb-2019 00:00 To 05-Feb-2022 23:59
Address LANE,PARKAL,WARANGAL, TELENGANA, ,,
WARANGAL, ANDHRA PRADESH - 506164 Policy Tenure 3 Years
Contact No. 9848043826 LAN No. 19020618531140
Email Address [email protected] Policy Issuing Office MUMBAI MALAD
Nominee Name DR SUMATHI Policy Issued On 06-Feb-2019
Relationship With Policyholder SELF Previous Policy No. NA
Appointee Name NOT APPLICABLE Nominee Age 45 years
GSTIN Number (Customer) Servicing Branch Name Mumbai
Servicing Branch Address 414, ICICI LOMBARD HOUSE, VEER SAVARKAR Invoice Number 100219146030
MARG, NEAR SIDDHI VINAYAK TEMPLE MAIN
GATE, PRABHADEVI, MUMBAI, 400025,
MAHARASHTRA
Date of Joining

Date of Risk Relationship with Beneficiary / Relation of Nominee with the

Insured Name Age Gender Occupation
Birth Category Proposer Nominee Insured
NAVEEN KUMAR
10/10/1972 46 M EXECUTIVE I SELF DR SUMATHI SPOUSE
KODURU

Benefit & Extension Table 2

Section Benefit Cover Benefit Amount Sum Insured (Rs.)
Benefit 1 Death resulting from Accident 100% of the Sum Insured
Section A 2500000
Benefit 2 Permanent Total Disablement resulting from Accident 100% of the Sum Insured

Premium Details (` )
IGST
Basic Premium Total Tax Payable Total Premium
% `
7538 18 1356.84 1357.00 8895

GSTIN Reg.No HSN/SAC code

The stamp duty of ` 125 paid vide deface no. CSD299201914419 dated 11-Jan-2019
27AAACI7904G1ZN 9971 / GENERAL INSURANCE SERVICES
414, ICICI LOMBARD HOUSE, VEER SAVARKAR MARG, NEAR SIDDHI VINAYAK TEMPLE MAIN GATE, PRABHADEVI, MUMBAI, 400025,
GSTIN Address
MAHARASHTRA
Important: Insurance benefit shall become voidable at the option of the company, in the event of any untrue or incorrect statement, misrepresentation non-description of any material particular in the proposal
form/ personal statement, declaration and connected documents, or any material information has been withheld by beneficiary or anyone acting on beneficiary's behalf to obtain insurance benefit. Please note
that any claims arising out of pre-existing illness/ injury/ symptoms is excluded from the scope of this policy subject to applicable terms and conditions. Refer to policy wordings for the terms and conditions.
All disputes are subject to the jurisdiction of Mumbai High Court only. For claims, please call us at our toll free no. 1800 2666 or e-mail to us at [email protected] or write to us at ICICI
Lombard GIC, ICICI Bank Tower, Plot no-12, Financial district Nanakramguda, Gachibowli, Hyderabad, Andhra Pradesh 500032.

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. 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.
102/20170517/754

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 Toll free no.: 1800 2666 UIN - ICIPAIP06001V020506
Mailing Address: Registered Office: Alternate No.: +9186552 22666
(chargeable)
401 & 402, 4th Floor, Interface 11, New Linking ICICI Lombard House, 414 Veer Savarkar Marg, Near Email: [email protected]
Road, Malad (West), Mumbai - 400 064. Siddhi Vinayak Temple, Prabhadevi, Mumbai - 400 025. Website: www.icicilombard.com