Date: 16-Dec-2024

Dispatch Advice Letter

ERRAMELLI NAG DIVYA

50-96-4/1, 4TH FLOOR SRI GOWRI NILAYAM
SEETAMMADHARA NORTH EXTENSION VIZAG
VISAKHAPATANAM,ANDHRA PRADESH
530013
Phone: 96******53

Sub: Your Health Care And Medical Professional Liability Insurance policy

Dear Sir/Madam,

Welcome to the ICICI Lombard family!

We value your relationship with ICICI Lombard General Insurance Company Limited and thank you for choosing
us as your preferred insurance provider.

Please find attached your Health Care And Medical Professional Liability Insurance policy bearing policy no
4161/372403759/00/000 The details of your insurance policy are as follows:

Policy No : 4161/372403759/00/000
Policy Start Date : 05-Dec-2024
Policy End Date : 04-Dec-2027
Premium Amount : (`) 16513

We herewith attach the electronic copy of the policy kit for your records and reference.

In case you have any queries / clarifications, please call us on our toll free number 1800 2666 or e-mail us at
[email protected].

Assuring you of our best service at all times.

Warm Regards,
For ICICI Lombard General Insurance Company Ltd.

Authorized signatory

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2025.06.18 14:59:41 IST

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : IRDAN115RP0002V01202425 Health Care And Medical Professional Liability Insurance
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, P Balu Marg, Off Alternate no: 86552 22666 (chargeable)
New Linking Road, Malad (West) Veer Savarkar Road, Nr Siddhi Vinayak E-mail : [email protected]
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
 Date: 16-Dec-2024
ERRAMELLI NAG DIVYA
50-96-4/1, 4TH FLOOR SRI GOWRI NILAYAM
SEETAMMADHARA NORTH EXTENSION VIZAG
ANDHRA PRADESH, VISAKHAPATANAM, 530013

Risk Assumption Letter

Dear Sir/Madam,
We value your relationship with ICICI Lombard General Insurance Company Limited and thank you for
choosing us as your preferred insurance provider.
Please find attached herewith Policy No. 4161/372403759/00/000 which has been issued based on
the details furnished to us on 16-Dec-2024.
Please go through the details as furnished in the format and also as provided in the policy document
to ensure that they are in order. If you feel that there are any discrepancies/variations, please write to
us immediately for the necessary changes / rectification. In the absence of any communication from
you in this regard within a period of 15 days of receipt of this letter, we would understand that you
have accepted the contents and the coverage to be in accordance with your application.
Thank you once again and look forward to a lasting relationship.

Warm Regards,
For ICICI Lombard General Insurance Company Ltd.

Authorized signatory

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : IRDAN115RP0002V01202425 Health Care And Medical Professional Liability Insurance
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, P Balu Marg, Off Alternate no: 86552 22666 (chargeable)
New Linking Road, Malad (West) Veer Savarkar Road, Nr Siddhi Vinayak E-mail : [email protected]
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
 HEALTH CARE & MEDICAL PROFESSIONAL LIABILITY
(DOCTORS, MEDICAL PRACTICE, HEALTHCARE SERVICES)

Preamble

ICICI Lombard Health Care And Medical Professional Liability Insurance Policy no.
4161/372403759/00/000 dated 16-Dec-2024. has been issued at GURGAON by ICICI Lombard
General Insurance Company Limited to the Insured, ERRAMELLI NAG DIVYA, 50-96-4/1, 4TH
FLOOR SRI GOWRI NILAYAM, SEETAMMADHARA NORTH EXTENSION VIZAG, ANDHRA
PRADESH, VISAKHAPATANAM, 530013 and governed by the subject to the terms, conditions and
exclusions therein contained or otherwise expressed in the said Policy, but not exceeding the Sum
Insured as specified in Part I of the Schedule.

ICICI Lombard General Insurance Company Limited ("the Company"), having received a Proposal
and the premium from the Proposer 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
Proposer 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 will be paid by the Company.

Part 1 of the POLICY SCHEDULE

Item 1 Policyholder : ERRAMELLI NAG DIVYA

50-96-4/1, 4TH FLOOR SRI GOWRI NILAYAM, SEETAMMADHARA
Address : NORTH EXTENSION VIZAG, VISAKHAPATANAM, ANDHRA
PRADESH, 530013
Item 2 Professional Services Radiologist
Health Professional ID 0
Field of Specialization Radiologist
Registration No APMC-83623
Educational Qualification (Year of
MD
Passing)
Item 3 Policy Period : From: 05-Dec-2024 00:00 Hours To Midnight of 04-Dec-2027
Item 4 Limit of Liability : ` 30000000 For all Losses during the Policy Period
Item 5 Deductible :
Item 6 Gross Premium (including taxes) : ` 16513
Item 7 Territorial Limits : India
Customer Service Department ICICI Lombard General Insurance
Item 8 Insurer : Company Ltd. ICICI Lombard House, 414 Veer Savarkar Marg, Near
Siddhi Vinayak Temple Prabhadevi (W), Mumbai-400 025
Item 9 Extended Reporting Period : 30 days
Item 10 Proposal Form Date : 05-Dec-2024
Item 11 Endorsements attached at inception :
Item 12 Extensions Applicable/ Not Applicable Sublimit
Item 13 Retroactive Date 2024-12-05
Intermediary Code: 200713487256
Item 14 Intermediary Details
Intermediary Name: SECURE NOW INSURANCE BROKER PRIVATE

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : IRDAN115RP0002V01202425 Health Care And Medical Professional Liability Insurance
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, P Balu Marg, Off Alternate no: 86552 22666 (chargeable)
New Linking Road, Malad (West) Veer Savarkar Road, Nr Siddhi Vinayak E-mail : [email protected]
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
 LIMITED
Intermediary Contact Details: [email protected],9355157573
PEP Declaration

*Politically Exposed Persons (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign
country, e.g., Heads of States/Governments, senior politicians, senior government/judicial/military

officers, senior executives of state¬owned corporations, important political party officials, etc.
Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/ Close relatives/Associates of PEPs*? No

I hereby give my consent to the Company to verify my identity through Central KYC Registry or
Yes
UIDAI or through any other modes for the purpose of undertaking KYC
I hereby declare and confirm that the premium has been paid out of legally acquired sources of income an
d the subsequent premiums if any, will continue to be paid out of legally declared and assessed source of Yes
income

The stamp duty of ` 0.5 paid in cash or by demand draft or by pay order, vide Receipt/Challan
No.CSD372024252885 dated. 15-Jul-2024

Signed for and on behalf of the ICICI Lombard General Insurance Company Limited, at GURGAON on this date 16-Dec-2024

Authorised signatory

Scan the below QR Code for Policy Terms and Conditions

Click or Scan QR Code for Policy Wordings

Click here or scan the QR code to view the Customer Information Sheet (CIS). It provides an
overview of the policy features, service and claim processes, as well as other important terms.

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : IRDAN115RP0002V01202425 Health Care And Medical Professional Liability Insurance
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, P Balu Marg, Off Alternate no: 86552 22666 (chargeable)
New Linking Road, Malad (West) Veer Savarkar Road, Nr Siddhi Vinayak E-mail : [email protected]
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com