Dear Ghori Nilesh Viththalbhai
Thank you for trusting ICICI Lombard with your
Health Insurance needs.
Your Elevate - 4225i/ELVT/351969105/00/000 is
due for renewal on 13-07-2025.
Premium Options
Existing (₹) Recommended (₹)
Sum Insured ₹10,00,000 ₹15,00,000
1 Year ₹21,188 ₹25,599
2 Year ₹40,257 ₹48,638
3 Year ₹58,267 ₹70,397
Your expiring policy is issued with ZONE A premium
for 1 Year Tenure.
₹ 15,00,000
Scan to
Review and Renew
₹ 10,00,000
Discount
2.5% If renewed before
30 days of expiry
Age Sum Loyalty www.icicilombard.com
Insured Details:
(Yr/s) Insured (₹) Bonus (₹) IL TakeCare Insurance App
Ghori Nilesh 18002666
33 yr
Viththalbhai
Whatsapp on 7738282666
GHORI RITABEN
31 yr Agent Name- Turtlemint Insurance Broking
NILESHBHAI
10,00,000 2,00,000 Services Pvt Ltd
GHORI KRUSHN
7 yr Agent Contact Number- 9004753729
NILESH
GHORI AADHYA Agent Code- 3000000273538
2 yr
NILESH
Only for the existing customer. ^updated as on 23rd Jan 2025. *Can be availed only if Befit optional cover is opted and additional premium is paid. The Renewal Notice contains
only an indication of cover offered. For more details on risk factors, terms, conditions and exclusions, please read the policy documents carefully before concluding a sale. ICICI
trade logo displayed above belongs to ICICI Bank and is used by ICICI Lombard GIC Ltd. under license and Lombard logo belongs to ICICI Lombard GIC Ltd. ICICI Lombard
General Insurance Company Limited, ICICI Lombard House, 414, P. Balu Marg, Off Veer Savarkar Road, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025. Toll Free:
1800 2666 Fax No: 022 61961323 IRDAI Reg. No. 115 CIN: L67200MH2000PLC129408, Elevate UIN: ICIHLIP25048V042425, Customer Support Email Id:
customersupport@icicilombard.com Website Address: www.icicilombard.com.
KNOW YOUR CLIENT (KYC) APPLICATION FORM – FOR INDIVIDUALS
(Please fill this form in ENGLISH and in BLOCK LETTERS)
A. IDENTITY DETAILS:
1. Name of the Applicant:
2. Date of birth: D D M M Y Y Y Y 3. PAN:
4. Specify the *Proof of Identity submitted:
B. ADDRESS DETAILS
1. Contact Details: Current residential Address: ________________________________________________________________________
__________________________________________________________ City/Town/Village: ____________________________________
State: _____________________Country: _____________________ Pin Code/ Post box No: ____________________________________
Tel. (Off.): ______________________ Tel. (Res.): _________________________ Fax: ________________________________________
Mobile No.: _____________________ Email id: _______________________________________________________________________
2. Specify the *proof of address submitted for current residential address: ___________________________________________________
______________________________________________________________________________________________________________
*Please refer the list at Annexure A for Identity Proof and Address Proof
C. OTHER DETAILS
1. Occupation Details: (a) Salaried (b) Self Employed/ Business (c) Other (Please specify)
2. Occupation and Nature of Business/Work: __________________________________________________________________________
3. PLEASE TICK, IF APPLICABLE:
(a) **Politically Exposed Person (PEP) (b) Family member/ Close relatives/Associates of PEPs (c) No
If Yes, (Explain Nature of relationship and position hold of PEP): ___________________________________________________________
DECLARATION
• I/We hereby give my/our consent to the Company to verify and obtain my/our identity/address proof for the purpose of undertaking KYC.
• I/We hereby declare and confirm that the premium has been paid out of legally acquired sources of income and the subsequent premiums if
any, will continue to be paid out of legally declared and assessed source of income.
• I/We understand that the Company has right to call for documents to establish source of funds
• I/We hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I/we undertake to
inform you of any changes therein, immediately and not later than 30 days.
• In case any of the above information is found to be false or untrue or misleading or misrepresenting, I/We am/are aware that I/We may be held
liable for it. Further, the Company has a right t o cancel the insurance contract in case, I am/have been found guilty by any competent court of
law under any statutes, directly or indirectly governing the prevention of money laundering.
Signature of Applicant Date: D D M M Y Y Y Y
Insured Name Add-ons
Ghori Nilesh Viththalbhai Befit Plan A
GHORI RITABEN NILESHBHAI Befit Plan A
GHORI KRUSHN NILESH Befit Plan A
GHORI AADHYA NILESH Befit Plan A
Only for the existing customer. ^updated as on 23rd Jan 2025. *Can be availed only if Befit optional cover is opted and additional premium is paid. The Renewal Notice contains
only an indication of cover offered. For more details on risk factors, terms, conditions and exclusions, please read the policy documents carefully before concluding a sale. ICICI
trade logo displayed above belongs to ICICI Bank and is used by ICICI Lombard GIC Ltd. under license and Lombard logo belongs to ICICI Lombard GIC Ltd. ICICI Lombard
General Insurance Company Limited, ICICI Lombard House, 414, P. Balu Marg, Off Veer Savarkar Road, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025. Toll Free:
1800 2666 Fax No: 022 61961323 IRDAI Reg. No. 115 CIN: L67200MH2000PLC129408, Elevate UIN: ICIHLIP25048V042425, Customer Support Email Id:
customersupport@icicilombard.com Website Address: www.icicilombard.com.
