RiskAssumptionLetter

Date:26/10/2016
PANNALALBAIRWA
S/oDevaRanBairwa,
R/oJawanpura,TehRashmi
CHITTORGARH,RAJASTHAN312001
MobileNo.:7737483181
TelNo.:

DearSir/Madam,
WewelcomeyoutotheICICILombardInsurancefamily.
PleasefindenclosedPolicyNo.:3003/A/I49916709/00/000whichhasbeenissuedbasedonthedetailsfurnishedtousasbelow:

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NameoftheInsured:PANNALALBAIRWA
VehicleMake/Model:TATAMOTORS/ACEHT
RTOCity:BHILWARA
VehicleRegistrationNumber:RJ06GA3846
EngineNumber:275IDI05DRZS17938
ChassisNumber:445051DRZV17962
Previouspolicydetailsprovided:No
PreviousPolicyperiod:NotApplicable
PeriodofInsurance:From:00:0027/10/2016To:26/10/2017midnight
PreviousYearNCB:NotApplicable
Dateofregistration:08/06/2008
Claimsmadeinpreviouspolicy:NotApplicable
PreviousInsurerName:NotApplicable
PreviousPolicyNumber:NotApplicable
Previouspolicytype:NotApplicable

Theinformationprovidedhereinaboveisbasedontheinformationreceivedfromyouandaccordingly,thepolicyhasbeenissued.Coverageofriskissubjecttorealisationof
thepremiumbyus.Insurancecoverageunderthepolicywouldcommenceonlyonrealizationoffullpremium.Incasethepremiumisnotreceivedbyusduetodishonouror
whatsoeverreason,theinsurancecovershallbevoidabinitio.
Shouldyoufeelthatthereareanychangesrequired,youarerequestedtoinformusimmediatelybyeitheremailingusatcustomersupport@icicilombard.comorcallingour24
hourtollfreehelplineon18002666.Intheabsenceofanycommunicationfromyouinthisconnectionwithinaperiodof15daysofreceiptofthisletter,wewouldtakeitthat
theissuedpolicyisinorderandasperyourproposal.
Theinformationprovidedaremerelyillustrativeandshallnotbeconstruedtobeanevidenceofexistenceofcontractofinsurance.TheRiskAssumptionLettershallbe
consideredasnullandvoidwithoutthepolicydocumentissuedbytheCompany.ThisRiskAssumptionLetteristobereadinconjunctionwiththepolicycopyattached
herewith.
ThankingYou,
YoursSincerely,

AuthorisedSignatory
ICICILombardGeneralInsuranceCo.Ltd

GOODSCARRYINGVEHICLESLIABILITYPOLICY
CertificatecumPolicySchedule
CertificatecumPolicyNo:3003/A/I49916709/00/000
ForCLAIMS:Call18002666(Tollfreefromallphones)
ForRENEWALS:Visitwww.icicilombard.comorcall18002666
DETAILSOFPOLICYHOLDER

POLICYDETAILS

InsuredName

P A N N A L A L B A I R W A

InsuredAddress

S/oDevaRanBairwaR/oJawanpuraTehRashmi,
C H I T T O R G A R H , R A J A S T H A N , 3 1 2 0 0 1

ContactNo.

7 7 3 7 4 8 3 1 8 1

EmailAddress

leoschittor@gmail.com

PolicyIssuingOffice

ICICILombardGeneralInsuranceCompany
Ltd.ICICILombardHouse,414,VeerSavarkar
Marg,NearSiddhiVinayakTemple,Prabhadevi,
Mumbai400025

PeriodofInsurance

From00:00:00hrsof27 O c t 2016toMidnightof
2 6 O c t 2 0 1 7

PolicyIssuedon

2 6 / 1 0 / 2 0 1 6

CoverNoteNo

A / I 4 9 9 1 6 7 0 9

PolicyClass

PublicCarrier

RTOLocation

B H I L W A R A

IntermediaryID

2 0 1 7 9 6 0 0 4 2 8 5

VEHICLEDETAILS
RegistrationNumber

Make

VehicleSubClass

Model

ModelBuilt

RJ06GA3846

T A T A M O T O R S

P I C K U P V A N S

ACEHT

FULLYBUILT

ChassisNo

EngineNo

445051DRZV17962

275IDI05DRZS17938

TrailerChassisNo

Typeofbody
Open

Trailer

CC

GVW

Mfg.Year

CarryingCapacity

SeatingCapacity

702

1550

2008

SCHEDULEOFPREMIUM(INRS.)
Liability
BasicPremiumincludingpremiumforTPPDvehicle

1 4 3 9 0

TrailersLiability( I M T 3 0 )

Total:

14390

Add
LegalLiabilityToPaidDriver(I M T 4 0)

5 0

SubTotal(Additions):

50

Less
SubTotal(Deductions):

TotalLiabilityPremium

14440

ServiceTax@15%(includes0.5%ofSwachhBharatCess&0.5%KrishiKalyanCess)

2166
TotalPremiumPayable(inRs.)16606

GeographicalArea:India
LIMITSOFLIABILITY:(a)UnderSectionII 1(i)ofthepolicy >Deathoforbodilyinjury:SuchamountasisnecessarytomeetthererequirementsofthemotorvehiclesAct.1988.
(b)UnderSectionII 1(i)ofthepolicy >DamagetoThirdPartyPropertyRs7 5 0 0 0 0PACoverforOwner DriverundersectionIII C S I R s 0 VoluntaryDeductibleRs.
LIMITATIONSASTOUSE:ThePolicycoversuseonlyunderapermitwithinthemeaningoftheMotorVehiclesAct,1988orsuchacarriagefallingundersubsection(3)ofSection66of
theMotorVehiclesAct,1988.Thepolicydoesnotcover1)Usefororganisedracing,pacemaking,reliabilitytrailsorspeedtesting,2)Usewhilstdrawingatrailerexceptthetowing
(otherthanforreward)ofanyonedisabledmechanicallypropelledvehicle3)Useofcarryingpassengersinthevehiclesexceptemployees(otherthanthedriver)notexceedingthe
numberpermittedintheregistrationdocumentandcomingunderthepurviewofWorkmens'sCompensationAct,1923.
DRIVER'SCLAUSES:Anypersonincludingtheinsured:ProvidedthatapersondrivingholdsaneffectiveDrivingLicenseatthetimeoftheaccidentandisnotdisqualifiedfromholdingor
obtainingsuchalicense.ProvidedalsothatthepersonholdinganeffectiveLearner'sLicensemayalsodrivethevehicleandthatsuchapersonsatisfiestherequirementsofRule3ofthe
CentralMotorVehiclesRules,1989.
IMPORTANTNOTICE:TheInsuredisnotindemnifiedifthevehicleisusedordrivenotherwisethaninaccordancewiththisschedule.Anypaymentmadebythecompanybyreasonof
widertermsappearinginthecertificateinordertocomplywiththeMotorVehicleAct,1988isrecoverablefromtheinsured.Seethe c l a u s e h e a d e d ' A V O I D A N C E O F C E R T A I N T E R M S
ANDRIGHTOFRECOVERY'.Forlegalinterpretation,Englishversionwillholdgood.
SubjecttoIMTEndorsementNos.&Memorandumprintedherein/attachedhereto:40
PremiumCollectionDetails: [CollectionNo/Amount/ReceiptDate]2 6 2 4 9 9 5 2/Rs.1 6 6 0 6/2 6 / 1 0 / 2 0 1 6

AgencyCode

9452828

AgencyName

Agent'sMobileNo
EmailId

917737483181
leos606@gmail.com

AgentlandlineNo

VISHNUPRAKASHDHOOT

DISCLAIMER:Pleasevisitwww.icicilombard.comforthepolicywordingsforcompletedetailsontermsandconditionsgoverningthecoverageandNCB.Thisdocumentistobereadwiththepolicy
wordings.

ThispolicyisunderwrittenonthebasisoftheinformationprovidedbyyouandasdetailedintheRiskAssumptionLettersharedwithyoualongwiththepolicy.Incaseofanydiscrepancykindlyletusknow
within15daysfromthedateofreceiptofthisletter.
Policyisvalidsubjecttorealizationofcheque.Weacceptpremiumonlyvialegallyrecognizedmodes.

Incaseofdishonourofpremiumcheque(s)thecompanyshallnotbeliableunderthepolicyandpolicyshallbevoidabinitio(frominception)

GrivanceClause
Forresolutionofanyqueryorgrievance,InsuredmaycontacttherespectivebranchofficeoftheCompanyormaycallat18002098888ormaywriteanemailatcustomersupport@icicilombard.com.Incasethe
insuredisnotsatisfiedwiththeresponseoftheoffice,insuredmaycontacttheGrievanceOfficeroftheCompanyatgrievanceofficer@icicilombard.com.Intheeventofunsatisfactoryresponsefromthe
GrievanceOfficer,he/shemay,subjecttovestedjurisdiction,approachtheInsuranceOmbudsmanfortheredressalofgrievance.DetailsofInsuranceOmbudsmanofficesareavailableatIRDAwebsite:
www.irdaindia.org,oronthewebsiteofGeneralInsuranceCouncil:www.generalinsurancecouncil.org.inorontheCompanyswebsiteatwww.icicilombard.com.

I/Weherebycertifythatthepolicytowhichthecertificaterelatesaswellasthecertificateofinsuranceareissuedinaccordancewiththe
provisionofchapterX,XIofM.VAct1988
ServiceTaxRegistrationNo.:GIS/MUMBAII/1528/2001
ServiceTaxCodeNumber:AAACI7904GST001
Category:GeneralInsuranceBusinessServices00440005.
IRDARegistrationNo.115
InWitnesswhereofthispolicyhasbeensignedatMumbaithisinlieuofcovernoteNoThestampdutyofRs.paidincashorbydemanddraftorby
payorder,videReceipt/Challanno.dated

ForICICILombardGeneralInsuranceCompanyLtd

DulyConstitutedAttorney(s)

ICICILombardGeneralInsuranceCompanyLtd.
MailingAdd.Office:
ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,414,VeerSavarkarMarg,Near
SiddhiVinayakTemple,Prabhadevi,Mumbai400025

CorporateOffice:
ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,414,VeerSavarkarMarg,Near
SiddhiVinayakTemple,Prabhadevi,Mumbai400025