TWOWHEELERVEHICLEPACKAGEPOLICY

CertificatecumPolicySchedule
CertificatecumPolicyNo:3005/W57325299/00/000
ForCLAIMS:Call18002666(Tollfreefromallphones)
ForRENEWALS:Visitwww.icicilombard.comorcall18002666
DETAILSOFPOLICYHOLDER POLICYDETAILS
InsuredName SANDRALANAVEENKUMAR ICICILombardGeneralInsurance
HNO316109/4/1,STNO3VASAVINAGAR CompanyLtd.ICICILombardHouse,414,
PolicyIssuingOffice
InsuredAddress RAMANTHAPUR,HYDERABAD,TELANGANA, VeerSavarkarMarg,NearSiddhiVinayak
500013 Temple,Prabhadevi,Mumbai400025
ContactNo. 8686595802 From12:58:02hrsof21Apr2017to
PeriodofInsurance
Midnightof20Apr2018
EmailAddress
PolicyIssuingon 21Apr2017
CoverNoteNo W57325299
RTOLocation HYDERABAD
Hypothecatedto N/A
TypeofAgreement None
VEHICLEDETAILS
RegistrationNumber Make Model Typeofbody C C Mfg.Year SeatingCapacity ChassisNumber EngineNumber
TS08EJ1272 YAMAHA FZSFI SoloWithPillion 149 2015 2 ME1RG0723F0081008 G3C8E0135418
INSUREDDECLAREDVALUE
VehicleIDV(inRs.) SideCar NonElectricalAcc(inRs.) Elec/ElectronicAcc(inRs.) CNG/LPGUnit(inRs.) TotalValue(inRs.)
56700 0 0 0 0 56700
SCHEDULEOFPREMIUM(INRS.)
OwnDamage(A) Liability(B)
BasicPremium 935 BasicPremiumincludingpremiumforTPPDvehicle 720
RoadSideAssistance 199 Total: 720
Total: 1134 Add
Add PAcoverforOwnerDriver 50
Less PAcoverforUnnamedPassenger 140
Deduct25%forNCB 234 SubTotal(Additions): 190
Total: 234 Less
SubTotal(Deductions): 0
TotalOwnDamagePremium 900 TotalLiabilityPremium 910

TotalPackagePremium(A+B) 1810
ServiceTax 253
SwachhBharatCess 9
KrishiKalyanCess 9
TotalPremiumPayable(inRs.)2082
Compulsorydeductibles:Rs.100/ GeographicalArea:India
FeaturesofAddoncover:
1.ListofServicesforRoadsideassistance:Towingonbreakdown/accidentupto50KMs,Arrangement/Supplyoffuel,FlatTyre
support,Breakdownsupportoverphone,MinoronspotRepairs,AccommodationBenefitsforonepersonuptoRs.1000

PAToOwnerDriverNomineeDetails
NomineeName Age RelationShip
saidulu 45 Father

LIMITSOFLIABILITY:(a)UnderSectionII1(i)ofthepolicy>Deathoforbodilyinjury:Suchamountasisnecessarytomeetthere
requirementsofthemotorvehiclesAct.1988.
(b)UnderSectionII1(i)ofthepolicy>DamagetoThirdPartyPropertyRs1,00,000PACoverforOwnerDriverundersectionIIICSIRs
1,00,000
LIMITATIONSASTOUSE:Thepolicycoversuseofthevehicleforanypurposeotherthan:Hireorreward,Carriageofgoods(otherthansamples
orpersonalluggage),Organizedracing,Pacemaking,Speedtesting,Reliabilitytrials,AnypurposeinconnectionwithMotorTrade.
DRIVER'SCLAUSES:Anypersonincludingtheinsured:ProvidedthatapersondrivingholdsaneffectiveDrivingLicenseatthetimeofthe
accidentandisnotdisqualifiedfromholdingorobtainingsuchalicense.ProvidedalsothatthepersonholdinganeffectiveLearner'sLicensemay
alsodrivethevehicleandthatsuchapersonsatisfiestherequirementsofRule3oftheCentralMotorVehiclesRules,1989.
IMPORTANTNOTICE:TheInsuredisnotindemnifiedifthevehicleisusedordrivenotherwisethaninaccordancewiththisschedule.Anypayment
madebythecompanybyreasonofwidertermsappearinginthecertificateinordertocomplywiththeMotorVehicleAct,1988isrecoverablefrom
theinsured.Seetheclauseheaded'AVOIDANCEOFCERTAINTERMSANDRIGHTOFRECOVERY'.Forlegalinterpretation,Englishversionwillhold
good.
SubjecttoIMTEndorsementNos.&Memorandumprintedherein/attachedhereto:22,16
PremiumCollectionDetails:[CollectionNo/Amount/ReceiptDate]NA/Rs.2082/21/04/2017
DISCLAIMER:Pleasevisitwww.icicilombard.comforthepolicywordingsforcompletedetailsontermsandconditionsgoverningthecoverageandNCB.This
documentistobereadwiththepolicywordings.
GrievanceRedressal
Forresolutionofanyqueryorgrievanceyoumaycontactusonourtollfreeno.18002666,orvisitanyofourbranchoffices.Youcanalsowritetousat
customersupport@icicilombard.com.Fordetailedgrievanceredressalmechanismpleasevisitthe"GrievanceRedressal"sectiononourwebsite
www.icicilombard.com.
Policyisvalidsubjecttorealizationofcheque.Weacceptpremiumonlyvialegallyrecognizedmodesexceptforcash.Ifourrepresentativerequestyou
topayincash,kindlyreportittous.Forinformationonombudsmanyoumayvisitourwebsitewww.icicilombard.com
I/Weherebycertifythatthepolicytowhichthecertificaterelatesaswellasthecertificateofinsuranceare ForICICILombardGeneralInsurance
issuedinaccordancewiththeprovisionofchapterX,XIofM.VAct1988 CompanyLtd
ServiceTaxRegistrationNo.:GIS/MUMBAII/1528/2001
ServiceTaxCodeNumber:AAACI7904GST001
Category:GeneralInsuranceBusinessServices00440005.
IRDARegistrationNo.115
InWitnesswhereofthispolicyhasbeensignedatMumbaithisinlieuofcovernoteNoThestampdutyofRs. DulyConstitutedAttorney(s)
paidincashorbydemanddraftorbypayorder,videReceipt/Challanno.dated
 ICICILombardGeneralInsuranceCompanyLtd.
MailingAdd.Office: RegisteredOffice:
ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,414, ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,414,
VeerSavarkarMarg,NearSiddhiVinayakTemple,Prabhadevi,Mumbai400 VeerSavarkarMarg,NearSiddhiVinayakTemple,Prabhadevi,Mumbai400
025 025
 TwoWheelerPAProposalForm

VehicleDetails
Registrationlocation(RTO) HYDERABAD Registrationnumber TS08EJ1272
Manufacturer YAMAHA Enginenumber G3C8E0135418
Model FZSFI Chassisnumber ME1RG0723F0081008
Manufacturingyear 2015 Purchase/Registrationdate 11Apr2015
Color Registrationtype Individual
Currentshowroomprice(Rs.) 81000

Detailsofdiscounts&additionalcovers
Electricalaccessories(Rs.) 0 Voluntarydeductible(Rs.) 0
Nonelectricalaccessories(Rs.) 0 ARAIapprovedantitheftdevice No
Automobileassociationmembership Consumables No
ValueofLPG/CNGkitifany(Rs.) 0 Returntoinvoicecover No
Noclaimbonusprotectioncover No
Garagecashcover No

Insureddetails
NameoftheInsured SANDRALANAVEENKUMAR Relationship 0
HNO316109/4/1,STNO3 City HYDERABAD
AddressofTwoWheelerOwner(Policywill
VASAVINAGAR
besenthere)
RAMANTHAPUR
Pincode 500013

Newpolicydetails
Insurancevalue(IDV)(Rs.) 56700 NoClaimBonus(%) 25
Policystartdate 21Apr201712:58:02 Policyenddate Midnightof20Apr2018

TotalPremiumAmount: 2082

I.OwnDamage
Thisproductprotectsyouagainstlossordamagetoyourmotorvehicleand/oraccessoriesdueto*Fire*SelfIgnition*Explosion*Lightning*Theft
*Burglary*Housebreaking*Riot*Strike*Earthquake*Floodandalliedperils*Accidentalexternalmeans*Maliciousacts*Terroristactivity*Transit
*Landslide/rockslide
II.ThirdPartyLiability
Inadditiontothecoveragenotedabove,thisproductcoversyouagainstlegalliabilitytowardsthirdparty,inrespectofthefollowing:*Deathofor
bodilyinjurytoanyperson*damagetopropertyaspertheprovisionsofMotorVehicleAct.Wearepleasedtoinformyouthatinaddition,the
productalsoincludesthefollowing:

l PersonalaccidentbenefitsforownerdriveruptoavalueofRs.200,000.
l Legalliabilitytowardsthepaiddriver.
l CoverforRs.7.5Lacsthirdpartypropertydamage.
l PAcoverforUnnamedpassengers.

SignificantExclusions:
Wewouldlikeyoutoknowthatthepolicydoesnotcoverconsequentialloss,depreciation,normalwearandtear,mechanicalorelectrical
breakdownfailuresorbreakages.Thevehicleisnotheldcoveredifusedforcommercialpurposesorifdrivenbyanunauthorizeddriver.Note:The
foregoingisonlyanindicationofthecoveroffered.Fordetailspleaserefertothepolicy.Itisourendeavortoprovideconsistentqualityserviceto
allourcustomers.WewouldliketoletyouknowthatinsuranceisacontractofUtmostGoodFaithrequiringthecustomertodiscloseallmaterial
facts.Ifinyouropinionanyfactismaterialandisnotcoveredbytheinformationsoughtintheapplicationform,werequestyoutodiscloseit.
Itisimportanttonotethatourliabilitywillcommenceonlyafterwehaveacceptedyourproposalandthepremiumhasbeenreceivedinfull.

Declaration:
I/Weherebydeclarethatthestatementsmadebyme/usinthisProposalFormaretruetothebestofmy/ourknowledgeandbeliefandnomaterial
information,whichmayberelevant,hasbeenwithheldornotdisclosedI/Weherebyagreethatthisdeclarationshallformthebasisofthecontract
betweenme/usandthe"ICICILombardGeneralInsuranceCo.Ltd."

I/Wealsodeclarethatanyadditionsoralterationsarecarriedoutafterthesubmissionofthisproposalformthenthesamewouldbeconveyedto
theinsurersimmediately.

I/WeagreethatthePolicyshallbecomevoidableattheoptionoftheInsurer,intheeventofanyuntrueorincorrectstatement,misrepresentation,
nondescriptionornondisclosureinanymaterialparticularintheproposalform/personalstatement,declarationandconnecteddocuments,or
anymaterialinformationhasbeenwithheldbymeoranyoneactingonmybehalftoobtainanybenefitunderthispolicy.I/Weherebydeclareand
warrantthattheabovestatementsaretrue,accurateandcomplete.I/WedesiretoeffectaninsuranceasdescribedhereinwiththeCompanyand
I/Weagreethatthisproposalanddeclarationsshallbethebasisofcontractbetweenme/usandtheCompanyandI/Weagreetoacceptapolicy
subjecttotheconditionsprescribedbytheCompany.


ProhibitionofRebatesUnderSection41ofInsuranceLaw(AmendmentAct2015)
1.Nopersonshallalloworoffertoallow,eitherdirectlyorindirectlyasaninducementtoanypersontotakeoutorreneworcontinueaninsurance
inrespectofanykindorriskrelatingtolivesorpropertyinIndia,anyrebateofthewholeorpartofthecommissionpayableoranyrebateofthe
premiumshownonthepolicy,norshallanypersontakingoutorrenewingorcontinuingapolicyacceptanyrebateexceptsuchrebateasmaybe
allowedinaccordancewiththeprospectusortablesoftheInsurer.
2.Anypersonmakingdefaultincomplyingwiththeprovisionsofthissectionshallbeliableforapenalty,whichmayextendtotenlakhsrupees.

SCHEDULEOFDEPRECIATIONFORARRIVINGATIDV
AGEOFTHEVEHICLE %OFDEPRECIATIONFORFIXINGIDV
Notexceeding6months 5%
Exceeding6monthsbutnotexceeding1
15%
year
Exceeding1yearbutnotexceeding2years20%
Exceeding2yearsbutnotexceeding3
30%
years
Exceeding3yearsbutnotexceeding4
40%
years
Exceeding4yearsbutnotexceeding5
50%
years
Note.IDVofobsoletemodelsofvehicles(ie.Modelswhichthemanufacturershavediscontinuedtomanufacture)andvehiclesbeyond5yearsof
agewillbedeterminedonthebasisofandunderstandingunderstandingbetweentheinsurerandtheinsured.