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TWOWHEELERVEHICLEPACKAGEPOLICY CertificatecumPolicySchedule CertificatecumPolicyNo:3005/W21854786/00/000 ForCLAIMS:Call18002666(Tollfreefromallphones) ForRENEWALS:Visitwww.icicilombard.comorcall18002666 DETAILSOFPOLICYHOLDER InsuredName InsuredAddress ContactNo. EmailAddress MRAKASAPUPRASANTKUMAR H19RoomNo702PratikshaNagarSion, MUMBAI,MAHARASHTRA,400022 8879562818 prasant_akasapu@yahoo.

com POLICYDETAILS ICICILombardGeneralInsurance CompanyLtd.ICICILombardHouse,414, VeerSavarkarMarg,NearSiddhiVinayak Temple,Prabhadevi,Mumbai400025 From02:30:28hrsof12Nov2013to Midnightof11Nov2014 12Nov2013 W21854786 MUMBAI N/A None

PolicyIssuingOffice

PeriodofInsurance PolicyIssuingon CoverNoteNo RTOLocation Hypothecatedto TypeofAgreement

VEHICLEDETAILS RegistrationNumber Make Model Typeofbody C C Mfg.Year SeatingCapacity ChassisNumber EngineNumber MH02BN0986 BAJAJ AVENGER200CC SoloWithPillion 200 2009 2 15886 15313 INSUREDDECLAREDVALUE VehicleIDV(inRs.) SideCar NonElectricalAcc(inRs.) Elec/ElectronicAcc(inRs.) CNG/LPGUnit(inRs.) TotalValue(inRs.) 34036 0 0 0 0 34036 SCHEDULEOFPREMIUM(INRS.) OwnDamage(A) BasicPremium Total: Add Less Deduct20%forNCB Total: Liability(B) 567 BasicPremiumincludingpremiumforTPPDvehicle 567 Total: Add PAcoverforOwnerDriver 113 PAcoverforUnnamedPassenger 113 SubTotal(Additions): Less SubTotal(Deductions): 454 TotalLiabilityPremium 420 420 50 140 190 0 610 1064 132 TotalPremiumPayable(inRs.)1196 Compulsorydeductibles:Rs.100/ GeographicalArea:India LIMITSOFLIABILITY:(a)UnderSectionII1(i)ofthepolicy>Deathoforbodilyinjury:Suchamountasisnecessarytomeetthere requirementsofthemotorvehiclesAct.1988. (b)UnderSectionII1(i)ofthepolicy>DamagetoThirdPartyPropertyRs1,00,000PACoverforOwnerDriverundersectionIIICSIRs 1,00,000VoluntaryDeductibleRs.0 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.1196/12/11/2013 DISCLAIMER:Pleasevisitwww.icicilombard.comforthepolicywordingsforcompletedetailsontermsandconditionsgoverningthecoverageand NCB.Thisdocumentistobereadwiththepolicywordings. GrievanceClause Forresolutionofanyqueryorgrievance,InsuredmaycontacttherespectivebranchofficeoftheCompanyormaycalltollfreeno.18002666ormay approachusatthesubsection"GrievanceRedressal"onourwebsitewww.icicilombard.com(CustomerSupportsection).However,iftheresolution providedbyusisnotsatisfactoryyoumayapproachInsuranceRegulatoryandDevelopmentAuthority(IRDA)throughtheIntegratedGrievance ManagementSection(IGMS)orIRDAGrievanceCallCentre(IGCC)attheirtollfreeno.155255.YoumayalsoapproachInsuranceOmbudsman, subjecttovestedjurisdiction,fortheredressalofgrievance.DetailsofInsuranceOmbudsmanofficesareavailableatIRDAwebsite: www.irdaindia.org,orontheCompany'swebsiteatwww.icicilombard.com. Policyisvalidsubjecttorealizationofcheque.Weacceptpremiumonlyvialegallyrecognizedmodesexceptforcash.Ifourrepresentative requestyoutopayincash,kindlyreportittous. Forinformationonombudsmanyoumayvisitourwebsitewww.icicilombard.com I/Weherebycertifythatthepolicytowhichthecertificaterelatesaswellasthecertificateofinsurance areissuedinaccordancewiththeprovisionofchapterX,XIofM.VAct1988 ServiceTaxRegistrationNo.:GIS/MUMBAII/1528/2001 ServiceTaxCodeNumber:AAACI7904GST001 Category:GeneralInsuranceBusinessServices00440005. InWitnesswhereofthispolicyhasbeensignedatMumbaithis12Nov2013inlieuofcovernoteNoW 21854786ThestampdutyofRs.0.50paidincashorbydemanddraftorbypayorder,vide Receipt/Challanno.627977dated28Oct2013 ForICICILombardGeneralInsurance CompanyLtd

TotalOwnDamagePremium TotalPackagePremium(A+B) ServiceTax(InclEdu.CessAndHigherEdu.Cess)

DulyConstitutedAttorney(s)

ICICILombardGeneralInsuranceCompanyLtd. MailingAdd.Office: CorporateOffice: ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse, ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse, 414,VeerSavarkarMarg,NearSiddhiVinayakTemple,Prabhadevi, 414,VeerSavarkarMarg,NearSiddhiVinayakTemple,Prabhadevi, Mumbai400025 Mumbai400025

TwoWheelerPAProposalForm VehicleDetails Registrationlocation(RTO) Manufacturer Model Manufacturingyear Color Currentshowroomprice(Rs.) Detailsofdiscounts&additionalcovers Electricalaccessories(Rs.) Nonelectricalaccessories(Rs.) Automobileassociationmembership ValueofLPG/CNGkitifany(Rs.) Noclaimbonusprotectioncover Garagecashcover Insureddetails MRAKASAPUPRASANT Relationship KUMAR City AddressofTwoWheelerOwner(Policywill H19RoomNo702Pratiksha besenthere) NagarSion Pincode 400022 NameoftheInsured Newpolicydetails Insurancevalue(IDV)(Rs.) Policystartdate TotalPremiumAmount: 1196 34036 12Nov201302:30:28 NoClaimBonus(%) Policyenddate 20 Midnightof11Nov2014 0 MUMBAI 0 No No 0 0 Voluntarydeductible(Rs.) ARAIapprovedantitheftdevice Consumables Returntoinvoicecover 0 No No No MUMBAI BAJAJ AVENGER200CC 2009 68072 Registrationnumber Enginenumber Chassisnumber Purchase/Registrationdate Registrationtype MH02BN0986 15313 15886 15Jun2009 Individual

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 l l l

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

INSURANCEACT1938,SECTION41PROHIBITIONOFREBATES 1.Nopersonshallalloworoffertoallow,eitherdirectlyorindirectlyasaninducementtoanypersontotakeoutorreneworcontinueaninsurance inrespectofanykindorriskrelatingtolivesorpropertyinIndia,anyrebateofthewholeorpartofthecommissionpayableoranyrebateofthe premiumshownonthepolicy,norshallanypersontakingoutorrenewingorcontinuingapolicyacceptanyrebateexceptsuchrebateasmaybe allowedinaccordancewiththeprospectusortablesoftheInsurer. 2.Anypersonmakingdefaultincomplyingwiththeprovisionsofthissectionshallbepunishablewithfine,whichmayextendtofivehundred rupees. SCHEDULEOFDEPRECIATIONFORARRIVINGATIDV %OFDEPRECIATIONFORFIXINGIDV

AGEOFTHEVEHICLE

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