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VEHICLEDETAILS

INSUREDDECLAREDVALUE
SCHEDULEOFPREMIUM(INRS.)

TWOWHEELERVEHICLEPACKAGEPOLICY
CertificatecumPolicySchedule
CertificatecumPolicyNo:3005/W26476515/00/000
ForCLAIMS:Call18002666(Tollfreefromallphones)
ForRENEWALS:Visitwww.icicilombard.comorcall18002666
DETAILSOFPOLICYHOLDER POLICYDETAILS
InsuredName BUDDHADEVGANTAYATB.G
InsuredAddress
NO133BF2RBFLATSMADURAMNAGAR
3RDSTREETIYYAPPANTHANGALPIN
600122,CHENNAI,TAMILNADU,600056
ContactNo. 9444414177
EmailAddress
PolicyIssuingOffice
ICICILombardGeneralInsurance
CompanyLtd.ICICILombardHouse,414,
VeerSavarkarMarg,NearSiddhiVinayak
Temple,Prabhadevi,Mumbai400025
PeriodofInsurance
From00:00:00hrsof23Apr2014to
Midnightof22Apr2015
PolicyIssuingon 20Apr2014
CoverNoteNo W26476515
RTOLocation CHENNAI
Hypothecatedto N/A
TypeofAgreement None
RegistrationNumber Make Model Typeofbody CC Mfg.Year SeatingCapacity ChassisNumber EngineNumber
TN10H2155 HEROHONDA SPLENDOR Solo 100 2003 2 21605 10896
VehicleIDV(inRs.) SideCar NonElectricalAcc(inRs.) Elec/ElectronicAcc(inRs.) CNG/LPGUnit(inRs.) TotalValue(inRs.)
17150 0 0 0 0 17150
OwnDamage(A)
BasicPremium 463
Total: 463
Add
Less
Deduct50%forNCB 232
Total: 232
Liability(B)
BasicPremiumincludingpremiumforTPPDvehicle 464
Total: 464
Add
PAcoverforOwnerDriver 50
PAcoverforUnnamedPassenger 140
SubTotal(Additions): 190
Less
SubTotal(Deductions): 0
TotalOwnDamagePremium 231 TotalLiabilityPremium 654
TotalPackagePremium(A+B) 885
ServiceTax(InclEdu.CessAndHigherEdu.Cess) 109
TotalPremiumPayable(inRs.)994
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.994/20/04/2014
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.
InWitnesswhereofthispolicyhasbeensignedatMumbaithis23Apr2014inlieuofcovernoteNoW
26476515ThestampdutyofRs.0.50paidincashorbydemanddraftorbypayorder,vide
Receipt/Challanno.1783054dated28Feb2014
ForICICILombardGeneralInsurance
CompanyLtd

DulyConstitutedAttorney(s)
ICICILombardGeneralInsuranceCompanyLtd.
MailingAdd.Office:
ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,
414,VeerSavarkarMarg,NearSiddhiVinayakTemple,Prabhadevi,
Mumbai400025
CorporateOffice:
ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,
414,VeerSavarkarMarg,NearSiddhiVinayakTemple,Prabhadevi,
Mumbai400025
TwoWheelerPAProposalForm
VehicleDetails
Registrationlocation(RTO) CHENNAI
Manufacturer HEROHONDA
Model SPLENDOR
Manufacturingyear 2003
Color
Currentshowroomprice(Rs.) 49000
Registrationnumber TN10H2155
Enginenumber 10896
Chassisnumber 21605
Purchase/Registrationdate 19Apr2011
Registrationtype Individual
Detailsofdiscounts&additionalcovers
Electricalaccessories(Rs.) 0
Nonelectricalaccessories(Rs.) 0
Automobileassociationmembership 0
ValueofLPG/CNGkitifany(Rs.) 0
Noclaimbonusprotectioncover No
Garagecashcover No
Voluntarydeductible(Rs.) 0
ARAIapprovedantitheftdevice No
Consumables No
Returntoinvoicecover No
Insureddetails
NameoftheInsured BUDDHADEVGANTAYATB.G
AddressofTwoWheelerOwner(Policywill
besenthere)
NO133BF2RBFLATS
MADURAMNAGAR3RD
STREETIYYAPPANTHANGAL
PIN600122
Pincode 600056
Relationship 0
City CHENNAI
Newpolicydetails
Insurancevalue(IDV)(Rs.) 17150
Policystartdate 23Apr201412:00:00
NoClaimBonus(%) 50
Policyenddate Midnightof22Apr2015
TotalPremiumAmount: 994
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.
INSURANCEACT1938,SECTION41PROHIBITIONOFREBATES
1.Nopersonshallalloworoffertoallow,eitherdirectlyorindirectlyasaninducementtoanypersontotakeoutorreneworcontinueaninsurance
inrespectofanykindorriskrelatingtolivesorpropertyinIndia,anyrebateofthewholeorpartofthecommissionpayableoranyrebateofthe
premiumshownonthepolicy,norshallanypersontakingoutorrenewingorcontinuingapolicyacceptanyrebateexceptsuchrebateasmaybe
allowedinaccordancewiththeprospectusortablesoftheInsurer.
2.Anypersonmakingdefaultincomplyingwiththeprovisionsofthissectionshallbepunishablewithfine,whichmayextendtofivehundred
rupees.
SCHEDULEOFDEPRECIATIONFORARRIVINGATIDV
AGEOFTHEVEHICLE %OFDEPRECIATIONFORFIXINGIDV
Notexceeding6months 5%
Exceeding6monthsbutnotexceeding1
year
15%
Exceeding1yearbutnotexceeding2years20%
Exceeding2yearsbutnotexceeding3
years
30%
Exceeding3yearsbutnotexceeding4
years
40%
Exceeding4yearsbutnotexceeding5
years
50%
Note.IDVofobsoletemodelsofvehicles(ie.Modelswhichthemanufacturershavediscontinuedtomanufacture)andvehiclesbeyond5yearsof
agewillbedeterminedonthebasisofandunderstandingunderstandingbetweentheinsurerandtheinsured.