Two Wheeler Package Policy

CERTIFICATE CUM POLICY SCHEDULE

For all your insurance needs & query call us at our Toll free No.: 1800-2666(Accessible from your mobile also), you can also E-mail us at:
customersupport@icicilombard.com
Certificate cum Policy No : 3005/2010043749/0000001878
Policy Issuing Office ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025.
ANDHRA PRADESH-
RTO Location
Period of Insurance From 00:00 13/12/2010 To 12/12/2011 midnight RANGAREDDY
Intermediary Code 201765978056
12/12/2010
Insured Name R MANI KUMAR Policy Issued On
15:12:37
FLATNO:201,PADMA SRI ENCLAVE,KUKATPALLY,NIZAMPET
Insured Address Hypothecated With
ROAD ,Kukatpalli, HYDERABAD, ANDHRA PRADESH, Pin - 500085
Primary Vertical Name Bancassurance-Reliance Retail Category
Contact No. 91-9963128902(Mobile No.)
Registration Mfg Seat Chassis
Make Model Type of body CC Engine Number
Number Year Cap Number
DUMCRL150440
AP-28-BB-3750 BAJAJ BAJAJ CT 100 Solo 100 2004 2 DUMBLT03610

Vehicle IDV Side Car Additional Acc NonElectrical Acc Electrical/Electronic Acc CNG/LPG Unit Total Value
11840 0 0 0 0 0 11840
SCHEDULE OF PREMIUM
Own Damage(A) Liability(B)
Basic Own Damage 367.00 Basic Third Party Liability 300.00
Total 367.00 PA Cover For Owner-Driver Of Rs. 100000 50.00
Less
Total 350.00
Bonus Percent 50.00 % 184.00
Sub Total(Deductions): 184.00
Total Own Damage Premium 183.00 Total Liability Premium 350.00
Total Package Premium (A+B) 533.00
Net Premium 533.00
Service Tax(Incl Edu.Cess And Higher Edu.Cess) 55.00
Total Premium 588.00
For No claim Bonus (NCB), Coverages and exclusion of policy Please refer to the policy wordings attached with this schedule, in case of you have not received
your kindly write to us at the below mentioned mailing address.
Compulsory Deductibles : Rs.50 GeographicalArea India *** All Premium figures are in Rupees
Limits Of Liability : (a)Under Section II-1 (i) of the policy->Death of or bodily injury: Such amount as is necessary to meet there requirements of the Motor
Vehicles Act,1988.(b)Under Section II-1 (ii)of the policy-> Damage to Third Party Property Rs 100000.00; PA Cover for Owner-Driver under section III: CSI
Rs 100000.00 Voluntary Deductable Rs.0.00
LIMITATIONS AS TO USE: The policy covers use of the vehicle for any purpose other than : Hire or reward, Carriage of goods(other than samples or personal
luggage), Organized racing, Pace making, Speed testing, Reliability trials, Any purpose in connection with Motor Trade.
DRIVER'S CLAUSES: Any person including the insured : Provided that a person driving holds an effective Driving License at the time of the accident and is not
disqualified from holding or obtaining such a license. Provided also that the person holding an effective Learner's License may also drive the vehicle and that such a
person satisfies the requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.
IMPORTANT NOTICE : The Insured is not indemnified if the vehicle is used or driven otherwise than in accordance with this Schedule. Any payment made by the
Company by reason of wider terms appearing in the Certificate in order to comply with the Motor Vehicle Act, 1988 is recoverable from the Insured. See the clause
headed "AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY". For legal interpretation,English version will hold good
Subject to IMT Endorsement Nos. & Memorandum printed herein / attached hereto : 22,28
Premium Collection Details :
I/We hereby certify that the policy to which the certificate relates as well as the certificate of insurance are issued in accordance with the provision of chapter X,XI
of M.V.Act 1988.

Agency Name: RELIANCE RETAIL INSURANCE

Agency Code: DB35606
BROKING LTD
Agent's Mobile No.: 91-0044771482 Agent's Landline No.:
Disclaimer: Policy is valid subject to Realization of Cheque.
Grievance Clause:
For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 1800-2666 or may write an e-mail at
customersupport@icicilombard.com . In case the insured is not satisfied with the response of the office , insured may contact the Grievance Officer of the
Company at grievanceofficer@icicilombard.com. In the event of unsatisfactory response from the Grievance Officer , he/she may, subject to vested jurisdiction,
approach the Insurance Ombudsman for the redressal of grievance. Details of Insurance Ombudsman offices are available at IRDA website: www.irdaindia.org, or
on the website of General Insurance Council: or on the Company’s website at www.icicilombard.com.
For ICICI Lombard General Insurance Company Ltd
The stamp duty of Re 0.5 paid in cash or by demand draft or by payorder,vide
receipt/challan no. 28125 dated 13/10/2010
Service Tax Registration No. : GIS / MUMBAI-I / 1528 / 2001
Service Tax Code Number. :AAACI7904GST001
Duly Constituted Attorney(s)
Category: General Insurance Business Services 00440005.
COPY OF POLICY
 ICICI Lombard General Insurance Company Ltd
Mailing Add. Office: ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025.
Corporate Office: ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025.
 Invoice
(Issued in terms of Rule 4A of Service Tax Rules, 1994)

Invoice No. :M/2029/101659

Invoice Date: 12/12/2010

Name of client / customer:

R MANI KUMAR
FLATNO:201,PADMA SRI ENCLAVE,KUKATPALLY,NIZAMPET ROAD ,Kukatpalli, HYDERABAD, ANDHRA PRADESH, Pin -
500085

Description of Service: Service Charges

PARTICULARS AMOUNT
Service Charges 89.76
Sub Total 89.76
Add: Service Tax @ 10.00% 8.98
Add: Education Cess @ 2.00% 0.18
Add: SHE Cess @ 1.00% 0.09
Total Amount 99.00
Amount in words: Rupees Ninety Nine Only

Central Service Tax Registration: AADCR4759HST001

Category of Service : Insurance Auxiliary Services

For Reliance Retail Insurance Broking Limited

Authorised Signatory

Corporate Office : Reliance Corporate Park, Building No. 4, 1st Floor, ‘A’ Wing, Ghansoli, Navi Mumbai – 400 701.
Registered Office : 4th Floor, Brindavan, Shriram Mills Compound, Ganpatrao Kadam Marg, Worli, Mumbai – 400 013.
 TWO WHEELER
Proposal Form No. :3005/2010043749/0000001878

Main Features:
I. Own Damage : This product Protects you Against loss or damage to your motor vehicle and/or accessories due to
fire self ignition explosion lightning theft burglary housebreaking riot
strike earthquake flood and allied perils accidental external means malicious acts terrorist activity transit landslide, rockslide
II. Third Party Liability : In addition to the coverage noted above,this product covers you against legal liability towards third party, in respect of the following:
death of or bodily injury to any person damage to property (as per the provision of Motor Vehicle Act.)
We are pleased to inform you that in addition, the product also includes the following:
Personal accident benefits for owner driver upto a value of Rs. 1 lakhs Legal liability towards the paid driver Cover for Rs.1 lakhs for third party property damage
Insured's
Year of Cubic Seating Electrical Non Electrical Additional Date of
Make of Vehicle Model of Vehicle Declared
Manufacturing Capacity Capacity Accessories. Accessories. Accessories. Registration
Value (IDV)
BAJAJ BAJAJ CT 100| 2004 100 2 Rs. 11840.00 Rs. 0.00 Rs. 0.00 Rs. 0.00 12/12/2004
Premium: Rs. 588.00 R. T .O Authority ANDHRA PRADESH-RANGAREDDY
Engine No. DUMBLT03610
Chassis No. DUMCRL150440
Additional Risks, if any
Special Conditions : (Details of
,
HYP/HP/Lease)
1. Registration mark and number and description of vehicle insured AP-28-BB-3750
2. Name R MANI KUMAR
Flat/Building FLATNO:201,PADMA SRI ENCLAVE,KUKATPALLY,NIZAMPET ROAD
Street/Road/Sector
Area/Village/Taluka Kukatpalli
Landmark
City HYDERABAD State ANDHRA PRADESH
PIN 500085 Telephone
Email Mobile No. 9963128902
3. Effective date and time of commencement of insurance for the purpose of the Act Time 00:00 Date 13/12/2010
4. Date of expiry of insurance Midnight of : 12/12/2011
5. Are you entitled to No claim bonus? ( 50.00% ) Yes No if yes, please submit the proof
6. Liability to Third Parties - The Policy Provides Third Party property
Damage (TPPD) of Rs. 1 lakh/-
Do you wish to restrict the above limits to ICICI statutory TPPD liability limit
of Rs. 6000/-only? Yes No
7. Type of Cover Package Policy Liability Only Other Pls. Specify
8. Do you wish to include P.A. Cover for Paid drivers, Cleaners and Conductors Yes No
9. Additional Covers

INSURANCE ACT 1938 SECTION 41-PROHIBITION OF REBATES

No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk
relating to lives or property in india, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy,nor shall any person taking out or
renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the prospectuses or tables of the insurer.Any person making default in
complying with the provisions of this section shall be punishable with fine which may extend to five hundered rupees.

If corporate,vehicle used by Mr./Ms. Use of my vehicle is limited to own premises : Yes No

Phone(with STD Code) : (R) (O) The vehicle is used for Personal purposes : Yes No
Mobile Number : Fax No. : The vehicle belongs to foreign embassy/consulate? : Yes No
Email ID : The car is certified as Vintage car by
(For claim status and renewal reminders) Date of birth : 12/07/1962 Vintage and Classic Car Club of India : Yes No
Sex: M F Marital status: Single Married The vehicle is designed for use of Bind/Handicaped/mentally challenged persons
Professional Qualification: and duly endorsed as such by RTA : Yes No
Doctor MBA Engineer Lawyer Architect The vehicle is chauffeur driven : Yes No
CA Journalist IT Student Graduate Are you a member of Automobile Association ofIndia : Yes No
Post Graduate Other (pl. specify) If Yes : Association Name
Membership Number : Date of expiry:
Status : Individual Proprietorship Partnerships Is the vehicle fitted with the any Anti-theft
Pvt./Public Co's Other (pl. specify) device approved by the ARRI : Yes No
If Individual : Salaried Self Employed Professional Retired Do you wish to avail a Voluntary Excess? : Yes No
If entity Business : Urban Rural Social If yes,please indicate your choice.Select Whichever Applicable
Paid up Capital of Company in Rupees : Private Car 2500 5000 7500 15000
< 10 Crores 10-25 Crores >25 Crores Two-Wheeler 750 1000 1500 3000
Category of Business Whether extension of grogrphical area to the following countries required?
Trading Manufacturing Contracting : Yes No
Financial Services Hospitality Other (pl.specify) Bangladesh,Bhutan,Maldives,Nepal,Pakistan & Sri Lanka.
Do you wish to cover Legal Liability to? If 'Yes' state the name of the countries. 1) 2) 3)
A) Driver (No.of persons ) Yes No Whether the vehicle is driven by non-conventioanl source of power? : Yes No
B) Other employees (No.of persons ) Yes No If yes,please give details.
C) Unnamed Passengers (No.of persons ) Yes No Whether the vehicle is fitted with fibre glass tank? : Yes No
Details of Hire Purchase/Hypothecation/Lease
Are you the ownerdriver* Yes No A)Is the vehicle proposed for insurance:- Under Hire Purchase: Yes No
 Under Lease agreement: Yes No
Optioanl personal accident capital sum insured can be upto Rs 2 lakh per person. Number Under Hypothecation agreement: Yes No
of persons that can be covered is restricted to carrying capacity of the vehicle(excluding B)If yes,give name and address of cencerned parties
driver)
Do you wish to include Personal Accident 5. Are you entitled to No claim Bonus? Yes No if yes,please submit the proof
(P.A.) Cover for named persons? Yes No 6.Liability to Third Parties - The Policy Provides Third Party property
Do you wish to include P.A.Cover for Damage(TPPD) of Rs. 1.0 lakhs/-
unnamed persons, Yes No Do you wish to restrict the above limits to ICICI statutory TPPD liability limit
provide Details in the list below. You may include paid cover, in the list of Rs.6000/-only? Yes No
Sr.No. Name CSI opted(Rs.)
Paid 7. Type of Cover Package Policy Liability Only Other Pls.Specify
Driver
8. Do you wish to include P.A. Cover for Paid drivers, Cleaners and Conductors
1.
Yes No
2.
3. We would like you to know that the policy does not cover consequential loss,
4. depriciation,normal wear and tear,mechanical or electrical breakdown failures or
5. breakages. The vehicle is not held covered if used for commercial purposes or if driven
by an unauthorised driver.
Note: The foregoing is only an indication of the cover offered. For details please refer
(a)Age:Owner Driver Other
to the policy It is our endeavour to provide consistent quality service to all our
Licence effective date : Licence expiry date :
customers. To enable us to deliver our promise, we would appreciate if you take some
I or my driver of this vehicle suffer from defective vision, hearing or are physically
of your precious time to answer all questions fully and correctly to the extent possible.
challenged in any manner.: Yes No
We would like to let you know that insurance is a contract of Utmost Good Faith
If yes, details are
requiring the customer to disclose all material facts without supressing any vital
There is a previous history of driving offences
information whether material or otherwise.
by me or my drivers: Yes No
If in you opinion any fact is material and is not covered by the information sought in the
If yes, details are
application form, we request you to diclose it.
It is important to note that our liability will commence only after we have accepted your
Name and Address of Previous Insurer: ICICI LOMBARD
proposal and the premium has been received in full.
HYDERABAD
Insured's Declared Value (IDV)
Date of purchase of vehicle 12/12/2004
Previous Policy Type :Liability only Cover Package Cover Others Insured's Additional Electrical & Non Side Car Value of Total
Previous Policy No. :00000000989 Declared accessories electronic Electrical (Two CNG/LPG Value
Period of Insurance :13/12/2009 12/12/2010 Value of fitted to the accessories Accessories Wheeler) Kit
Existing bonus/malus status : 45 % vehicle vehicle fitted to the Trailer
(Please attach a copy of last policy/renewal notice held.) vehicle (Pvt.Cars)
In the last three years, is there any history of loss experienced by the propose(s) or Rs.11840 Rs.0 Rs.0 Rs.0 Rs.0 Rs.0 Rs.11840
other drivers who would be using this vehicle Yes No Note:The IDV of the vehicle will be deemed to be the 'SUM INSURED' for the purpose
If Yes, details are: of this tariff and it will be fixed at the commencement of each policy period for each
Date&Time of Name of the driver at the Amount claimed insured vehicle. The IDV of the vehicle is to be fixed on the basis of manufacturers
Nature of Loss listed selling price of the brand and model as the vehicle proposed for insurance at the
loss time of Loss (Rs.)
0 commencement of insurance/renewal, and adjusted for depreciation (as per schedule
specified below).The IDV of this side car(s) and/ or accessories, if any, fitted to the
vehicle but not included in the manufacturers listed selling price of the vehicle is / are
also likewise to be fixed. The schedule of age wise depreciation as shown below is
Has any insurance company ever : applicable for the purpose of total loss/constructive total loss(TL/CTL) claims only. A
A) declined the proposal : Yes No vehicle will be considered to be a CTL where the aggregate cost of retrieval and / or
B) Cancelled&refused to renew : Yes No repair of the vehicle subject to terms and conditions of the policy exceeds 75% of the
(If yes, reasons there for ) IDV.
C) imposed special Condition or excess : Yes No Table 1:Schedule of depriciation for arriving at IDV.
The Insured's declared value (IDV) of the vehicle will be deemed to be the 'Sum
I/We hereby declare that the above statements and particulars are true, accurate and insured'.
complete and I/We declare that this declaration and the answer given above shall be held IDV CALCULATION
to promissory and shall be the basis of the contract between me/us and ICICI Lombard.
The policy may however be continued at the sole discretion of ICICI Lombard , subject to AGE OF THE VEHICLE Depreciation
the payment of the amount payable as determined by ICICI Lombard ,resulting from the Upto 6 Months 5%
difference in the bonus/malus status. I shall endeavor to procure the renewal notice and 6Months 1day to 1Year 15%
pass the same to ICICI Lombard immediately upon receipt of such notice. 1Year 1day to 2Years 20%
2Year 1day to 3Years 30%
Date: 13/12/2010 Signature of Proposer 3Year 1day to 4Years 40%
4Year 1day to 5Years 50%
At the time of Purchase the vehicle was : New Secondhand NOTE:IDV of vehicles beyond 5 years of age and of obsolete models of the vehicles
Will the vehicle be used exclusively for private,social, (i.e.models which the manufacturers have discontinued to manufacture) is to be
domestic,pleasure&professional purposes : Yes No determined on the basis of an understanding between insurer and the insured.
Will the vehicle be used for carriage of *1 Owner driver is defined as "Owner of the Insured Vehicle holding an effective driving
goods other than samples or personal luggage : Yes No license"
The vehicle is in good condition : Yes No 12 A vehicle in "Good Condition" means any vehicle which is in drivable condition
The vehicle is self owned : Yes No without structural and/or mechanical defects.
The vehicle is used for driving tutions : Yes No
The vehicle is used for Commercial purposes : Yes No

I/We hereby declare that the statements made by me/us in this Proposal Form are true to the best of my/our knowledge and belief and I/We hereby agree that this declaration shall
form the basis of the contract between me/us and the ICICI Lombard General Insurance Co. Ltd.
I/We also declare that any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the insurers immediately.
I agree that the Policy shall become voidable at the option of the Insurer, in the event of any untrue or incorrect statement, misrepresentation,non-description or non-disclosure in
any material particular in the proposal form/personal statement, declaration and connected documents, or any material information has been with held by me or anyone acting my
behalf to obtain any benefit under this policy. I affirm, and under take that have read and understood the terms and conditions for usage of Insurance online service of ICICI
Lombard General Insurance Company as displayed on the Web Site www.icicilombard.com and I agree to abide by them.
I/We hereby declare and warrant that the above statements are true, accurate and complete. I/We desire to effect an insurance as described herein with the Company and I/We
agree that this proposal and declarations shall be the basis of contract between me/us and the Company and I/We agree to accept a policy subject to the conditions prescribed by
the Company.
Note : In case of any discrepancy in the policy details, please revert back within 15 days from the date of issue of this policy.
Disclaimer : The Policy stands cancelled or void in the event of Cheque Dishonored.
Place Hyderabad
Proposal Date: 13/12/2010 Print Date: 23/01/2012 Signature of the Proposer