ICICISlombard

SCHEDULE
POLICY
OF
INSURANCE CUM
IFICATE
Ascellaneous
vehicles Package Policy
P0015V01200203
Nibhaye Vaade
Product Codo:
3008
UIN IRDAN11SR
SASIKUMAR K Pollcy No0 3008/220667228/00/000
Insured N3me

NO-45/90/B/1, 6TH CROSS,

6TH BLOCK, DR RAJKUMAR Perlod ofInsurance May 06, 2021 00:00 to
Addres> ROAD, RAJAJI NAGAR, BANGALORE, KARNATAKA 560010 Midnight of May 05, 2022
Mobile No: 9900054116 E-Policy No
Telephone No
Pollcy Issued On May 26, 2021
Email Address PUNITH9839@GMAILCOM
Named Passengers Nomineo: Covomoto No 220667228
Nominee Namo

Relationship
RTO Locallon KARNATAKA-8ANGALORE
Age
Hypothocatod To KOTAK MAHINDRA BANK

GSTIN Number (Customer)

LTD.BANGALORE
Category SG
Servicing Branch Name Bangalore Involce Number :10052172316
Servicing BranchAddress SecondSVR Complex Hosur Mainroad Bangalore Karnalaka 560068
Registration No. Mako Vehicle SubClass Model Model Build Type of CC Mig Yr Carrying
ESCORTS Body Capacity
KAS1MG6641CONSTRUCTIo
CRANES F15 CRANE
NEQUIPMENT FULLY BUILT| Open 2015
LTD
Chassis No. Engine No. Trailer Body IDV Chassis DV Traller Electrical/Electronic Non Electrical CNG/LPG Total IDVV
Chassis No. () (R) Accessorlas( Accessories(L Unit
169E003620 E413CDEM011
556E 1300000
1300000

RremlomiDatar 2N
oWN DANMAGELA! LIABIUTY[B!
Basic OD Premium
4805 Basic Third Party Llabilly 6847
Overturning Loading 1950 Total
Sub Total 6847
6755 Add:
Less:
PA Cover lor Owner Driver 375
No Cla.m Bonus 25%
1689 Legal Liabilily lo Paid Driver 50
Sub-Tolal Doductions
1689 Sub-Total 425
Total Own Damage Premium(A) 5066| Total Llability Premlum(B)_ 7272
Total Package Premium(A+B) 12338
CGST 1110.42
SGST 1110 42 |

Total Tax Payable In 2221

Total Premlum Payable In 14559 |

Geographical Area: India Applicable IMT Clauses:7

Compuls ory Deductible: 0.5% of lDV of the vehicle subject to a minimum of Rs. 2000/ |Voluntary Deductible: 0
Premium Colleci1on No. 1126731860 Premium Amount 14559 Receipl Dale 04/05/2021
GSTIN Reg No 29AAACI7904G12J HSN/SAC code 997134/ GENERAL INSURANCE SERVICES
Limits ot Liabilty: (a) Under Sectian l-1() of the policy. Death of or bodily injury Such amount as is necessary to meel the requirements ofthe Molor Vehicles Act1988 (b)
Under Seclion 11.I(u) of the policy. Damage lo Third Party Property 750000; PA Cover lor Owner-Driver under Section : CSI R 1500000/. Limitations as to Use: The
Policy covers use only under a permil wilhin the meaning of the Molor Vehicles Acl,1988 or such a cariage fall1ng under sub seclion(3) of Seclion 66 of the Motor Vehicles
Act,1988 The policy does nol cover 1) Use lor organised racing. pace makin9. reliablity Irails or speed lesting. Driver's Clause: Any person includ1ng the insured.
Provided thal a person drivi1ng holds an effeclive driving license at the lime of he accident and is nol disqualilied lrom holding of oblaining such a license. Provided also
iha! Ihe person holding an effecive learners license may also drive Ihe vehicle and that such a person salisfies lhe requirements of Rule 3 of the Ceniral Motor Vehicles
Rules. 1989 Important Notice. The insured is nol indemnified if the vehicle is used or driven othenwise han in accordance with this schedule. Any payment made by the
Company by reason of wider terms appear1ng in the Cert1ficate in order lo comply i l h the Molor vehicle Ac, 1988 is recoverable lrom the insured See the clause headed
AVOIDANCE CF CERTAIN TERMS AND RIGHT OF RECOVERY".In consideration of the premium for Ihis exlension being calculaled al a pro-rata propontion of the annua
. . hered, ceelared and agraed by the insured Ihat upon explry of thia exlensicn, Ihis policy sha be icne ~cd tor a period of tiave months, fa:ing which th
a.lierence berween ihe extension premum now paid on pro rata basis and the premium al short penod rale shall become payable by the insured.
For Leça' inerpietation. English version will hold good. Disclaimer: Please visit www.icicilombard.com lor the policy wordings, for complele delails on term.s and
condiors qverning the coverage and NCB. This documenl is lo be read wilh he policy wordings. Ihe policy Is valid subject to realizalion ol ct.eque. Wa accep: premium
only via legally 1ecognized modes. In case of dishonour of premium cheqve, Ihe company shall not be liable under the policy and ihe policy skall be void ab-irtio. in case
3 Crepancy with respect to the polcy. please revert wilh1n 15 days lrom Ihe policy slarl dale. This policy is underwritlen on Ihe basis of the inlormalion provided by
you and as deladed in Ihe Risk Assumpiion Leller shared wilh you along wilh the policy. On renewai, the benefils provided under the poiicy and/or terms and conditions of
Ihe polcy including premium tale may be subject lo change. Griovance Rodressal: For resolution of any query or grievance you may contact us on our toll free no 1800
2666. or visil any of our branch ofices. You can also wrile lo us al cuslomersuppori@icicilombard.com. For delailed grievance redressal mechanism please visit the
Gievance Redressal' seclion on our websile www.lcicilombard.com.
I/ We hereby ceriily that the Policy lo which this Certifnicale relates, as well as, this Certificate of Insurance are issued in accordance with Ihe provisions of Chapter X and
Chapler XI of M V Act, 1988 in wilness whereof, this Policy has been signed at Mumbal on May 26, 2021 in lieu of Covermote no. 220667228. The slamp duly ot z 0.5 pad
vIde delace no. CSD0820211460 dated Apr 12, 2021.
Veer Savarkar Marg. Near Siddhi Vinayak Temple, Prabhadew,
Policy Issuing Office: ICICI Lombard General Insurance Company Limited, ICICI LOMBARD HOUSE. 414,
Mumbai 400 025
Waranted that the insured named heren/owner of he vehicle holds a valid Polluton Under Control (PUC) Certificals andlorvalid fness certicate.as apphcabl o
date of commencement of the Polhcy and undertakes to ienew and mainlain a valid and ellectve PUC andior ftness Certifcole.a s applicable, during the subssience o

InePolhcy Further the Company reservesIhe nght totake appropriale actionincase of any discrepancy inthe PUC or iness Ceruicote

h c e da cam, imadcioy nctiy Ca Lombrd Gernaral rsusce Carpar Lnted oi a Tol Free Number 1800 26¬0 1{Chargeatie) a655 222566 Co SSA O/
atad 1He bTa0
ealing kcresICI Lotad Generd Inaeranc Compmy Lmdod roetacn Budsing A 18.3011 60, 6r Foo, Hr L Rond Tearse, Pratrada, u
c0
egstred mce Adiros:ICICI Lorrbeu4 Gerdl brsurunce Compssy Lmlzd, KUCI Lambas Hos, 414vir Savaksr .rgi Noar Sodts vinaya
RCALy l19 CN:L57200N-/2000PLC12940
May 26 2021
 s o ri2epainenn.Karnataka
t

COMPUTERISED POLLUTION UNDER CHECK CENTERS

(Rule 231(B)(8) of KMV Rules 1989)
Licence No 548/2002-03 Photo of Vehicle
Center Name
aMG Service
Station & ETC
CenterNear saptagiri Petrol Bunk,
Address B.B.Road, Yelahanka,
Eangalore-560064
Customer
Name SAS! KUMAR K

Customer 9900054116
Mobile
Pucc No D181KA106722 KAS
Vehicle No: KAS1MG6641
Year of Regn
Type of
Vehicle :
06-01-2015
CRANE
HG66
Make: Escorts
Model: CRANE
Test Date: 12-08-2021
Time 16:49
Valid UpTo: i1-02-2022 Holo
Test Data

Flushing Cycle
Certificate is not acceptable without Hologram Sticker 62i
Avg RPM Min RPM Max
Teap Renewed the Certificate within the Expiry Da'
0763 2933 075 Certificate price: 125

RPM
Max
it
Pres Limit for K(Light
Diesel vehicleAbsorption Co- Harriige
Units o
efficient)
Free
0650 29s0 0.13 05.44 075
Acceleration 2.45 65
2 O630 2820 0.47 18.30 075
This Vehicie meets Emission Standaras
3069o| 2880 o.73 26.94 075s Prescribed by Rule 115(2) of CMVR
1989
Certificate is AI! India valid, Six Months for
Mean o.44 17.24 Bharat Stage III or below and one
year fo
Bharat Stage IV
vehicles.

Seal,of Testing Station Testiny Station Code Authorised Signatory

0181
KINDLY DESTROY THE OLD CERTIFICATE & DO NOT HAND OvER TO ETC IN ANY CIRCuMSTANCES.
"

Penalty for
Ai Pollution" Not exceeding for Rs. 1000 for the 1st offence and Not

exceeding
**
for Rs. 2000 for the 2nd & subsequent offence.

Prnt

2 . 1 3 8 10 37 dhest eh s ny-1S,css DICILA tu92.t *IN.. / .1 . .

 T080 2975305
dctortsh@gmail com
wwwesuIaksha kainataka gov.in 3edz d . soriiato-seo o29
o: D®DoK/aza/eot-07/2021-2022
CTao: 04-08-221

e. ad. oxoD
. , rkeseo

(adbas 3lD) dos)

tOBF dis Toi 1948

Be. . zraA

9 ) O: 07-08-2021 Ooc 06-08-2022 d eoasrd esoeaeabsd.

(. beDaa)

o 5), Sde su
becocxtdc,
dorivud-5) 021.
 Date 21.08.202
Ref SMCHMC-17/2021

CERTIFICATE
WHOM SO EVER IT MAY CONCERN

Sub Certificate for Fitness to Operate lHlydraulic Mobile Crane Up to- 15Tons Capacity.

Mr. DEEPAK KUMAR S/o PURNA W ASI SAi!

This is io Certify that
HYDRAULIC MOBILE CRANES whih are
has undergone Safety and Operational Training for
and Operation of
Knowledge about Safety
being used at Construction Work. He is having good

Hydraulic Mobile Crane -15Tons.

the following Points
This letter is issued afier assessing
Address
. Experience Mr.Sashikmar K
2. Operating Procedures Devarachikkanahalli, Bangalore - 569 064

3. Hand Signals

OMPETE
NT PERS

C.J. RAGHURAMU PCR07/2021-2022 198 699

Competent Person
For Iuspeclion, T esting & Cerun
OrCranes, loists, I ifts & Tiftng kiG 2
Government of Karnataka.

Eactories, Boilers, Industrial

Competent Person Authorised bytheDirector of
Safety and IHealth,andGovern1nent of Karnataka.
Certitication of Cranes, Hoists. Lifis
Competent
person for Testing
Tackles
Lifting Tools and
Certificate No. PV PSMC/FYA/CR-07/2021-22.

io 20.08.2022
This Certificate is Valid Up
Validity ;

NAME DEEPAK KUMAR

So. PURNAWASHI SAH
DOB 04.05.1994

Experience:02Years
issued ininout ny
at the tield and
the training provided by
us

being issued is purcly based on

N. B: The certilicate Authorities.
to the terms & conditions laid down by Licencing
Prejudice
 Iest Ceruficate No M S n i ?

FORM NO. 32
(SEE RULE 63)
PRESCRIBEDFOR REPORTOF EXAMINAIION FOR CRANES AND OIHER
LIFTING MACHINEES
EQPT ESCORTS F15 PICK & CARRY MOBILE CRANE
Name of Occupier of the Factory. Mr.SASI KUMARK
Address of the Factory. 43. 2nd A Main Road. Krishna l.ayout.
Devarachikkanalnalli, Bangalore 560976
-

Distinguishing nunmber or mark (if any) and Hydraulic Mobile Crane

desciption sufticient to identify the iifting apacity SWL 14Tons
Machines Chain, Rope or the lifting T'ackle. Hoist Hydraulic winch,4falls. I 3mm diamneter repe
Boom heighi : 17.6OMtrs. YOM 04 2015
Make / Mode! EScORTS FI5 Crane
Registration No KA-S1 MG-6641
Chassis No: 169E003620. Engine No :E413CDENIO1155:
4. Date when the Lilting Machine Chain Rope
Tackle was first taken into use in the
Lifting 2015
factory
Date and number of the Certificate relating to

any test and examination made under Rule

Inspected by us on 21.08.2021
64(5) and 64(6) together with the name and
address of the person who issued the

Cerificate.
Date of each Periodical through Examination
made under Clause (a) (ii) of Sub Seetion (1) Visual examination & tested b, us on u 8 U
of Sec.29 of the Act and Rule 64(7) and by and found in good working conditon
whom itis carried out.
Particulars of any defects affecting the safe No defeets, No damages.
working load found at such through Rated Capucity
examination or after annealing and of the step .35Ton Cap a 2 Oni iadus
aken to remedy such defects. SWL:14Ton, FTT FOR USE.

1We Certify that oin 21-08-2021, 1 We thoroughly examined the above meniioned Liftng Mauitine Cha
Rope / Lifting Tackle and that the above is a correct report of the result.

Datc of Inspeetion 21.08.2021 Next lnspection Due on 219.48.2iy22

NTPERSO
OMPg

PPEMCAA
CR-07/2021-20
C.. RAGHURAN
Competent P'erso
For luspection, Testing & CertificataU.5:
olí ranes, JHoists, L.ifts &Lifting tackle
Goverunienl of Karnataka.

Qualification B.E..
Address Kanthi Industries.
No 59, 5th Main,
Srirampuram, Bangalore - $60021
Certiticate No. PVPSMC FYA/CR-07 021-22
 8 KARNATAKA STATE
INDIAN UNION MOTrOR DRIVING LICENCE

FOR
HA5O 30160008892
HAME DEEPAK KUMAR
DO.B 04/06/1994 B.G.
VALID TIL 02/08/2036{NT) 28/01/2025(TR
BADGE NO 5000245208

VALIO TNROUGHOUT INDIA

CoVLMY 03/06/201
MCWS
PSVBUS
0w08r016
29/01/2020
TRANS 29/01/2020

PURNAWASI SAH
ACORESS NO 817 $T CROsS
JA A ORE
AYOUTYELAHANIA BANGA.ORE SO064
NGALORE NORTH,BANGALORE, KA
Sign Licancing Aurny
SC Heider YELAHANKA-BLORE