ICICI Lombard General Insurance Company Limited

Corp. Office: ICICI Lombard House, 414, Veer Savarkar Marg,

Deal No. - DL-3001/13652 Agent Name :-
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025
IRDA Registration no.115
Intermediary Code -`2000222162320001, Type -E CHANNEL, A/I - A, IL
Branch - MUMBAI - CO
RENEWAL NOTICE Renewal notice date:- Sep
24, 2023

Insured Name: R C ABDUL RAHIMAN

Insured Address: CHEENATH HOUSE PAVARATTY VIA MARUTHAYOOR
THRISSUR -680507
THRISSUR - 680507, Kerala
Contact Nos: (M):94******80
Email Id: RC*****@YA.COM
Customer Relationship No: `102100572397
Ref:- Renewal of your Private Car Vehicle, Policy Number 3001/236316140/01/B00
Dear Customer,
This is to remind you that your Vehicle insurance policy - Policy no: 3001/236316140/01/B00 expires on Jan 05, 2024. We
will be delighted if you renew the policy with us and give us the opportunity to serve you again. Our representative will get in
touch with you shortly to facilitate your policy renewal.
Your vehicle details and renewal premium computation is given below:
Vehicle Details:- Vehicle Registration Date:Sep 23, 2015
Year
Vehicle Make Registration no NCB/Loading Claims No.of Claim
Engine no. Chasis no. of
Model & RTO Location % Status Claims Amount
mfg.
POLO 1.5
KL46M3616
COMFORTLINE
KERALA- `CWX108301 `MEXE15601FT104258 2015 25 No 0 0.00
DIESEL
GURUVAYUR
VOLKSWAGEN
Renewal premium computation:- Ex. Price:- 724005.00
Depreciated IDV: 217202.00 Basic Premium Including Premium For TPPD Vehicle: 3416.00
Basic Premium: 2547.00 Total Liability Premium: 3416.00
Own Damage Premium: 2547.00 Package Premium: 5278.00
Anti theft discount 64.00 Loading For Break-In-Insurance 0%: 0.00
Deduct NCB / Loading 25% 621.00 GST: 950.00
Total Own Damage Premium: 2061.00 Final Premium: 6228.00

Vehicle Hypothecated with :-

Now add essential add-on covers to your

existing Motor Policy

Add on Covers Amount

Road Side Assistance(RSA) 199.00
Total of Add on Covers 199.00
GST: 36.00
Final Premium(With Add-ons) 6463.00

Named Passenger - PA nominee details

Named of Passenger CSI Name of Nominee Relationship
0.00 FAHD ABDUL RAHIMAN SON
NOTE:
1.In case a claim is lodged before the commencement of the renewed policy, “No Claim Bonus” shall not be applicable and the
Company would be entitled to recover the same. Policy premium/covers would be charged/offered as per company
underwriting guidelines effective on the date of renewal.
2.If the renewal happens after Jan 06, 2024 acceptance of risk is subjective to satisfactory inspection vehicle.
3.Please issue the cheque/DD in favour of "ICICI Lombard General Insurance Co. Ltd."
4.If policy is sought to be renewed after renewal date then premium would be calculated and charged as per company
underwriting guidelines effective on that day.
5.The risk for following cover has been adjusted according to maximum limits provided under India Motor Tariff . Number of
Non fare Paying passenger . Number of Workmen . Number of Employees
6.If any address change please mentioned herein below:-
Address
Telephone/Mobile no.
Nominee details PA-Owner Driver Named Passenger PA(Add/Delete/Modify)

Name: Age:
Relationship:
PA Owner-driver nominee applicable for individual customer only
7. Declaration for PEP:-
Are you or any of the proposed applicants a PEP* or a close relative of a PEP*? Yes No
If yes, please give details:……………………………………………..
*Politically Exposed Persons (PEPs) are individuals who are or have been entrusted with prominent public functions in a
foreign country, e.g., Heads of States/Governments,senior politicians,senior government/judicial/military officers,senior
executives of state-owned corporations,important political party officials,etc.
8. I/We hereby give my/our consent to the Company to verify and obtain my/our identity/address proof as well as the identity
/address proof of the insured through Central KYC Registry or UIDAI or through any other modes for the purpose of
undertaking KYC.
9. Source of Funds:-
Salary Business Others (in case of others, please specify………………………)
I/We hereby declare and confirm that the premium has been paid out of legally acquired sources of income and the subsequent
premiums if any, will continue to be paid out of legally declared and assessed source of income
10. If there is any revision in Motor Third Party (TP) rates, the difference in premium due to the revised rates will be payable
by the policyholder immediately, and if such revised premium is not paid then the motor insurance policy will not be valid.
I agree to receive a One Page Motor Insurance Policy in Physical Form Yes No

Payment Details

Cheque/DD Cheque/DD
Dated:______________________
Number:______________________ Amount:______________________

Bank Name:___________________________________________________ Branch:_______________________

For other mode of

Payment:_______________________________________________________________________________________________
Customer Signature: Date:
"For more information, please visit our website www.icicilombard.com orcallus at our 24 hours All India Toll Free Number
1800 2 666 (Also accessible fromyourmobile)"

Deal No. - DL-3001/13652 Agent Name :-

Intermediary Code - `2000222162320001, Type - E CHANNEL, A/I - A, IL Branch - MUMBAI - CO