no

Product Code: 3005/O UIN: IRDAN115RP0002V01201920

Ref. No. W62624167

Date: Mar 25, 2020

JASWANT SINGH
F 2 THIRD FLOOR BEHIND CANARA BANK
LADO SARAI MEHRAULI
DELHI
DELHI 110030
Mobile No: 9971032297

Sub: Risk Assumption Letter

Dear Sir/Madam,

Thank you for choosing ICICI Lombard General Insurance Company Limited (ICICI Lombard) as your preferred service provider.

Please find enclosed Policy No. 3005/O/197640078/00/000, which has been issued based on the below mentioned details:

Insured & Vehicle Details

Name of Insured JASWANT SINGH
Period of Insurance - Own Damage Mar 31, 2020 to Mar 30, 2021
Vehicle Make / Model HONDA MOTORCYCLE / CB SHINE SP
RTO City DELHI-NEW DELHI
Vehicle Registration No. DL3SEF9067
Vehicle Registration Date Mar 31, 2019
Engine No. JC73E72100163
Chassis No. ME4JC739BK7013558
Current Year NCB(%) 20%
Previous Policy Details
Previous Policy No. 3005/168508988/00/000
Previous Policy Period 31-03-2019 to 30-03-2020
Previous Year NCB(%) 0%
Claims Made Under Previous Policy 0
Previous Insurer Name 0
Previous Policy Type Bundled Package Policy
Third Party Insurance Details
Third Party Policy No. 3005/168508988/00/000
Third Party Period of Insurance Mar 31, 2019 to Mar 30, 2024
Third Party Insurer Name ICICI LOMBARD
1
The information provided above is based on the information received from you and accordingly, the policy has been processed. Coverage of risk is subject to
realisation of the full premium, post which, insurance coverage under the policy would commence. In case the premium is not received by us due to cheque
dishonour or any other reason, the insurance cover shall be void ab-initio.

We have issued the policy basis your confirmation that you hold a valid PUC and/or Fitness certificate, as applicable.

If you require any changes in the Certificate of Insurance cum Policy Schedule, you are requested to inform us by writing to
[email protected] or calling our 24 hour toll free helpline on 1800 2666. Absence of any communication within a period of 15 days of the date
mentioned on this letter, would mean that the issued policy is in order and as per your proposal.

The information provided is merely illustrative and shall not be construed to be an evidence of existence of a contract of insurance. The Risk Assumption Letter
is to be read in conjunction with the policy and shall be considered null and void without the same.

CORP/SUP/OPI/2014/1777

Mar 25, 2020

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
no
Stand-Alone Own Damage Two wheeler Insurance Policy
Product Code: 3005/O UIN: IRDAN115RP0002V01201920

Insured Name : JASWANT SINGH Policy No : 3005/O/197640078/00/000

Address : F 2 THIRD FLOOR BEHIND CANARA BANK, LADO SARAI Period of Insurance - : Mar 31, 2020 00:00:00 to
MEHRAULI, DELHI, DELHI 110030 Own Damage Midnight of Mar 30, 2021
Telephone No : Mobile No: 9971032297 Tenure : 1 year
Email Address : [email protected] E-Policy No : 3005/O/197640078/00/000
Nominee Name : subhadra kumari chauhan Named Passenger's Nominee: Policy Issued On : Mar 25, 2020
Relationship : MOTHER - Covernote No : 197640078
Age : 47 - RTO Location : DELHI-NEW DELHI
GSTIN Number (Customer) : Hypothecated To : -
Servicing Branch Name : New Delhi Invoice Number : 1003201189613
:
This Policy covers only Own Damage Risk with no other liability in connection with Two Wheeler Vehicle including Third Party Cover and is issued basis the following:
Third Party Policy No. - 3005/168508988/00/000, valid from Mar 31, 2019 to Mar 30, 2024, Insured by ICICI LOMBARD

Servicing Branch Address : Fourth Parsavnath Capital Tower Bhai Veer Singh Marg, New Delhi New Delhi 110001 yes

Registration No. Make Model Type of Body CC/KW Mfg Yr Seating Chassis No. Engine No.
Capacity
HONDA Solo With
DL3SEF9067 CB SHINE SP 125 2019 2 ME4JC739BK7013558 JC73E72100163
MOTORCYCLE Pillion
Vehicle IDV Side Car Additional Accessories (`) Electrical / Electronic Non Electrical CNG / LPG Unit Total IDV
(`) (`) Accessories (`) Accessories (`) (`) (`)
54412 0 0 0 0 0 54412

Premium Details
OWN DAMAGE(A) (`)
Basic OD Premium 743
Zero Depreciation (Silver) 463
Sub Total 1206
Less:
No Claim Bonus 20% 149
Sub-Total Deductions 149
Total Own Damage Premium(A) 1057
% 9
CGST
` 95.13
% 9
SGST
` 95.13
Total Tax Payable in ` 190
Total Premium Payable In ` 1247

Unique Identification Number (UIN) Details 46 0 0 0 0

Zero Depreciation
IRDAN115RP0002V01201920/A0003V01201920

Geographical Area: India Applicable IMT Clauses: 22

Compulsory Deductible: ` 100 Voluntary Deductible: ` 0

Features of Add-on Covers:

1. Zero Depreciation Coverage : Zero Depreciation covers only the depreciation on the replaced parts. Consumables are not coverd under Zero Depreciation unless opted as
separate add-on.

Premium Collection No. 1111728843 Premium Amount ` 1247 Receipt Date 25-03-2020
GSTIN Reg.No 07AAACI7904G1ZP HSN/SAC code 9971 / GENERAL INSURANCE SERVICES

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 of personal luggage),
Organised racing, Pace Making, Reliability trails or Speed testing, any purpose in Connection with Motor Trade. Driver's Clause: 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 i s 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. Disclaimer: Please visit www.icicilombard.com
for the policy wordings, for complete details on terms and conditions governing the coverage and NCB. This document is to be read with the policy wordings. The policy is
valid subject to realization of cheque. We accept premium only via legally recognized modes. In case of dishonour of premium cheque, the company shall not be liable
under the policy and the policy shall be void ab-initio. In case of any discrepancy with respect to the policy, please revert within 15 days from the policy start date. This
policy i s underwritten on the basis of the information provided by you and as detailed in the Risk Assumption Letter shared with you along with the policy. On renewal, the
benefits provided under the policy and/or terms and conditions of the policy including premium rate may be subject to change. Grievance Redressal: For resolution of any
query or grievance you may contact us on our toll free no. 1800 2666, or visit any of our branch offices. You can also write to us at [email protected]. For
detailed grievance redressal mechanism please visit the "Grievance Redressal" section on our website www.icicilombard.com.
I/We hereby certify that the Policy to which this Certificate relates, as well as, this Certificate of Insurance are issued in accordance with the provisions of Chapter X and
Chapter XI of Motor Vehicle Act, 1988. In witness whereof, this Policy has been signed at Mumbai on this date of Mar 25, 2020 in lieu of Covernote no. 197640078. The
stamp duty of ` 0.5 paid vide deface no. CSD33120208702020 dated Feb 27, 2019.
Policy Issuing Office: ICICI Lombard General Insurance Company Limited, ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi,
Mumbai 400 025.
Warranted that the insured named herein/owner of the vehicle holds a valid Pollution Under Control (PUC) Certificate and/or valid fitness certificate, as applicable, on the
date of commencement of the Policy and undertakes to renew and maintain a valid and effective PUC and/or fitness Certificate, as applicable, during the subsistence of
the Policy. Further, the Company reserves the right to take appropriate action in case of any discrepancy in the PUC or fitness certificate.
CORP/SUP/OPI/2014/1777

Mar 25, 2020

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
no
Stand-Alone Own Damage Two wheeler Insurance Policy
Product Code: 3005/O UIN: IRDAN115RP0002V01201920

Agency Code AAACO4347B46865

:

Agency Name :
OM SONS PROJECTS PVT
LTD
Agent's Contact No 9212355512
:

Contact Person :

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE COMPANY
LIMITED
Date: 2020.03.25 23:09:22 IST
CORP/SUP/OPI/2014/1777

Mar 25, 2020