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Product Code: 3005 UIN: IRDAN115RP0015V05201415

Reference No.: W330539744

Date: Jul 10, 2024
SHRUTHI C Y
D O YOGESH C T MATHIGA V
SHIMOGA
KARNATAKA 577222
Mobile No: 9481989388

Sub: Risk Assumption Letter

Dear SHRUTHI C Y,

We value your relationship with ICICI Lombard General Insurance Company Limited and thank you for choosing us as your
preferred insurance provider.
Please find enclosed Policy No. 3005/351608486/00/B00, The same has been issued based on below mentioned details, provided by you at the time of policy
purchase.

Insured & Vehicle Details

Name of the Insured SHRUTHI C Y
Period of Insurance Jul 13, 2024 to Jul 12, 2025
Vehicle Make / Model TVS / SCOOTY ZEST
RTO City KARNATAKA-SHIMOGA
Vehicle Registration No. KA14EQ9167
Vehicle Registration Date May 29, 2018
Engine No. 03417
Chassis No. 03390
Current Year NCB(%) 50%
Previous Policy Details
Previous Policy No. 3005/A/294671754/00/B00
Previous Policy Period 15-06-2023 to 14-06-2024
Previous Year NCB(%) 50%
Claims Made Under Previous Policy 0
Previous Insurer Name ICLB
Previous Policy Type Comprehensive Package
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The commencement of coverage of risk under the policy is subject to realisation of payment of premium in full. In case the premium is not realised due to
cheque dishonour or any other reason, the insurance cover shall be void ab-initio.
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We have issued the policy basis your confirmation that you hold a valid PUC and/or Fitness certificate, as applicable.
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Government of India has mandated electronic toll payments using FASTag to reduce vehicular traffic at toll plazas. Customers are advised to comply with the
direction of the government and get their FASTag from Point of Sale locations at Toll Plazas or from Issuer Agency. Please visit http://www.fastag.org/ for
details.

“Updating your bank details with us would help facilitating future transactions. Bank details can be easily updated using “IL – Take care” App.Download the app
now for all your insurance and wellness needs and for faster resolution”

Please check the policy details for accuracy. Should you find any discrepancy / require any changes in the Certificate of Insurance cum Policy Schedule, please
contact us immediately at our toll free number 1800 2666 or email us at [email protected], so that we can rectify the same. 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.

Important Points:
a. Any accidental loss, damage and/or liability caused, sustained or incurred, while vehicle not being registered permanently will not be covered.
b. Any minor scratches to the vehcile, paint fading, wear and tear arising out of normal use and requiring touch-up or minor repair under routine maintenance
will not be covered.
c. Any liability of whatsoever nature caused by, contributed by or arising due to the vehicle being driven by a person without having valid driving license will not
be covered.

( Please visist www.icicilombard.com for the policy wordings, for complete details on terms and conditions governing the coverage and NCB)

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

Jul 10, 2024

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CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
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Two Wheeler Vehicles Package Policy
Product Code: 3005 UIN: IRDAN115RP0015V05201415

The Compulsory Personal Accident cover has not been opted in this policy on account that, the Owner driver has a separate existing Personal Accident cover
against Death and Permanent Disability (Total and Partial) for Sum Insured of at least Rs.15 lacs.

CORP/SUP/OPI/2014/1777

Jul 10, 2024

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CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
0
Two Wheeler Vehicles Package Policy
Product Code: 3005 UIN: IRDAN115RP0015V05201415

Name of the Insured : SHRUTHI C Y Policy No. : 3005/351608486/00/B00

Address : D O YOGESH C T MATHIGA V, SHIMOGA, KARNATAKA Period of Insurance : Jul 13, 2024 00:00:00 to
577222 Midnight of Jul 12, 2025
Telephone No : Mobile No: 9481989388 E-Policy No. : 3005/351608486/00/B00
Email Address : [email protected] Policy Issued On : Jul 10, 2024
Nominee Name : - Named Passenger's Nominee: Covernote No. : 351608486
Relationship : - - RTO Location : KARNATAKA-SHIMOGA
Age : - Hypothecated To : -
GSTIN No. (Customer) : Invoice No. : 100724917977
Servicing Branch Name : Mumbai
Servicing Branch Address : 414, ICICI LOMBARD HOUSE, VEER SAVARKAR MARG, NEAR SIDDHI VINAYAK TEMPLE MAIN GATE, PRABHADEVI, MUMBAI,
400025, MAHARASHTRA

Politically Exposed Person (PEP)/close relative of PEP: No

Vehicle Registration Make Model Type of Body CC/KW Mfg Yr Seating Chassis No. Engine No.
No. Capacity
Solo With
KA14EQ9167 TVS SCOOTY ZEST 109 2018 2 03390 03417
Pillion
Vehicle IDV Side Car Additional Accessories (`) Electrical / Electronic Non Electrical CNG / LPG Unit Total IDV
(`) (`) Accessories (`) Accessories (`) (`) (`)
31,466.00 0.00 0.00 0.00 0.00 0.00 31,466.00

Premium Details
OWN DAMAGE(A) (`) LIABILITY(B) (`)
Basic OD Premium 28.00 Basic Third Party Liability 714.00
Sub Total 28.00 Total 714.00
Less:
No Claim Bonus 50% 14.00
Sub-Total Deductions 14.00
Total Own Damage Premium(A) 14.00 Total Liability Premium(B) 714.00
Total Package Premium(A+B): 728
% 0.00
CGST
` 0.00
% 0.00
SGST
` 0.00
% 0.00
UTGST
` 0.00
% 18.00
IGST
` 131.04
Total Tax Payable in ` 131.00
Total Premium Payable In ` 859.00
Geographical Area: India Applicable IMT Clauses: 22
Compulsory Deductible: ` 100.00 Voluntary Deductible: ` 0.00

Premium Collection No. 1211529032 Premium Amount ` 859 Receipt Date 10-07-2024
GSTIN Reg.No 27AAACI7904G1ZN HSN/SAC code 997134 / GENERAL
INSURANCE SERVICES
We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under sub-rule (4) of
rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.
Limits of Liability: (a) Under Section II-I(i) of the policy: Death of or bodily injury & (b) Under Section II-I(ii) of the policy: Damage to Third Party Property- Such amount as is
necessary to meet the requirements of the Motor Vehicles (Amendment) Act, 2019 ; PA Cover for Owner-Driver under Section III: CSI 0.00/-. The Compulsory Personal
Accident cover has not been opted in this policy on account that, the Owner driver has a separate existing Personal Accident cover against Death and Permanent
Disability (Total and Partial) for Sum Insured of at least Rs.15 lacs. 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 i s 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".
In consideration of the premium for this extension being calculated at a pro-rata proportion of the annual premium, it is hereby declared and agreed by the insured that upon
expiry of this extension, this policy shall be renewed for a period of twelve months, failing which the difference between the extension premium now paid on pro rata basis
and the premium at short period rate shall become payable by the insured.For Legal interpretation, English version will hold good. Note: After expiry and/or discontinuance
of the Own Damage Cover in the policy, if further Renewal of the Own Damage cover is not done with Us then the coverage available under Section II – “Liability to Third
Parties” will strictly be as per the provisions of the Standard terms of “Liability-Only Policy.” 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 is underwritten on
CORP/SUP/OPI/2014/1777

Jul 10, 2024

 1
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
0
Two Wheeler Vehicles Package Policy
Product Code: 3005 UIN: IRDAN115RP0015V05201415
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 is 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.
The Company reserves the right to cancel this Policy immediately upon becoming aware of any mis-representation, fraud, non-disclosure of material facts or non-
cooperation by or on behalf of the Insured; the Company is not obliged to refund the premium paid under this Policy
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 Jul 10, 2024 in lieu of Covernote No. 351608486. The
stamp duty of ` 0.50 paid vide deface no. CSD0220242018 dated Apr 10, 2024.
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.

Agency Code DB82220 :

Agency Name :
PHONEPE INSURANCE
BROKING SERVICES PVT LTD
Agent's Contact No 8068727888
:

Contact Person :

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2024.07.10 20:34:09 IST
CORP/SUP/OPI/2014/1777

Jul 10, 2024