Private Car Package Policy CERTIFICATE CUM POLICY SCHEDULE Certificate cum Policy No:3001/73925065/00/000 For any assistance

please call 1800 2 666 Please save the number for your reference For RENEWALS : Visit www.icicilombard.com or call 1800 2 666 DETAILS OF THE POLICY HOLDER POLICY DETAILS

Insured Name Insured Address

BHAGWANBHAI LAKHJRAM THAKKER 42 A2, ARJUN TOWER, NR, SAUNDARYA FLAT, C P NAGAR V2 GHATLODIA, AHMEDABAD GUJARAT PIN - 380061, MOBILE NO. - 919924999000, TELEPHONE NO.:91-Mobile Number 919924999000

Policy Issuing Office

ICICI Lombard General Insurance Company LTD , ICICI LOMBARD HOUSE , 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025 From 00:00 12/09/2012 To 11/09/2013 midnight 24/09/2012 12:00:00 PP10240872 200281629593

Period of Insurance

Contact No. (s) Email Address

Policy Issued On Cover Note No: Intermediary ID

VEHICLE DETAILS

INSURED DECLARED VALUE

Registration no & RTO Location GJ-07-KM-7377 & GUJARAT-AHMEDABAD Vehicle IDV (In Rs.) 5,40,000.00

Make & Model Engine No. Chassis No. MFG Year CC Seating capacity Type of body Volks Wagon & POLO COMFORT LINE DIESEL 141779 65366 2011 1199 5 Saloon Non-Elec Accessories (in Rs.) 0.00 CNG/LPG unit (in Rs.) 0.00 Trailer (in Rs.) 0.00 Total Value (in Rs.) 5,40,000.00 925.00 50.00 100.00 1,075.00 250.00 250.00 250.00 1,325.00 15,743.00 1,945.83 17,689.00

SCHEDULE OF PREMIUM(IN RS.)

Elec/Electronic Accessories (in Rs.) 0.00 10,638.00 3,780.00 14,418.00

Own Damage (A) Basic Own Damage Zero Depreciation (ZD ) Total

Total Own Damage Premium Total Package (A+B) Service Tax(Incl Edu.Cess And Higher Edu.Cess) Geographical Area : India Compulsory Deductibles :

14,418.00

Liability(B) Basic Third Party Liability Paid Driver (Endt. IMT-28) PA Cover For Owner-Driver Of Rs. 2,00,000 Total Add Unnamed PA Cover for 5 Persons of Rs. 1,00,000.00 each Sub Total(Additions) : Total Total Liability Premium Total premium (in Rs.)

Rs.1000

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 7,50,000.00 ; Rs 2,00,000.00 ; Voluntary Deductible Rs. 0 PA Cover for Owner-Driver under section III: CSI

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), organised racing, Pace making, reliability trails or speed testing any purpose in connection with Motor Trade. DRIVER'S CLAUSES: Any person including the insured : Provided that a person driving holds and 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 : Premium Collection Details :- [Collection No / Amount / ReceiptDate] 16,22,28 1032193069 / Rs.17,689.00 / 05/09/2012

Agency Code:- 951121

Agency Name:- HARDIK HARISHKUMAR PARIKH

Agent's mobile no.:- +919924999900

Agent's landline no.:-

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. Policy is valid subject to realization of cheque. We accept premium only via legally recognized modes except for cash. If our representative request you to pay in cash, kindly report it to us. Grievance Clause For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 1800 2 666 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: www.generalinsurancecouncil.org.in or on the Company's website at www.icicilombard.com. 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. Service Tax Registration No. : GIS/MUMBAI-I/1528/2001 Service Tax Code Number : AAACI7904GST001 Category: General Insurance Business Services 00440005. In Witness whereof this Policy has been signed at Mumbai this 24day of September of 2012 in lieu of covernote No PP10240872 The stamp duty of Rs. 0.5 paid in cash or by demand draft or by pay order,vide receipt/challan no. 59419 dated 16/05/2011 For ICICI Lombard General Insurance Company Ltd

Duly Constituted Attorney(s) Copy Of Policy

Mailing Add. Office: ICICI Lombard General Insurance Company LTD , ICICI LOMBARD HOUSE , 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025 Corporate Office: ICICI Lombard General Insurance Company LTD , ICICI LOMBARD HOUSE , 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025