RiskAssumptionLetter

Date:16/12/2015

RoopalNPatel

8NEWASITAPP.,

INQUILABSOC.GULBAITEKRANARANPURA,

AHMEDABAD,GUJARAT380013

MobileNo.:8000561417

TelNo.:

DearSir/Madam,
WewelcomeyoutotheICICILombardInsurancefamily.
PleasefindenclosedPolicyNo.:3005/I40603518/00/000whichhasbeenissuedbasedonthedetailsfurnishedtousasbelow:

1. NameoftheInsured:RoopalNPatel
2. VehicleMake/Model:Suzuki/ACCESS
3. RTOCity:AHMEDABAD
4. VehicleRegistrationNumber:GJ01LM2176
5. EngineNumber:F486293600
6. ChassisNumber:MBCF4CAM98293531
7. Previouspolicydetailsprovided:Yes
8. PreviousPolicyperiod:From18/12/2015to17/12/2016
9. PeriodofInsurance:From:00:0018/12/2015To:17/12/2016midnight
10. PreviousYearNCB:
11. Dateofregistration:17/12/2009
12. Claimsmadeinpreviouspolicy:NO
13. PreviousInsurerName:ICICILombardGeneralInsuranceCo.
14. PreviousPolicyNumber:3005/97295522/00/000
15. Previouspolicytype:ComprehensivePackage

Theinformationprovidedhereinaboveisbasedontheinformationreceivedfromyouandaccordingly,thepolicyhasbeenissued.Coverageofriskissubjecttorealisation
ofthepremiumbyus.Insurancecoverageunderthepolicywouldcommenceonlyonrealizationoffullpremium.Incasethepremiumisnotreceivedbyusduetodishonour
orwhatsoeverreason,theinsurancecovershallbevoidabinitio.

Shouldyoufeelthatthereareanychangesrequired,youarerequestedtoinformusimmediatelybyeitheremailingusatcustomersupport@icicilombard.comorcallingour
24hourtollfreehelplineon18002666.Intheabsenceofanycommunicationfromyouinthisconnectionwithinaperiodof15daysofreceiptofthisletter,wewouldtakeit
thattheissuedpolicyisinorderandasperyourproposal.

Theinformationprovidedaremerelyillustrativeandshallnotbeconstruedtobeanevidenceofexistenceofcontractofinsurance.TheRiskAssumptionLettershallbe
consideredasnullandvoidwithoutthepolicydocumentissuedbytheCompany.ThisRiskAssumptionLetteristobereadinconjunctionwiththepolicycopyattached
herewith.

ThankingYou,
YoursSincerely,

AuthorisedSignatory
ICICILombardGeneralInsuranceCo.Ltd


TWOWHEELERVEHICLEPACKAGEPOLICY
CertificatecumPolicySchedule
CertificatecumPolicyNo:3005/I40603518/00/000
ForCLAIMS:Call18002666(Tollfreefromallphones)
ForRENEWALS:Visitwww.icicilombard.comorcall18002666
DETAILSOFPOLICYHOLDER POLICYDETAILS

InsuredName M R R O O P A L N P A T E L ICICILombardGeneralInsuranceCompany
8NEWASITAPP.INQUILABSOC.GULBAI Ltd.ICICILombardHouse,414,VeerSavarkarMarg,
PolicyIssuingOffice
InsuredAddress TEKRANARANPURA,AHMEDABAD,GUJARAT, NearSiddhiVinayakTemple,Prabhadevi,Mumbai400
3 8 0 0 1 3 0 2 5

ContactNo. 8 0 0 0 5 6 1 4 1 7 From00:00:00hrsof18 D e c 2015toMidnightof

PeriodofInsurance
1 7 D e c 2 0 1 6
EmailAddress R A D H I K A . R A V A L @ R E L I A B L E I N S . I N
PolicyIssuingon 1 6 / 1 2 / 2 0 1 5
CoverNoteNo I 4 0 6 0 3 5 1 8
RTOLocation A H M E D A B A D
Hypothecatedto N / A
TypeofAgreement N o n e

VEHICLEDETAILS
RegistrationNumber&RTOLocation Make&Model Typeofbody C C Mfg.Year SeatingCapacity ChassisNumber EngineNumber
G J 0 1 L M 2 1 7 6 Suzuki&A C C E S S 1 2 5 2 0 0 9 2 M B C F 4 C A M 9 8 2 9 3 5 3 1 F 4 8 6 2 9 3 6 0 0
INSUREDDECLAREDVALUE
VehicleIDV(inRs.) SideCar N o n ElectricalAcc(inRs.) Elec/ElectronicAcc(inRs.) CNG/LPGUnit(inRs.) TotalValue(inRs.)
2 2 5 0 0 0 0 0 0 2 2 5 0 0
SCHEDULEOFPREMIUM(INRS.)
OwnDamage(A) Liability(B)
BasicPremium 4 0 3 BasicPremiumincludingpremiumforTPPDvehicle 5 3 8
Total: 403 Total: 538
Add Add
Less PAcoverforOwnerDriver 5 0
Deduct5 0% forNCB 2 0 2 PAcoverforUnnamedPassenger 1 4 0
Total: 202 SubTotal(Additions): 190
Less
SubTotal(Deductions): 0

TotalOwnDamagePremium 201 TotalLiabilityPremium 728

TotalPackagePremium(A+B) 929

ServiceTax(includes0.5%ofSwachhBharatCess) 135

TotalPremiumPayable(inRs.)1064

Compulsorydeductibles:Rs.100/
GeographicalArea:India

LIMITSOFLIABILITY:(a)UnderSectionII 1(i)ofthepolicy >Deathoforbodilyinjury:SuchamountasisnecessarytomeetthererequirementsofthemotorvehiclesAct.1988.

(b)UnderSectionII 1(i)ofthepolicy >DamagetoThirdPartyPropertyRs1 , 0 0 , 0 0 0PACoverforOwner DriverundersectionIII C S I R s 1 , 0 0 , 0 0 0
LIMITATIONSASTOUSE:Thepolicycoversuseofthevehicleforanypurposeotherthan:Hireorreward,Carriageofgoods(otherthansamplesorpersonalluggage),Organizedracing,
Pacemaking,Speedtesting,Reliabilitytrials,AnypurposeinconnectionwithMotorTrade.
DRIVER'SCLAUSES:Anypersonincludingtheinsured:ProvidedthatapersondrivingholdsaneffectiveDrivingLicenseatthetimeoftheaccidentandisnotdisqualifiedfromholdingor
obtainingsuchalicense.ProvidedalsothatthepersonholdinganeffectiveLearner'sLicensemayalsodrivethevehicleandthatsuchapersonsatisfiestherequirementsofRule3ofthe
CentralMotorVehiclesRules,1989.
IMPORTANTNOTICE:TheInsuredisnotindemnifiedifthevehicleisusedordrivenotherwisethaninaccordancewiththisschedule.Anypaymentmadebythecompanybyreasonof
widertermsappearinginthecertificateinordertocomplywiththeMotorVehicleAct,1988isrecoverablefromtheinsured.Seethe c l a u s e h e a d e d ' A V O I D A N C E O F C E R T A I N T E R M S
ANDRIGHTOFRECOVERY'.Forlegalinterpretation,Englishversionwillholdgood.
SubjecttoIMTEndorsementNos.&Memorandumprintedherein/attachedhereto:22,16
PremiumCollectionDetails: [CollectionNo/Amount/ReceiptDate]NA/Rs.1 0 6 4/1 6 / 1 2 / 2 0 1 5

AgentCode 10032551 AgentName VANDANADEVANGBHAISHAH

AgentMobileNo 918000561417 AgentTelephoneNo
EmailId devang.shah@reliableins.in
DISCLAIMER:Pleasevisitwww.icicilombard.comforthepolicywordingsforcompletedetailsontermsandconditionsgoverningthecoverageandNCB.Thisdocumentistobereadwiththepolicy
wordings.

ThispolicyisunderwrittenonthebasisoftheinformationprovidedbyyouandasdetailedintheRiskAssumptionLettersharedwithyoualongwiththepolicy.Incaseofanydiscrepancykindlyletusknow
within15daysfromthedateofreceiptofthisletter.
Policyisvalidsubjecttorealizationofcheque.Weacceptpremiumonlyvialegallyrecognizedmodes.
GrievanceClause
Forresolutionofanyqueryorgrievance,InsuredmaycontacttherespectivebranchofficeoftheCompanyormaycalltollfreeno.1800 2666ormayapproachusatthesubsection"Grievance
Redressal"onourwebsitewww.icicilombard.com(CustomerSupportsection).However,iftheresolutionprovidedbyusisnotsatisfactoryyoumayapproachInsuranceRegulatoryandDevelopment
Authority(IRDA)throughtheIntegratedGrievanceManagementSection(IGMS)orIRDAGrievanceCallCentre(IGCC)attheirtollfreeno.155255.YoumayalsoapproachInsuranceOmbudsman,
subjecttovestedjurisdiction,fortheredressalofgrievance.DetailsofInsuranceOmbudsmanofficesareavailableatIRDAwebsite:www.irdaindia.org,orontheCompany'swebsiteat
www.icicilombard.com.

I/Weherebycertifythatthepolicytowhichthecertificaterelatesaswellasthecertificateofinsuranceareissuedinaccordancewiththe ForICICILombardGeneralInsuranceCompanyLtd
provisionofchapterX,XIofM.VAct1988
ServiceTaxRegistrationNo.:GIS/MUMBAII/1528/2001
ServiceTaxCodeNumber:AAACI7904GST001
Category:GeneralInsuranceBusinessServices00440005.

IRDARegistrationNo.115
DulyConstitutedAttorney(s)
InWitnesswhereofthispolicyhasbeensignedatMumbaithisinlieuofcovernoteNoThestampdutyofRs.paidincashorbydemand
draftorbypayorder,videReceipt/Challanno.dated

ICICILombardGeneralInsuranceCompanyLtd.
MailingAdd.Office: CorporateOffice:
ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,414,VeerSavarkarMarg, ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,414,VeerSavarkarMarg,
NearSiddhiVinayakTemple,Prabhadevi,Mumbai400025 NearSiddhiVinayakTemple,Prabhadevi,Mumbai400025
 TwoWheelerPAProposalForm

VehicleDetails

Registrationlocation(RTO) A H M E D A B A D Registrationnumber G J 0 1 L M 2 1 7 6
Manufacturer Suzuki Enginenumber F 4 8 6 2 9 3 6 0 0
Model A C C E S S Chassisnumber M B C F 4 C A M 9 8 2 9 3 5 3 1
Manufacturingyear 2 0 0 9 Purchase/Registrationdate 1 7 D e c 2 0 0 9
Color Registrationtype Individual
Currentshowroomprice(Rs.) 4 5 0 0 0

Detailsofdiscounts&additionalcovers
Electricalaccessories(Rs.) 0 Voluntarydeductible(Rs.)
N o n electricalaccessories(Rs.) 0 ARAIapprovedanti theftdevice N o
Automobileassociationmembership Consumables N o
ValueofLPG/CNGkitifany(Rs.) 0 Returntoinvoicecover N o
Noclaimbonusprotectioncover N o
Garagecashcover N o
EngineProtectPlus N o
TyreProtect N o
KeyProtect N o
LossofPersonalBelonging N o

Insureddetails
NameoftheInsured M R R O O P A L N P A T E L Relationship 0
AddressofTwoWheelerOwner(Policywillbesent 8NEWASITAPP.INQUILAB C i t y A H M E D A B A D
here) SOC.GULBAITEKRANARANPURA
Pincode 3 8 0 0 1 3

Newpolicydetails
Insurancevalue(IDV)(Rs.) 2 2 5 0 0 NoClaimBonus(%) 5 0
Policystartdate 1 8 D e c 2 0 1 5 1 2 : 0 0 : 0 0 Policyenddate Midnightof17 D e c 2 0 1 6

TotalPremiumAmount: 1 0 6 4
I.OwnDamage
Thisproductprotectsyouagainstlossordamagetoyourmotorvehicleand/oraccessoriesdueto*Fire*SelfIgnition*Explosion*Lightning*Theft*Burglary*Housebreaking*Riot
*Strike*Earthquake*Floodandalliedperils*Accidentalexternalmeans*Maliciousacts*Terroristactivity*Transit*Landslide/rockslide
II.ThirdPartyLiability
Inadditiontothecoveragenotedabove,thisproductcoversyouagainstlegalliabilitytowardsthirdparty,inrespectofthefollowing:*Deathoforbodilyinjurytoanyperson*damageto
propertyaspertheprovisionsofMotorVehicleAct.Wearepleasedtoinformyouthatinaddition,theproductalsoincludesthefollowing:

l PersonalaccidentbenefitsforownerdriveruptoavalueofRs.200,000.
l Legalliabilitytowardsthepaiddriver.
l CoverforRs.7.5Lacsthirdpartypropertydamage.
l PAcoverforUn namedpassengers.

SignificantExclusions:
Wewouldlikeyoutoknowthatthepolicydoesnotcoverconsequentialloss,depreciation,normalwearandtear,mechanicalorelectricalbreakdownfailuresorbreakages.Thevehicleis
notheldcoveredifusedforcommercialpurposesorifdrivenbyanunauthorizeddriver.Note:Theforegoingisonlyanindicationofthecoveroffered.Fordetailspleaserefertothepolicy.
Itisourendeavortoprovideconsistentqualityservicetoallourcustomers.WewouldliketoletyouknowthatinsuranceisacontractofUtmostGoodFaithrequiringthecustomerto
discloseallmaterialfacts.Ifinyouropinionanyfactismaterialandisnotcoveredbytheinformationsoughtintheapplicationform,werequestyoutodiscloseit.
Itisimportanttonotethatourliabilitywillcommenceonlyafterwehaveacceptedyourproposalandthepremiumhasbeenreceivedinfull.

Declaration:
I/Weherebydeclarethatthestatementsmadebyme/usinthisProposalFormaretruetothebestofmy/ourknowledgeandbeliefandnomaterialinformation,whichmayberelevant,has
beenwithheldornotdisclosedI/Weherebyagreethatthisdeclarationshallformthebasisofthecontractbetweenme/usandthe"ICICILombardGeneralInsuranceCo.Ltd."

I/Wealsodeclarethatanyadditionsoralterationsarecarriedoutafterthesubmissionofthisproposalformthenthesamewouldbeconveyedtotheinsurersimmediately.

I/WeagreethatthePolicyshallbecomevoidableattheoptionoftheInsurer,intheeventofanyuntrueorincorrectstatement,misrepresentation,non descriptionornon disclosurein

anymaterialparticularintheproposalform/personalstatement,declarationandconnecteddocuments,oranymaterialinformationhasbeenwithheldbymeoranyoneactingonmybehalf
toobtainanybenefitunderthispolicy.I/Weherebydeclareandwarrantthattheabovestatementsaretrue,accurateandcomplete.I/Wedesiretoeffectaninsuranceasdescribedherein
withtheCompanyandI/Weagreethatthisproposalanddeclarationsshallbethebasisofcontractbetweenme/usandtheCompanyandI/Weagreetoacceptapolicysubjecttothe
conditionsprescribedbytheCompany.

INSURANCEACT1938,SECTION41PROHIBITIONOFREBATES
1.Nopersonshallalloworoffertoallow,eitherdirectlyorindirectlyasaninducementtoanypersontotakeoutorreneworcontinueaninsuranceinrespectofanykindorriskrelatingto
livesorpropertyinIndia,anyrebateofthewholeorpartofthecommissionpayableoranyrebateofthepremiumshownonthepolicy,norshallanypersontakingoutorrenewingor
continuingapolicyacceptanyrebateexceptsuchrebateasmaybeallowedinaccordancewiththeprospectusortablesoftheInsurer.
2.Anypersonmakingdefaultincomplyingwiththeprovisionsofthissectionshallbepunishablewithfine,whichmayextendtofivehundredrupees.

SCHEDULEOFDEPRECIATIONFORARRIVINGATIDV
A G E O F T H E V E H I C L E % O F D E P R E C I A T I O N F O R F I X I N G I D V
Notexceeding6months 5 %
Exceeding6monthsbutnotexceeding1year 1 5 %
Exceeding1yearbutnotexceeding2years 2 0 %
Exceeding2yearsbutnotexceeding3years 3 0 %
Exceeding3yearsbutnotexceeding4years 4 0 %
Exceeding4yearsbutnotexceeding5years 5 0 %
Note.IDVofobsoletemodelsofvehicles(ie.Modelswhichthemanufacturershavediscontinuedtomanufacture)andvehiclesbeyond5yearsofagewillbedeterminedonthebasisofand
understandingunderstandingbetweentheinsurerandtheinsured.