{I IC1c1~Lombard e;

Two Wh eeter Package Policy

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.Motor Insurance .--
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CERTIFICATE CUM POLICY SCHEDULE

For instant renews/ of '·,,)

your insurance pohcy Jog on to ,,-
www.., ·c,·c,·1 0mbard .com
For all your in sura nce needs & query ca ll us at our Toll free No .: 1800-266 6(Accessible from your mobile also), you can also E-mail us
at:
custo mersueeort l(llJCICt
· tombara .com
Certificate cum Pol icy No: 3005/2011286737 /00/0000000416
N a m e of the Servicing IL Panaji
Branch
Address of IL Branch 101 First Kamat Tower Opp. KTC Bus Sta nd • Panaji Goa 403001

Period of Insurance From 13 :00 28/09/2017 To 27/ 09/2018 midnight RTO Location GOA-PANJIM
Intermediary Code 201428618611
Insured Name AKHIL DINESH TIWARI Policy Issued On 28/09/2017
FLAT NO .C-1,SHRIDHAR APARTMENTS, MERCES,TISWADI, NORTH GOA,
Insured Address

Invoice No
GOA, Pin - 403001
1709172058516 3 ,- , ,?"f;..n~1tl~ 111
- Hypothecated With

I I
Primary Vertical Name BANCASSURANC~M oforJ'i¥:_0,,,1,'lli,etll~ ,(f46i)f ~ IL,{ JI 111 J, ()it~qry
Contact No.
Registration
Number Make
91-9028407 046(MQ.il"ile Ng,) _,..._

Model '""'V
Type o ~.V.I
body
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cc
~,,~e ..::i;
~
Year
Seat
Cap
Chassis Number Engine Number
NEW HONDA ME4KC23AEH8005225 KC23E84015639
CB HORNET 160R Solo With Pillion 162
MOTORCYCLE 2017 2
Vehicle IDV Side Car Additional Ace NonElectrical Ace Electrical/Electroni c Ace CNG/LPG Unit Total Value
83546 0 0 0 0 0 83546
SCHEDULE OF PREMIUM
Own Damage( A) Liabili tvC Bl
Basic Own Damage 882.25
Zero Depreciation Basic Third Party Liabil ity 887 .00
417.73
Total PA Cover For Owner-Driver Of Rs. 100000 50.00
1300,00
Total 937.00
Total Own Damage Premium I 1300.00 Total Liability Premium 937 .00
Total Package Premium (A+B)
2237.00
Net Premium
2237.00
CGST@9%
201 .33
SGST@9%
2.01.33
Total Tax Payable
402 .66
Total Premium
2640.00
For No claim Bonus (NCB), Coverages and exclusion of policy Please refer to the policy wordings attached with this schedule, in case
of you have not received your
kin dly write to us at the below mentioned mailing address.
Compulsory Deductibles: Rs .100 GeographicalArea India *** All Premium figures are in Rupees
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 100000.00; PA Cover for Owner-Driver under section
III: CSI Rs 100000.00
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), Organ ized racing, Pace making, Speed testing, Reliability trials, Any purpose in connection with Motor Trade .
DRIVER'S CLAUSES: 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 obta ining 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 wid er terms appearin g 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 mterpretation,English version will hold good
Subject to IMT Endorsement Nos. & Memorandum printed herein / attached hereto : 22,28
Premium Collection Details : .. , .
I /We hereby certify that the policy to which the certificate relates as well as the cert1f1cate of msurance are .issued .m accordance . . .
with the prov1s1on of chapter X,XI of
M.V.Act 1988.
Disclaimer: Policy is valid subject to Realization of Cheque.

Grievanc~ Clause: . t ct us on our toll free no.1800-2666, or visit any of our branch offices. You can also write to us at
For resolution of any query or grievance yo u may co n a d mechanism please visit the "Grievance Redressal" section on our website www.icicilombard.co m .
customersup port @icicilombard .com . For detailed grievance re ressa I
·de For ICICI Lombard General Insurance Company Ltd
The stamp doty of Re 0.5 pa;d ;, mh o, by demaod d<aft °' by p,yo,de<," ),.:
receipt/challan no. 3115327 dated 7/ 7/2 017
GSTIN Registration No. : 30AAACI7904G1Z O ••
HSN/SAC Code: 9971
Duly Constituted Attorney(s)
SAC DESC: General Insurance Services
COPY OF POLICY
IRDA Registration no. 115
ard General Insurance Company Ltd
ICICI Lomb . . . . .
eer savarka r Marg, Near S1ddh1 Vmayak Temple, Prabhadev1, Mumbai 400025 .
Mailing Add, Office: ICICI LOMBARD HOUSE, 414 • Ver sa varkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025 .
Corporate Office: ICICI LOMBARD HOUSE, 414, Ve

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