ICICI Lombard General Insurance Company Limited

Servicing Office of Insurer: Second and Third Floor, Nungambakkam High Road, Chottabhai Centre, Chennai, Tamil Nadu
600034, Mumbai , Maharashtra-600034, PH-011-18002666 STATE CODE -33
GSTIN: 33AAACI7904G2ZT
IRDA Registration No : 150 UIN:IRDAN115RP0007V01201819
BUNDLED-TWO WHEELER POLICY (1 YR OD + 5 YRS TP) CUM RECEIPT
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)
Policy No. 3005/YA-14226912/00/000 GSTIN : NA Proposal No. & Date P2037136, 27-Apr-2019
Policy Issued On 27-Apr-2019 (17:50) Period Of Own Damage Cover 27-Apr-2019(17:50) to 26-Apr-2020(Midnight)
Period Of Liability Cover 27-Apr-2019 (17:50) to 26-Apr-2024(Midnight) PA Owner Driver 27-Apr-2019 (17:50) to 26-Apr-2020(Midnight)
Insured Name MR. VEERA KARTHICK RAJU Previous Policy No. NA
Insured Add. G3 97/B VILLAGE HIGH ROAD SHOLINGANALLUR Previous Insurer NA
NEAR ECR LINK ROAD TOLL GATE
SHOLINGANALLUR, CHENNAI , TAMIL NADU-
600119
Product Type : ADDON
Make Model Sub Model Cubic Capacity Manufacturing Year Seating capacity
YAMAHA RAY Z (2) B822 113 2018 2
Body Type Registration No. RTO Hypothecation/Lease* Fuel Type Chassis No.
SOLO New SHOLINGANALLUR No PETROL ME1SED1B7J0048641
Engine No. Invoice Date Vehicle IDV Elec. Accessories Non-Elec. Accessories Total IDV
E3Y3E0508198 27-Apr-2019 49,324 0 0 49,324
Schedule of Premium (Amount in Rs.)
Own Damage Premium (A)
Basic Premium Deductibles
Vehicle 465 Voluntary Deductibles (0) (IMT-22A) 0
Non-Elec. Accessories (IMT-24) 0 Anti Theft Device (IMT-10) 0
Elec. Accessories (IMT-24) 0 AA Membership (IMT-8) 0
Sub Total (Basic Premium) 465 No Claim Bonus (0%) 0
IMT 33 0 Handicap Discount (IMT-12) 0
Add On Coverages Nil Depreciation 164 Sub Total (Deductibles) 0
Net Own Damage Premium (A) 629
Liability Premium (B)
Basic Third Party Liability (Including TPPD) 3,285 PA Cover For Owner Driver of Rs. 1500000 (IMT-15)For 1 375
Year
Sub Total (Third Party Liability) 3285 PA Cover ( 100000 Per Person) for 0 Persons(IMT-16) 0
Geographical Area Extension 0 Sub Total (PA Cover) 375
Net Liability Premium (B) 3660
Total Premium (A+B) 4,289
SGST(9.00%) 387
CGST(9.00%) 387
Gross Premium Paid 5,063
Note: 1.Policy issuance is subject to realization of cheque.2.Consolidated stamp duty paid to state exchequer.3.The policy is subject to compulsory deductible of Rs.100 (IMT-22)*Subject to IMT Endt. Nos.& Memorandum:22

Nominee Details
Name of Nominee Age Relationship with Insured Name of Appointee Relationship with Nominee
BANU PRIYA 26 SPOUSE --NA-- --NA--
Insured Declared Value :The schedule of age-wise insured declared(IDV) as shown in the below table is applicable for the purpose of Total loss including Theft/Constructive Total Loss (TL/CTL)
claims only on basis of loss date falling in the respective year. A vehicle will be considered to be a CTL, where the aggregate cost of retrieval and/or repair of the vehicle subject to terms and
conditions of the policy exceeds 75% of the IDV.
Tenure 27-Apr-2019 to 26-Apr-2020 - - - -
IDV 49324 0 0 0 0
Limitations as to use: The policy covers use of the vehicle for any purpose other than (1) Hire or Reward (2) Carriage of goods (other than samples or personal luggage) (3) Organized racing (4)
Pace making (5) Speed testing (6) Reliability trials (7) Any purpose in connection with motor trade.
Driver’s Clause: Any person including the insured: Provided that the person driving holds an effective driving license at the time of the accident and is not disqualified from holding or obtaining
such license. Provided also that the person holding an effective learner’s license may also drive the vehicle & that such a person satisfies the requirements of Rule 3 of the Central Motor Vehicle
Rules, 1989.
Limits of Liability Clause: Under Section II-1(i) of the policy-Death of or bodily injury: Such amount as is necessary to meet the requirements of the Motor Vehicle Act 1988.Under Section II-1
(ii) of the policy-Damage to third party property is Rs. 1 Lakhs PA Cover Under Section III for Owner-Driver is Rs. 1500000 .
Grievance Clause: For resolution of any query or grievance, Insured may contact the respective branch office of the company or may call at( 18002666) or may write an email 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
( customersupport@icicilombard.com).In the event of unsatisfactory response from the Grievance Office, 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.icici.in or on the company
website (www.icici.in).
Hypothecation Details: ----NA----
Important Notice: The insured is not indemnified, if the vehicle is used or driven otherwise than in accordance with the schedule. Any payment made by the company by reasons 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 & RIGHT OF
RECOVERY”. For legal interpretation, English version will hold good.
Disclaimer :Additional deductible: Rs.1000/- or 10% of the claim value whichever is higher for 6th or subsequent admissible claims during the policy period.

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
For & On Behalf of ICICI Lombard General Insurance Company Limited

MISP Code :TTIBI/Y/117502378

SAC :997134 , Description Of Service :MOTOR VEHICLE INSURANCE SERVICES , Place OF Supply :TAMIL NADU(State Code :33) , Invoice Authorized Signatory
:180419537550 Receipt No.180419537550 ,Payment Mode :Cheque
Broker’s Name & Add.: Toyota Tsusho Insurance Broker India Pvt. Ltd., No.53, (NP) Developed Plots, Industrial Estate, Ekkattuthangal,Chennai -600032.
Broker’s Code - DB-403/08
For Renewal/Claims assistance - please contact Ins.Co. & Broker through : BIKERZ CHENNAI at 044-43915776 / 7299075776