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ICICISLombard
Nibhaye Vaade

Product Code: 3005 UIN:IRDAN115RP0020V01202122


Date:Sep 27, 2023
MR. MANTRIPRAGADA AVINASH
2~9~11/6, KOTHABASTHI
MACHA BOLLARAM, ALWAL..MEDCHAL M GIRI
HYDERABAD
TELANGANA - 500010 - BOLLARAM
Mobile No:7993021631

Sub: Risk Assumption Letter

Dear Sir/Madam,
Thank you for choosing ICICI Lombard General Insurance Company Limited (ICICI Lombard) as your preferred service provider.
Please find enclosed Policy No. 3005/2011488876/00/0000023760, which has been issued based on the below mentioned details:

nsUe0 RVenice
MR. MANTRIPRAGADAAVINASH
Name of insured
Period of insurance-Own Damage |Sep 27, 2023 to Sep 26, 2024
Poriod of insurance-ThirdRarty Sep 27, 2023 to Sep 26, 2028
Period of insurance-PA Owner Driver Sep 27, 2023 to Sep 26, 2024
HONDA MOTORCYCLE l ACTIVA 125 SMART OBD2
Vehicle Make/Model
RTOCity TELANGANA-HYDERABAD
|Vehicle Registration No. NEW
Vehicle Registration Date Sep 27, 2023
Engine No. JK13EG8014273
Chassis No. ME4JK13EJPGO14004
The information provided above is based on the information received from you and accordingly, the policy has been processed. Coverage
of risk is subject to realization of the full premium, post which, insurance coverage under the policy would commence. Incase the premium
is not received by us due to cheque dishonour or any other reason, the insurance cover shall be void ab-initio.

We have issued the policy basis your confirmation that you hold a valid PUC and/or Fitness Certificate, as applicable.

Government of India has mandated electronic toll payments using FASTag to reduce vehicular traffic at toll plazas. Customers are advised
io 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.
If you require any changes in theor Certificate of Insurance cum Policy Schedule, you are requested to inform us by writing to
Customersupport@icicilombard.com calling our 24 hour toll free helpline on 1800 2666. 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.

to be an evidence of existence of a contract of insurance. The


The information provided is merely illustrative and shall not be construed be considered null and void without the same.
Risk A e t t e r is to be read in conjuction with the policy and shall

anio
ORTUN
nceely,

MOT
ral Insurance Company Ltd.

Sia ICICI Lombard General Insurance Company Ltd

In case of claim, immediately notify CICI Lombard General Insurance Conpany Linited on the
or SMS "CLAIM to 575758
Toll Free Number 1800 2666save the policy details and the contact numbers 1800 2666(Toll Free)
that you
For quick reference during emergencies, we recommand
09223622666(chargeable)
on your easily accessiblenemobile handset. CIN:L67200MH2000PLC129408
Malad(West), Mumbai - 400 064, |IRDAReg. No. 115,
Mailing Address: 401 & 402, 4th floor, Inteface 11, New Linking Road,

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Page 2 of5

Bundled - Two wheeler Policy


ICICILombard
Nibhaye Vaade. Product Code: 3005
UIN:IRDAN115RP0020V01202122
CERTIFICATE CUM POLICY SCHEDULE

For instant renewval of


your insurance policy log on to
www.icicilombard.com
For all your insurance needs & query call us at our Toll free No.: 1800-2666(Accessible from your moblle also), you can also E-mail us at
Customersupport@icicilombard.com
Certificate cum Policy No : 3005/2011488876/00/0000023760
Name of the Servicing IL Hyderabad
|Branch
Address of IL Branch D. No 6-3-352 1, Second and Third Osman Plaza Road No 1, Hyderabad Telangana
500034
Tenure Years RTO Location ITELANGANA-HYDERABAD
|OD-From 17:53 27/09/2023 To 26/09/2024 midnight
Period of Insurance TP-From 17:53 27/09/2023 To 26/09/2028 midnight Intermediary Code 2010765431450001
PA Owner Driver 17:53 27/09/2023 To 26/09/2024 midnight
Insured Name MANTRIPRAGADA AVINASH Policy Issued On 27/09/2023
IInsured Address |2~9~11/6, KOTHA BASTHI MACHA BOLLARAM, ALWAL,,,MEDCHAL BAJAJ FINANCE
M GIRI, HYDERABAD, TELANGANA, Pin - 500010 Hypothecation With LTD.,PRAKASH NAGAR,NEAR
METRO STATION,None
Invoice No 17092326046219 Category
Primary Vertical Name BANCASSURANCE-Motor Two Wheeler (M6) Contact No. 91-799302 1631(Mobile No.)
Registration Make Model
Mfg Seat
Number Type of body CC
Year Cap
Chassis Number Engine Number
HONDA ACTIVA 125 2023 ME4JK13EJPGO14004
NEW Solo With Pillion 125
MOTORCYCLE SMART OBD2 JK13EG8014273
NonElectrical CNG/LPG
Vehicle IDV Side Car Additional Acc Ac Electrical/Electronic Acc Unit
Total Value
86831 0 86831
SCHEDULE OF PREMIUM
Own Damage(A)
Basic Own Damage
Liability(B)
920.02 Basic Third Party Liability 3851.0o
Zero Depreciation 520.99 PA Cover For Owner-Driver Of Rs. 1500000 450.00
Total 1441.00
Total 4301.00
Total Own Damage Premium 1441.00 Total Liability Premium 4301.00
Total Package Premium (A+B) 5742.00
Net Premium 5742.00
jCGST@9% 516.78
sGST@9% 516.78
Total Tax Payable 1033.56
ITotal Premium 6776.00
UIN Details
Zero Depreciation
IRDAN115A0020V01200910
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
kindly write to us at the below mentioned mailing address.
Compulsory Deductibles : Rs. 100 GeographicalArea India *** AlI Premium fiqures are in Rupees
Limits Of Liability : (a)Under Section I1-1(i) of the policy: Death of or bodily injury &(b) Under Section II-1(i)0f the policy: Damage to Third Party Property- Such
amount as is necessary to meet there requirements of the Motor Vehicles (Amendment)Act,2019; PA Cover for Owner-Driver under section III: CsI 1500000.00/- for t
year
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), Organized 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
jdisqualified 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 : In consideration of the premium for thi_ extension being calculated at a pro-rata proportion airemium,
e it is hereby deciared and
agreed by the insured that upon expiry of this extension, this policy shall be renewed for a period of twelve month ANDweieference tween 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
Subject to IMT Endorsement Nos. & Memorandum printed herein /attached hereto 22,28
emium Collection Details :
h tr provision of Chapter XI of
hereby certify that the policy to which the certificate relates as well as, this certiflcate of insurance are
Motar vehicle Act. 1988. ance
Agency Code: AAACES155E44998 |Agency Name: FORTMOTOKYAIVATE LIMITED
Agent's Mobile No.: 91-9948888045 Agent's Landline No.:
Disclaimer:
ito Please
ho read with
be
visit www.icicilombard.com for the policy wordings, for complete details on terms and conditions governing the coverage and NCB. This docurment
the policy wordings.The policy is valid subject realization of cheque. We accept premium only via legally recognized modes. In case of dishonor of
premium cheque, The company
revert within 15 days
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. nle
the policy start date. This policy is underwritten on the basis of the information provided by you and as detailed in the Risk ASSUa
Letter shared with you
be subiect to change.
along with the policy. On renewal, the benefits provided under the polcy and/or terms and conditions of the policy including premium n
Grievance Clause:
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 lus at
customersupport@icicilombard.com. For detailed grievance redressal mechanism please visit the "Grievance Redressal" section on our website wwwiclcloms
The stamp duty of Re. 0.5 paid vide déface no. CSD52020224718 dated Nov 04, For ICICI Lombard General Insurance Company Ltd
2022
GSTIN Registration No. :36AAACI7904G1ZO
HSN/SAC Code: 997134
SAC DESC: General Insurance Services
Duly Constituted Attorney (s)

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Page 3 of 5

Registration no. 115 COPY OF POLICY

cae tat the insured named herein/owner of the vehicle holds aValid Pollution Under Control(PUC) Certificate and/or valid fitness certificate,
Jdate of commencem as aplicable,on the
the policy.Further . ,the c of the Policy
ho Company and undertakes
reserves the right to totake
renew and maintain
appropriate actionainvalid
caseand effective
of any PUCand/or
discrepancy in thefitness certificate,as
PUC or applicable
,during the subsistence of
fitness certificate.
ICICI Lombard General Insurance Company Ltd

In case of claim, immediately notify ICICI Lombard General Insurance Company Limited on the
Toll Free Number 1800 2666 or SMS "CLAIM" to 575758
For quick reference during emergencies, we recommand that you save the policy details and the contact numbers 1800 2666(Toll Free)
09223622666(chargeable)
on your easily accessible mobile handset.
Mailing Address: 401 &402, 4th floor, Interface 11, New Linking Road, Malad(West), Mumbai - 400 064, IRDA Reg. No. 115, CIN:L67200MH2000PLC129408

SA

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Page 4 of 5

cIcombard
ICICILOMBARD GENERAL INSURANCE COMPANY LTD.
IRDA Aegistration No.115
MOTOR INSURANCE PROPOSAL FORM
TWO WHEELER
Proposal Form No. :3005/2014488876/00/0000023760
Motor Proposal Form
Main Features:
1. Own
fire
Damage : This product
self ignition
Protects you Against loss or damage to your motor vehicle,and/or
explosion
accessories,díe to housebreaking riot
lightning theft burglary
strike earthquake flood and allied perils accidental external means emalicious ats terrorist activity transit landslide, rockslide
I1. Third Party Liability : In addition to the coverage noted above,this productcoversyou against lega liability towards third party, in respect of the following:
death of or bodily injury to any person damage to property (as per the pfovision of Motor Vehicle Act.)
We are pleased to inform you that in addition, the product also includes the foloing:
Personal accident benefits for owner driver upto a value of Rs. 15 lakhs Legafliability towards the paiddriver Cover for Rs.1 lakhs for third party property damage
Insured's Additional
Make of Vehicle Model of Vehicle
Year of Cubj Seating Declared
Electrical Non Electrical
Accessories.
Date of
Registration
M£nufacturing Capacity Çapacity Accessories Accessories.
Value (|DV)
HONDA ACTIVA 125 2 Rs. 86831.00 Rs. 0.00 27/09/2023
MOTORCYCLE SMART OBD2| 2023 125 Rs. 0.00 Rs. 0.00

Premium: Rs. 6776:00 RTOAuthority TELÁNGANA-HYDERABAD


Engine No. JK13EG8014273
Chassis No. ME4JK13EJPGO14004
Additional Risks, if aný
Special Conditions :(Details of BAJASFINANCE LTD.PRAKASH NAGAR,NEAR METRO STATION,None
HYPHP/Leasé)
|1. Registration mark andnumber and description of vehicle insured NEW

2. Name MÄNTRIPRAGADA AVINASH


Fla/Building 2-9-11/6, KOTHA BASTHI
StreetURoad/Sector MACHA BOLLARAM, ALWAL...MEDCHAL M GIRI
ArealVillage/Taluka
Landmark
HYDERABAD State TELANGANA
City
PIN 500010 Telephone
Mobile No. 7993021631
Email
17:53 Date 27/09/2023
3. Effective date and time of commencement of insurance for the purpose of the Act Time
Midnight of: 26/09/2028
4. Date of expiry of insurance
5. Are you entitled to No claim bonus? CyesNO if yes, please submit the proof
6. Liability to Third Parties -The Policy Provides Third Party property
Damage (TPPD) of Rs. 1 lakh/
Do you wish to restrict the above limits to ICICI statutory TPPD liability limit
of Rs. 6000/-only?YesNO
7. Type of Cover (OPackage PolicyLiability Only Other Pls. Specify
8. Do you wish to include P.A. Cover for Paid drivers, Cleaners and Conductors OvesN
9. Additional Covers Zero Depreciation - 86831

PROHIBITION OF REBATES
(Under Section 41 of Insurance Law)
(Amendment Act 2015) inducement to person to take out or renew or continue an insurance in respect of any kind of risk
1) No person shall allow or offer to allow, either airecuy or nalevuy iuahle or any rehate of the premium shown on the policy, nor shall any person taking out or
relating to lives or property, in India, any rebate of the whole or part of the commiss
renewing or continuing a Policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer.
2) Any person making default in complying with the provisions of this section sha liable for a penalty, which may extend to ten lakhs rupees.

The vehicle is used for Commercial purposes OYes DNo


Ifcorporate, vehicle used by Mr./Ms. Use of my vehicle is limited to own premises DYes No
Phone(with STD Code): (R) (O) DYes UNo
Mobile Number: Fax No. : The vehicle is used for Personal purposes DYes DNo
The vehicle belongs to foreign embassy/consulate?
Email ID
(For claim status and renewal reminders) Date of birth: 24/05/1993 The car is certified as Vintage car by DYes DNo
D Married Vintage and Classic Car Club of India
Sex: ZM OF Marital status: O
Single The vehicle is designed for use of Bind/Handicaped/mentally challenged persons
Professional Qualification:
and duly endorsed as such by RTA Yes DNO
DDoctor O
MBA OEngineer DLawyer DArchitect OYes ONo
The vehicle is chauffeur driven
OCA O Journalist DT OStudent DGraduate
Are you a member of Automobile Association ofindia
DPostaGraduate DOther (pl. specify)
Dccupation Details If Yes:Association Name
Status D ndividual DProprietorship O
Partnerships Membership Number;
Is the vehicle fitted with the any Anti-theft
DPvt./Public Co's Dother (pl. specify) OYes
If Individual :0Salaried D
Self Employed OProfessional DRetired device approved by the ARRI
If entity Business :DUrban ÜRural D Social Whether you want to opt for a Voluntary Deduible
Paid up Capital of Company in Rupees: offered under the policy, whichwould be appli NO
D<10 Crores D10-25 Crores D>25 Crores and above Complusory Deductible?
Voluntary Deductible Amount: Rs.O
Category of Business Rlicable
DTrading OManufacturing DContracting If yes,please indicate your choice.Salect Which 000
DFinancial Services Hospitality other (pl.specify) Private Car
d 1000 t00 P3000
Do you wish to cOver Legal Liability to?
DYes
Two-Wheeler
Addit eductible :Yes ZNO
A)Driver (No.of persons ) Whether extension of grogrphical area to the following countres required?
B) Other employees (No.of persons ) UYes ZNo
DYes
CMinnamed Passengers (No.0T ONo
pelsoNer (or
Compulsory Personal Accit Owner Drive Bangladesh, Bhutan, Maldives, Nepal, Pakistan &Sri Lanka.
2)
ONo If'Yes' state the name of the countries. 1)
Are you the ownerdnveronat Accident Cover
Yes Whether the vehicle is driven by non-conventioanl source of power? Yes CINO
Optioanl nagsonal accident capital sum insured can be upto Rs 2 lakh per person. Number If yes,please give details.
ersons that can be covered is restricted to carrving capacity of the vehicle(excluding Whether the vehlcle is fitted with fibre glass tank?: OYes No
driver)
Details of Hire Purchase/Hypothecation/Lease
Do you wish to include Personal Accident A)ls the vehicle proposed for insurance: Under Hire Purchase: OYes No
ZNo Under Lease agreement: Yes ZNo
(P.A.) Cover for named persons? DYes Under Hypothecation agreement: Yes ING
Do you wish to include PA.Cover for
ZNo B)lf yes,give namne and address of cencerned partiesBAJAJ FINANCE LTD
unnamed persons, OYes
provide Details in the list below. You may indude paid cover, in the list PRAKASH NAGAR,NEAR METRO STATION, None
Name CSI opted(Rs.) Are vou entitled to No claim Bonus? DYes No if yes, please submit the proof
Sr.No.
6.Liability to Third Parties -The Policy Provides Third Party property
Paíd Damage(TPPD) of Rs. 1.0 lakhs/
Do vou wish to restrict the above limits to ICICI| statutory TPPD liability limit
of Rs.6000/-only? Yes ZNo

file://C:/Users/sada-mgroad/1LPOS%20Motor%20insurance/PolicySchedule.htm] 27-09-2023
( s J e Owner Driver Tyoe of Cover Page 5of 5
vou wish to Package Policy
LiceCO effctive date 3. Do
of this
hallengox vehicle
manner suffer
yes, detaile from
defective Licence expiry date Other indude P.A. Cover for PaidLiability Only
There is a previous OYes vision, hearing or areDYSically
phy We w
Signiflcant
Would like youExclusions Other Pls.Specify
drivers, Cleaners and
drivers: history of driving
by me or my
If
yes, details are offences depri
anciages.
ation,nTheormalvehicleweaearis know
breakaae
to
that the ConductoNesrs No
Vehiciess lnSurance
Name and
Address HMistoryOYes ONO
by un
Note: The
eis and
unauthorised driy not heldtear,covered
poliCy does not
mechanicused
al electrical breakdow
or cover
Date of
Previouspurchase
Previous
of
Policy Type
of
vehicle Insurer: To enablicy foregoing only
the polic It
is
able us our
isS onl an
if

indication the
for consequent
commercial purposes ial loSsor
own failures
Previous Policy No. :Liability only Cover precious endeavour
to
deliver to
our proide
f
cover offered, For or if
driven
Period of Insurance We wou time to answer
Vould all promise, v consistent quality details please refer to
Existing bonus/malus status Package CoverO requi irino the like to let you questions fully and would apprecia service to all our
if you take
(Please
Inforr9
Others If in you
y nation whether mate to know
Customer that
insurance corecty to the
extent possible customers.
soOme of your
n the
lastattach
three
a la NA
copy ofFlast opinion naterial disclose
or othewise all
material
is a contrar
facts of
Utmost
years, is there policy/renewal application any fact
form,to we Good
notereqtequestour
other is withou
out
If Yes,drivers who would be
details are
any notice held.)
using thishistory of loss
It is im
important material and is not
you to diclose
liability will cit. covered the
by supressing any Faithvital
Date&Time of Name of the driver at the
vehicle experienced by the propose(s)
OYes orONo
propo
posal and the premimium
Insured's Declared
nat

has commence information sought in the


Value (|DV)been received in full. only after we have
loss time of Loss Nature of Loss
Insured'
Declared sitted
Additional
Value of access sories
t Electrical & Non
electronic
accepted your
Amount claimed the \Side CarValue of Value
(Rs.) vehicle
vehicle accessories Electrical (Tw CNGILPG
fitted to the Accessorieswheeler Traer) Total
Kit
Has any Rs.86831 Rs.0 vehicle
A) insurance Company ever Rs.0 Pvt.Cars)
B) declined the proposal Note:The
NO
IDV of the Rs.0
of this
tariff and it willvehicle will be Rs.0 Rs.0

C)
Cancelled&refusedto
reasons there forrenew
(If yes, DYes
DYes No insured vehicle. The IDVbe offixedthe at the
listed selling price of the
deemed to be ethe "SUM
vehiclecomm
is toencement INSURED'
of each
policy
Rs 86831
for the purpOse
imposed special Condition or DNo brand and model as the be fixed on period
the basis of ma for each
Detaration ) commencement of
9XC

/We hereby declare that


DYes
DNo specified
vehicle butbelow).The insurancelrenewal,
IDV of this side and
car(s)adjusted
vehicle
for proposed manufactuatrersthe
for insurance
complete and lWe decdarethethatabove statements and not
also likewise toincluded
and/ or depreciationit T(as per schedule
this and particulars
are true,
in the
accessories,
be fixed. The manufacturers listed selling price of any, fitted to the
policy may and shall be the basis ofdedaration
promissory the answer given accurate and
above shall be to applicable
schedule age wise
for the purpose of total of vehicle is l are
depreciation as shown
the
however be continued at the contract between me/us and ICICI Lombard. held vehicle will be considered loss/constructive total below is
payment of the amount payable as the sole discretion of ICICI Lombard ,
subject
The to be a
repair of the vehicie subject to CTL where the loss(TLICTL)
aggregate cost claims only. A
status.determined
difference by lCICILombard ,resulting to the IDV. terms and of retrieval
in the
pass the same tobonus/lmalus I shall ,r from the Table 1:Schedule of
conditions of the policy exceeds 75%andof /theor
ICICI Lombard endeavor to procure the
renewal
|hold a valid and effective PUC immediately upon receipt of such notice. notice and depriciation for
The Insured's
declared value (IDV) ofarriving at IDV.
mentioned herein and undertakeand/or fitness
to renew the certificate, as applicable, for the
vehicle
insured'. the vehicle will be
deemed to be the 'Sum
same during the policy period. IDVCALCULATION
Date: 27/09/2023 AGE OF THE VEHICLE
Other lntormation
Slgnature of Proposer Upto 6 Months Depreciation
At the time of
Purchase the vehicle was 6Months 1day to 1Year 5%
Will the vehicle be used :ONew 1Year 1day to 2Years 15%
exclusively for private,social,
domestic,pleasure&professional
Will the vehicle be used for purposes DYes
DSecondhand
ONo
2Year 1day to 3Years 20%

carriage of 3Year 1day to 4Years 30%


goods other than samples or personal 4Year 1day to 5Years 40%
The vehicle is in good condition luggage Yes ONo NOTE:IDV ofvehicles 50%
(i.e.models which the beyond
The vehicle is self owned OYes DNo 5 years of age and of
obsolete models of the vehicles
don the basis manufacturers
The vehicle is used for driving OYes ONo have discontinued
tutions OYes ONo determined
*1Owner
of an
understanding
driver is defined as "Owner between inst
een insurer
to
manufacture)
and the insured.
is to be
license of the Insured Vehice holding an effective driving
12 A vehicle in "Good
Condition" means any vehicle which is in drivable
without structural and/or
We hereby declare that the mechanical defects. condition
form the basis of the contractstatements made by melus in this Proposal Form are Declaration
true to the best of
between melus and the ICICI Lombard
IWe also decare that any additions General Insurance Co. Ltd. my/our knowledge and belief and IWe herebv aaree that this declaration shall
or alterations are carried out
lagree that the Policy shall after the submission of this proposal form then
any material particular in the
become voidable at the option of the Insurer, in the the same would be conveved to the
insurers immediately
ular in proposal event or any untrue or incorrect statement,
Denat t0 obtain any benefit under thisform/personal statement, declaration and connected documents,
policy. I affirm, and under take that have or any material in misrepresentation, non-description or non-disclosure in
read and understood the terme a n d n a s oen with held by me or anyone acting my
Lombard General Insurance Comoany as displayed on the Web Site
IWe hereby dedare and warrant that the above www.iciclombard.com and Iagree to abide by them. Conditions for usage of Insurance online service of lCICI
agree that this proposal and decarations shall be statements are true, accurate and complete. \We desire to effect an
insurance as
the Company.
the basis of contract between me/us and the Gompany and wVe agree to accept adescribed
policy hereitRSCA and /We
Note :in case of any discrepancy in the policy details, please revert back within 16 days from the date of issue of this pollcy. subjosibed by
Disclaimer : The Policy stands cancelled or vold in the event of Cheque Dlshonored.
Place BANJARA HILLS. Srat AG.F
Proposal Date: 27/09/2023 Print Date: 27/09/2023
pos

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