ICICI LOMBARD GENERAL INSURANCE COMPANY MOTOR INSURANCE PROPOSAL FORM PRIVATE CAR PACKAGE POLICY Proposal Form

No: Q-4794037 Motor Proposal Form

Main Features: I.Own Damage: This product protects you against loss or damage to your motor vehicle and/or accessories due to l Fire l Self Ignition l Explosion l Lighting l Theft l Burglary l Strike l Earth Quake l Flood and Allied Perils l Accidental external means l Malicious acts l Terrorist activities II.Third Party Liability: In addition to the coverage noted above,this product covers you against legal liability towards third party,in respect of the following: l Death of or bodily injury to any person l Damage to property(as per the provision of Motor vehicle act.) We are pleased to inform you that in addition,the product also includes the following: l Personal accident benefits for owner driver upto Rs. 1lakhs l Legal liability towards the paid driver Make of Vehicle Model of Vehicle Year of Manufacturing HYUNDAI I10 ERA 2008 Premium 5368 R.T.O. Authority Engine No. 10808 Chassis No. 191634 Additional Risks if any: Special Conditions : (Details of HYP/HP/Lease) Cubic Capacity 1086 NEW DELHI Seating Capacity 5 Insured's Declared Value (IDV) 260400

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House Breaking Transit

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Riot Landslide/Rockslide

Cover for Rs.1lakhs for 3rd party property Non Electrical Accessories 0 Date Of Registration 15/11/2008

Electrical Accessories 0

PA Cover for Owner driver: 100000 HDFC BANK

(Use Block Letters)

1.Registration mark and number and description of vehicle insured. 2.Name Flat/Building Street/Road/Sector Area/Village/Taluka Landmark City Pin Email DL4CND6104 HUKAM CHAND House No 55, Pocket B6, Sector 5, Rohini

NEW DELHI 110085 rameshvishw87@gmail.com

State Telephone Mobile No.

DELHI 9560461573

3.Effective date and time of commencement of insurance for the purpose of the act 4.Date of expiry of insurance 5.Are you entitled to no claim bonus'(0%) 6.Liability to Third parties - The policy provides Third Party property damage (TPPD) of Rs. 7,50,000 Do you wish to restrict the above limits to ICICI statutory TPPD liability limit of Rs.6000/- only. 7.Type of cover 8.Do you wish to include P.A. cover for paid drivers,cleaners and conductors 9.Additional covers.

Time : 00:00 Date : 05-Nov-2011 Midnight of : 04-Nov-2012

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Yes

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No If yes, provide the proof

Yes

No

Package Policy Yes

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Liability Only

Others pls. specify

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No

Others pls. specify

Statutory Warning INSURANCE ACT 1938 SECTION 41-PROHIBITION OF REBATES No person shall or offer to allow either directly or indirectly as an inducement to any person to take out or renew an insurance in respect of relating to lives or property in india, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person renewing or continuing a policy accept any rebate as may be allowed in accordance with the prospectuses or tables of the insurer.Any person complying with the provisions of this section shall be punishable with fine which may extend to five hundred rupees.

If corporate vehicle used by Mr/Ms: Phone(with STD code): Mobile Number: Email ID (For claim status and renewal reminders) Date of birth : Sex: (R) (O) Fax No.

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Doctor CA

Male

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Female

Marital Status:

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Single

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Married

Professional Qualification:

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MBA Journalist Other (pl. Specify)

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Engineer IT

Lawyer Student

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Architect Graduate The vehicle is designed for use of blind/handicapped/mentally challenged and duly endorsed by RTA :

Post Graduate

My occupation details
Status

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Yes Yes Yes

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2)

No No No

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Individual Pvt./Public Co's Salaried Urban <10 crore Trading Financial Services hospitality

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Proprietorship Other(pl. specify) SelfSelf-Employed Rural 1010-25 crore Manufacturing Other(pl. specify)

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Partnerships

The vehicle is chauffer driven : Are you a member of Automobile Association of India :

If Individual If Entity Business Paid up capital of company in rupees: Category of business

Professional

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Retired

If Yes: Association Name Membership number: Is the vehicle fitted with the any anti-theft device approved by ARAI Do you want to avail any voluntary excess' :

Date of expiry: Yes Yes No No

>25 crore Contracting

If yes,please indicate your choice.Select whichever Applicable. Private car : Two wheeler :

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2500 750

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1)

5000 1000 Yes

75000 1500 No

Do you wish to cover legal liability to ' A) Driver(No. of persons 1) B) Other employees(No. of persons) C) Unnamed passengers(No. of persons)

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Yes Yes Yes

No No No

Whether extension of geographical area to the following countries required Bangladesh,Bhutan,Maldives,Nepal,Pakistan & Sri Lanka If 'Yes' state the name of the countries Whether the vehicle is driven by non-conventional source of power If yes please give details. Whether the vehicle is fitted with fibre glass tank' : Details of Hire Purchase/Hypothecation/Lease A)Is the vehicle proposed for insurance :-

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Yes Yes

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No No

Compulsory Personal Accident Cover for owner driver

Are you a ownerdriver* Yes No

Optional Personal Accident Cover

Optional personal accident capital sum insured can be upto Rs.2 lakh per person.Number of persons that can be covered is restricted to carrying capacity of the vehicle(excluding driver) Do you wish to include personal accident (P.A)Cover for named persons' Do you wish to include P.A. cover for unnamed persons, provide details in the list below.You can include paid cover,in the list.
Sr. No. Paid Driver 1. 2. 3. 4. 5.

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Under Hire Purchase Under Lease Agreement Under Hypothetication Agreement None

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Yes

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Name

No

Yes

No
CSI Opted (Rs.)

B)If yes,give name and address of concerned parties. HDFC BANK NEW DELHI 5.Are you entitled to no claim bonus' :

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Yes

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No

6.Laibility to third party - The policy provides Third Party property Damage(TPPD) of Rs.7.5 lakhs/Yes Yes No No

Details of driver

Do you wish to restrict the above limits to ICICI statutory TPPD liability of Rs.6000/- only

a) Age: Owner Driver License effective date

Other License expiry date: 7.Type of cover:

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only

Liability

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Others

I or my driver of this vehicle suffer from defective vision,hearing or are physically challenged in any manner: If yes,Details are there is a previous history of driving offenses by me or my drivers :

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Yes Yes

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Yes Yes

8.Do you wish to include P.A. cover for paid drivers,cleaners and conductors.

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Yes

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No

Significant Exclusions
We would like to know that the policy does not cover corrosion, depreciation,normal,wear and tear,mechanical or electrical breakdown breakages. The Vehicle is not held covered if used for commercially driven by an unauthorized driver. Note:The foregoing is only an indication of the cover offered.For the policy it is our endeavor to provide consistent quality support to customers.To enable us to deliver our promise,we would appreciate of your precious time to answer all the questions fully and correctly.We would like to let you know that insurance is a contract of requiring the customer to disclose all material facts without supporting information whether material or otherwise. If in your opinion any fact is material and not covered by the information application form,we request you to disclose it. It is important to note that our liability will commence only after we have the proposal and the premium has been received in full. Insured's Declared Value(IDV)
Insured's Declared value of vehicle 260400 Non-electrical accessories fitted to the vehicle 0 Electrical & electronic Side car(Two accessories fitted to the Wheeler) Trailer vehicle (Pvt.Cars) 0 Value of CNG/LPG Kit 0

Vehicle insurance history

Name and address of previous insurer :RGIC Date of purchase of vehicle : 15/11/2008 Previous policy type

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Liability only cover

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Package cover

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Others

Previous Policy No: 1316702311005401 Period of insurance: 1 Year Existing bonus/malus status : 35 (Please attach a copy of last policy/renewal notice held.)/renewal notice held.) In the last three years,is there any history of loss experienced by the propose(s) or other drivers who would be using this vehicle If yes,details are:
Date & time of loss Name of the driver at the time of loss Nature of loss Amount claimed (Rs)

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Yes

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No

Has any company ever : A) Declined the proposal B) Cancelled & refused to renew (If yes,reasons there for) C) imposed special condition or excess:

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Yes Yes

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No No

Yes

No

"I/We undersigned hereby declare that the above statements and particulars are true, accurate and complete and I/We declare that this declaration and the answer given above shall be held to promissory and shall be the basis of the contract between me/ us and ICICI Lombard. The policy may however be continued at the sole discretion of ICICI Lombard, subject to payment of the amount payable as determined by ICICI Lombard, resulting from the difference in the bonus/ malus status. I shall endeavor to procure the renewal notice and pass on the same to ICICI Lombard immediately upon the receipt of such notice." Signature of Proposer: ___________________

Note:The IDV of the vehicle will be deemed to be the 'SUM INSURED' of this tariff and it will be fixed at the commencement of each policy insured vehicle.The IDV of thevehicle is to be fixed on the basis of the listed selling price of the brand and the model as the vehicle proposed for the commencement of insurance/renewal, and adjusted for depreciation specified below).The IDV of this side car(s) and/or accessories,if the vehicle but included in the manufacturers listed selling price of the also likewise to be fixed.The schedule of age wise deprecation as applicable for the purpose of total loss/constructive total loss(TL/CTL) vehicle will be considered to be a CTL where aggregate cost of the repair of the vehicle subject to terms and conditions of the policy exact IDV. Table 1: Schedule of depreciation for arriving at IDV. The Insured's declared value (IDV) of the vehicle will be deemed to be insured.
IDV CALCULATION AGE OF THE VEHICLE Upto 6 Months 6Months 1day to 1year 1Year 1day to 2years 2Year 1day to 3years 3Year 1day to 4years 4Year 1day to 5years DEPRECIATION 5% 15% 20% 30% 40% 50%

Other Information
The car is certified as Vintage car by At the time of purchase the vehicle was : Will the vehicle be used exclusively for private,social,domestic,pleasure & Professional purposes : Will the vehicle will be used for carriage of goods other than samples & personal luggage : The vehicle is in good condition : The vehicle is self owned : The vehicle is used for driving tutions : The vehicle is used for commercial purposes : Use of my vehicle is limited to own premises : The vehicle is used for personal purposes : The vehicle belongs to foreign embassy/consulate' :

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New Yes Yes Yes Yes Yes Yes Yes Yes Yes

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Secondhand No No No No No No No No No

Note:IDV of vehicles beyond 5 years of age and of obsolete model(i.e;models which the manufacturers have discontinued to manufacture is determined on the basis of an understanding between insurer and the) 1.Owner driver is defined as "Owner of the insured vehicle holding a valid driving license" 2.A vehicle in "Good Condition" means any vehicle which is in driving condition without structural and/or mechanical defects.

Vintage and Classic Car Club of Indiassic Car Club of India

Yes

No

Declaration
I/We hereby declare that the statements made by me/us in this proposal form are true to best of my knowledge and I/We hereby agree that this form the basis of the contract between me/us and the ICICI Lombard General Insurance Co. Ltd I/We also declare that any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the insurers immediately.I agree that the policy shall become voidable at the option of the insurer,in the event of any untrue or incorrect statement,misrepresentation,non-description or any material particular in the proposal form/personal statement, declaration and connected documents, or any material information has been with held by me or on behalf to obtain any benefit under this policy. a.I affirm and undertake that I have read and understood the policy wordings, terms & conditions and exclusions governing the cover and agree to abide by them. b.I agree to receive a One Page Motor Insurance Policy in Physical Form. g Yes g No c d e f c d e f (By agreeing to this, I understand that the same shall be read along with the standard terms and conditions available on the website www.icicilombard.com) I affirm and under take that I have read and understood the terms and conditions for usage of Insurance online ICICI Lombard General Insurance Company as displayed on the WebSite www.icicilombard.com and I agree to abide by them. I/We hereby declare and warrant that the above statements are true,accurate and complete.I/We desire to effect an insurance as described herein with the Cc agree that this proposal and declarations shall be on the basis of contract between me/us and the company and I/We agree to accept a policy subject to the condition of the company. Note:In case of any discrepancy in the policy details,please revert back within 15 days from the date of issue of this policy. Disclaimer:Policy is valid subject to realisation 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. Place: Date: Signature of proposer

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