ICICI Lombard General Insurance Company Limited

Plot No 10 Second Floor, Alankar Palace, MP Nagar, Zone II, Bhopal, Madhya Pradesh -
462011
Help Desk No.:18002666 IRDA Regn. No. : 115
SERVICING BRANCH GSTIN NO.:23AAACI7904G1ZV , PAN NO.:AAACI7904G
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
PRIVATE CAR STANDALONE OWN DAMAGE POLICY (IRDAN115RP0001V02201920) ISSUED AT: 19:04 HOURS ON 23-JAN-2024
POLICY DETAILS RENEWAL
POLICY NUMBER PROPOSAL NUMBER AND DATE PERIOD OF OWN DAMAGE (OD) COVER PERIOD OF LIABILITY (TP) COVER
TIL/11086878 P23660890 23-JAN-2024 (00:00 HOURS) 24-JAN-2024 To Midnight of 23-JAN-2025 - To Midnight of -
PREVIOUS POLICY DETAILS
OD POLICY INSURER OD POLICY NUMBER PERIOD OF OD POLICY TP POLICY INSURER TP POLICY NUMBER PERIOD OF TP POLICY
ILG TIL/10941263 24-JAN-2023 To 23-JAN-2024 ILG TIL/10941263 24-JAN-2023 To 23-JAN-2026
INSURED DETAILS CORPORATE
NAME GSTIN PANCARD NUMBER UIN PAY AS YOU DRIVE / USE
M/S VARUN ENTERPRISES 23AFLPA6958H1ZD AFLPA6958H 0
ADDRESS DATE OF BIRTH
NANAKHEDI MANDI, A.B. ROAD, , GUNA , MADHYA PRADESH-473001
NOMINEE NAME NOMINEE AGE NOMINEE RELATIONSHIP MOBILE NUMBER EMAIL ID
90****6290 maya****@[Link]
VEHICLE DETAILS PRIVATE
VARIANT MAKE/MODEL CHASSIS NUMBER ENGINE/ MOTOR NUMBER YEAR OF MANUFACTURE
TOYOTA / URBAN CRUISER
V EDRIVE 2WD HYBRID MBJUYMM1SPA109941 M15DNA30676 2023
HYRYDER
HYPOTHECATION/LEASE INVOICE DATE CC / KW / GVW SEATING CAPACITY FUEL TYPE
24-JAN-2023 1490 5 HYBRID
GEOGRAPHICAL AREA EXT. GEOGRAPHICAL AREA RTO CITY REGISTRATION NUMBER VEHICLE USAGE
INDIA GWALIOR MP-07-ZC-9690 -
INSURED DECLARED VALUE (Rs.)
AGE VEHICLE BODY NON ELECTRICAL ACCESSORIES ELECTRICAL ACCESSORIES CNG / LPG TOTAL
2 1640745 0 0 0 0 1640745
SCHEDULE OF PREMIUM
A. OWN DAMAGE (OD) SECTION AMOUNT (Rs.) B. LIABILITY SECTION AMOUNT (Rs.)
BASIC PREMIUM BASIC PREMIUM
VEHICLE 23561 THIRD PARTY LIABILITY ( INCLUDING TPPD ) 0
NON ELECTRICAL ACCESSORIES 0 GEOGRAPHICAL AREA EXT. ( IMT-1 ) 0
ELECTRICAL ACCESSORIES (IMT-24) 0 BI FUEL KIT 0
BI FUEL KIT (IMT-25) 0 SUB TOTAL (THIRD PARTY LIABILITY) 0
BODY 0
SUB TOTAL (BASIC PREMIUM) 23561 PERSONAL ACCIDENT (PA) COVER
GEOGRAPHICAL AREA EXT (IMT-1) 0 COMPULSORY PA COVER FOR OWNER DRIVER (IMT-15) Rs. 15 LAC 0
IMT 23 0 PA COVER FOR PAID DRIVER (IMT-17) Rs. 2 LAC 0
SUB TOTAL 23561 PA COVER (100000 FOR 5 UNNAMED PERSONS) (IMT-16) 0
DISCOUNTS SUB TOTAL (PA COVER) 0
VOLUNTARY DEDUCTIBLE (IMT-22A) 0 LEGAL LIABILITY
ANTI THEFT DEVICE (IMT-10) 0 PAID DRIVER (IMT-28) 0
AA MEMBERSHIP (IMT-8) 0 EMPLOYEE (FOR 5 PERSON) (IMT-29) 0
HANDICAPPED DISCOUNT (IMT-12) 0 NON-FARE PAYING PASSENGER (IMT-37) 0
NCB (0%) 0 UNNAMED PASSENGER (0) ON AMBULANCE/HEARSES (IMT- 46) 0
SUB TOTAL (DISCOUNTS) 0 SUB TOTAL (LEGAL LIABILITY) 0
NET LIABILITY PREMIUM (B) 0
ADD-ONS 10915 TOTAL PREMIUM (A+B) 34476
LOANER CAR PREMIUM (IMT-58) 0 CGST (9%) 3103
THEFT AND CONVERSION RISK (IMT-43) 0 SGST (9%) 3103
INDEMNITY TO HIRER (IMT-44) 0 - 0
PAY AS YOU DRIVE / USE DISCOUNT 0 - 0
NET OWN DAMAGE PREMIUM (A) 34476 GROSS PREMIUM PAID 40682
ADD-ON COVERS OPTED IN THE POLICY
CONSUMABLES NIL DEPRECIATION
KEY PROTECT

The CPA cover is not opted : The insured vehicle is not owned by an individual.
Note:- 1. Issue of Policy is subject to realisation of cheque if premium is paid by cheque. 2. ConSolidated stamp duty paid to state [Link] No.-CSD6920232872 Challan Date -14-JUN-2023 3. The Policy is subject to a
compulsory deductible of Rs. 1000 (IMT-22) and Voluntary Deductible of Rs. 0.
PREMIUM PAYMENT DETAILS : Cheque No.: 53560710, Cheque Date: 23-JAN-2024, Bank Name: ONLINE PAYMENT, Bank City: ONLINE PAYMENT
INVOICE NUMBER : TIL/11086878 SAC CODE : 997134 DESCRIPTION OF SERVICE : GENERAL INSURANCE SERVICE
The coverage under this policy is only for the Own Damage component of the package policy and no other liability in connection with the vehicle.
Warranty: Warranted that the insured named herein/owner of the vehicle holds a valid pollution under control (PUC) certificate and/or valid fitness certificate, as applicable, on the date of commencement of the policy and
undertakes to renew and maintain a valid and effective PUC and/or fitness certificate, as applicable, during the subsistence of the policy. Further, the company reserves the right to take appropriate action in case of any discrepancy in
the PUC or fitness certificate.
Limitations As To Use: Use only for social, domestic and pleasure purposes and for the insureds business. The policy does not cover the use for: (1) hire or reward (2) carriage of goods (other than samples or personal luggage) (3)
organised 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 a license. Provided also that the
person holding an effective learners 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 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 AND RIGHT OF RECOVERY". For legal interpretation, English version will hold good.
Grivence Clause : For resolution of any query or grievance, insured may contact the respective branch office of the company or may call at (1800-2666) or may write an email at (customersupport@[Link]). In case the
insured is not satisfied with the response of the office, insured may contact the grievance officer of the company at (grievanceofficer@[Link]).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 IRDAI website: [Link], or on the website of general insurance
council: [Link] or on the company website ([Link]).
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 Cchapter XI of M.V. Act, 1988.
We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in
terms of the provisions of the said sub-rule.
For & On Behalf of
BROKER NAME : Toyota Tsusho Insurance Broker India Pvt Ltd SCAN QR CODE TO VIEW THE POLICY
ICICI Lombard General Insurance Company Limited
Broker Code / IRDAI Composite Licence No. : 381 (Valid up to 01/09/2026).
CIN: U66010KA2008PTC045231
Email ID : bos@[Link]
Contact No. : 080-40449900

MISP Code : TTIBI/T/MP/ANA1150A

MISP Name : SHREE TULJA BHAVANI AUTOMOBILES PVT LTD
Designated Person Name :AISHWARYA ABHIJIT ATRAY
Authorised Signatory
PLEASE CONTACT [Link]./BROKER/ C/O ANANT TOYOTA TALAWALI CHANDAA.B. ROAD DEWAS NAKAINDORE INDORE MADHYA PRADESH 453771,
FOR RENEWAL / CLAIMS ASSISTANCE
INDORE, MADHYA PRADESH, PIN CODE: 474001 CONTACT NO: -91-9584468376