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Product Code: 3005 UIN: IRDAN115RP0015V03201415

Ref. No. W102101040

Date: Jul 09, 2021
SHANMUGARASU C
165 KARUKANAHALLI VILLAGE DHANUKARANAHALLI POST
DHARMAPURI
TAMIL NADU 636808
Mobile No: 9597982326

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. 3005/223253285/00/000, which has been issued based on the below mentioned details:

Insured & Vehicle Details

Name of Insured SHANMUGARASU C
Period of Insurance Jul 19, 2021 to Jul 18, 2022
Vehicle Make / Model HERO HONDA / CD DELUXE
RTO City TAMILNADU-DHARMAPURI
Vehicle Registration No. TN29AM0025
Vehicle Registration Date Feb 06, 2012
Engine No. HA11EDC9B17756
Chassis No. MBLA11ERC9B13166
Current Year NCB(%) 50%
Previous Policy Details
Previous Policy No. 3005/202198517/00/b00
Previous Policy Period 19-07-2020 to 18-07-2021
Previous Year NCB(%) 50%
Claims Made Under Previous Policy 0
Previous Insurer Name ICICI LOMBARD
Previous Policy Type Comprehensive Package
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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
realisation of the full premium, post which, insurance coverage under the policy would commence. In case the premium is not received by us due to cheque
dishonour or any other reason, the insurance cover shall be void ab-initio.
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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 to 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 the Certificate of Insurance cum Policy Schedule, you are requested to inform us by writing to
[email protected] or 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.

The information provided is merely illustrative and shall not be construed to be an evidence of existence of a contract of insurance. The Risk Assumption Letter
is to be read in conjunction with the policy and shall be considered null and void without the same.

The Compulsory Personal Accident cover has not been opted in this policy on account that, the Owner driver has a separate existing Personal Accident cover
against Death and Permanent Disability (Total and Partial) for Sum Insured of at least Rs.15 lacs.
CORP/SUP/OPI/2014/1777

Jul 09, 2021

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
0
Two Wheeler Vehicles Package Policy
Product Code: 3005 UIN: IRDAN115RP0015V03201415

Insured Name : SHANMUGARASU C Policy No : 3005/223253285/00/000

Address : 165 KARUKANAHALLI VILLAGE DHANUKARANAHALLI Period of Insurance : Jul 19, 2021 12:00:00 to
POST, DHARMAPURI, TAMIL NADU 636808 Midnight of Jul 18, 2022
Telephone No : Mobile No: 9597982326 E-Policy No : 3005/223253285/00/000
Email Address : [email protected] Policy Issued On : Jul 09, 2021
Nominee Name : - Named Passenger's Nominee: Covernote No : 223253285
Relationship : - - RTO Location : TAMILNADU-DHARMAPURI
Age : - Hypothecated To : -
GSTIN Number (Customer) : Invoice Number : 100721230766
Servicing Branch Name : Bangalore
Servicing Branch Address : Second SVR Complex Hosur Main road Bangalore Karnataka 560068

Registration No. Make Model Type of Body CC/KW Mfg Yr Seating Chassis No. Engine No.
Capacity
Solo With
TN29AM0025 HERO HONDA CD DELUXE 97 2012 2 MBLA11ERC9B13166 HA11EDC9B17756
Pillion
Vehicle IDV Side Car Additional Accessories (`) Electrical / Electronic Non Electrical CNG / LPG Unit Total IDV
(`) (`) Accessories (`) Accessories (`) (`) (`)
16800 0 0 0 0 0 16800

Premium Details
OWN DAMAGE(A) (`) LIABILITY(B) (`)
Basic OD Premium 296 Basic Third Party Liability 752
Sub Total 296 Total 752
Less:
No Claim Bonus 50% 148
Sub-Total Deductions 148
Total Own Damage Premium(A) 148 Total Liability Premium(B) 752
Total Package Premium(A+B): 900
% 18
IGST
` 162
Total Tax Payable in ` 162
Total Premium Payable In ` 1062
Geographical Area: India Applicable IMT Clauses: 22
Compulsory Deductible: ` 100 Voluntary Deductible: ` 0

Premium Collection No. 1128506682 Premium Amount ` 1062 Receipt Date 09-07-2021
GSTIN Reg.No 29AAACI7904G1ZJ HSN/SAC code 997134 / GENERAL INSURANCE SERVICES

Limits of Liability: (a) Under Section II-I(i) of the policy: Death of or bodily injury - Such amount as is necessary to meet the requirements of the Motor Vehicles Act 1988. (b)
Under Section II-I(ii) of the policy: Damage to Third Party Property ` 100000/-; PA Cover for Owner-Driver under Section III: CSI ` 0/-. The Compulsory Personal Accident
cover has not been opted in this policy on account that, the Owner driver has a separate existing Personal Accident cover against Death and Permanent Disability (Total
and Partial) for Sum Insured of at least Rs.15 lacs. 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 of personal luggage), Organised racing, Pace Making, Reliability trails or Speed testing, any purpose in Connection with Motor Trade. Driver's
Clause: 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 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: The insured i s not indemnified if the vehicle i s used or driven otherwise than in
accordance with this schedule. Any payment made by the Company by reason 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".
In consideration of the premium for this extension being calculated at a pro-rata proportion of the annual premium, it is hereby declared and agreed by the insured that upon
expiry of this extension, this policy shall be renewed for a period of twelve months, failing which the difference between 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. Disclaimer: Please visit
www.icicilombard.com for the policy wordings, for complete details on terms and conditions governing the coverage and NCB. This document is to be read with the policy
wordings. The policy i s valid subject to realization of cheque. We accept premium only via legally recognized modes. In case of dishonour of premium cheque, the
company 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, please revert within 15 days from
the policy start date. This policy i s underwritten on the basis of the information provided by you and as detailed in the Risk Assumption Letter shared with you along with
the policy. On renewal, the benefits provided under the policy and/or terms and conditions of the policy including premium rate may be subject to change. Grievance
Redressal: 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 us at
[email protected]. For detailed grievance redressal mechanism please visit the "Grievance Redressal" section on our website www.icicilombard.com.
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. In witness whereof, this Policy has been signed at Mumbai on this date of Jul 09, 2021 in lieu of Covernote no. 223253285. The
stamp duty of ` 0.5 paid vide deface no. CSD262021165121 dated May 05, 2021.
Policy Issuing Office: ICICI Lombard General Insurance Company Limited, ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi,
Mumbai 400 025.
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.
CORP/SUP/OPI/2014/1777

Jul 09, 2021

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
0
Two Wheeler Vehicles Package Policy
Product Code: 3005 UIN: IRDAN115RP0015V03201415

Agency Code : CA0606

Agency Name : JANA SMALL FINANCE BANK

Agent's Contact No : 7022653867

Contact Person :

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE COMPANY
LIMITED
Date: 2021.07.09 11:52:58 IST
CORP/SUP/OPI/2014/1777

Jul 09, 2021