TWOWHEELERVEHICLEPACKAGEPOLICY

CertificatecumPolicySchedule
CertificatecumPolicyNo:3005/W27287184/00/000
ForCLAIMS:Call18002666(Tollfreefromallphones)
ForRENEWALS:Visitwww.icicilombard.comorcall18002666
DETAILSOFPOLICYHOLDER
InsuredName

POLICYDETAILS

MRIMMANUELFERNANDEZG

ContactNo.

29C,Pocket1SunshineAppartment
MayurViharPhase3,NEWDELHI,DELHI,
110096
9650626583

EmailAddress

immanuel.civil@gmail.com

InsuredAddress

PolicyIssuingOffice

ICICILombardGeneralInsurance
CompanyLtd.ICICILombardHouse,414,
VeerSavarkarMarg,NearSiddhiVinayak
Temple,Prabhadevi,Mumbai400025

PeriodofInsurance

From00:00:00hrsof23May2014to
Midnightof22May2015

PolicyIssuingon
CoverNoteNo
RTOLocation

20May2014
W27287184
NEWDELHI

Hypothecatedto
TypeofAgreement

N/A
None

VEHICLEDETAILS
RegistrationNumber Make
Model
Typeofbody
C C Mfg.Year SeatingCapacity ChassisNumber EngineNumber
DL5SBG3515
HONDAMOTORCYCLE CBUNICORN SoloWithPillion 150 2012
2
8001346
2063182
INSUREDDECLAREDVALUE
VehicleIDV(inRs.)
SideCar NonElectricalAcc(inRs.)
Elec/ElectronicAcc(inRs.)
CNG/LPGUnit(inRs.)
TotalValue(inRs.)
52095
0
0
0
0
52095
SCHEDULEOFPREMIUM(INRS.)
OwnDamage(A)
BasicPremium
Total:
Add
Less
Deduct25%forNCB
Total:
TotalOwnDamagePremium

Liability(B)
623 BasicPremiumincludingpremiumforTPPDvehicle
623 Total:
Add
PAcoverforOwnerDriver
156 SubTotal(Additions):
156 Less
SubTotal(Deductions):
467 TotalLiabilityPremium

464
464
50
50
0
514

TotalPackagePremium(A+B)

981

ServiceTax(InclEdu.CessAndHigherEdu.Cess)

121
TotalPremiumPayable(inRs.)1102

Compulsorydeductibles:Rs.100/
GeographicalArea:India
LIMITSOFLIABILITY:(a)UnderSectionII1(i)ofthepolicy>Deathoforbodilyinjury:Suchamountasisnecessarytomeetthere
requirementsofthemotorvehiclesAct.1988.
(b)UnderSectionII1(i)ofthepolicy>DamagetoThirdPartyPropertyRs1,00,000PACoverforOwnerDriverundersectionIIICSIRs
1,00,000VoluntaryDeductibleRs.0
LIMITATIONSASTOUSE:Thepolicycoversuseofthevehicleforanypurposeotherthan:Hireorreward,Carriageofgoods(otherthansamples
orpersonalluggage),Organizedracing,Pacemaking,Speedtesting,Reliabilitytrials,AnypurposeinconnectionwithMotorTrade.
DRIVER'SCLAUSES:Anypersonincludingtheinsured:ProvidedthatapersondrivingholdsaneffectiveDrivingLicenseatthetimeofthe
accidentandisnotdisqualifiedfromholdingorobtainingsuchalicense.ProvidedalsothatthepersonholdinganeffectiveLearner'sLicensemay
alsodrivethevehicleandthatsuchapersonsatisfiestherequirementsofRule3oftheCentralMotorVehiclesRules,1989.
IMPORTANTNOTICE:TheInsuredisnotindemnifiedifthevehicleisusedordrivenotherwisethaninaccordancewiththisschedule.Anypayment
madebythecompanybyreasonofwidertermsappearinginthecertificateinordertocomplywiththeMotorVehicleAct,1988isrecoverablefrom
theinsured.Seetheclauseheaded'AVOIDANCEOFCERTAINTERMSANDRIGHTOFRECOVERY'.Forlegalinterpretation,Englishversionwillhold
good.
SubjecttoIMTEndorsementNos.&Memorandumprintedherein/attachedhereto:22
PremiumCollectionDetails:[CollectionNo/Amount/ReceiptDate]NA/Rs.1102/20/05/2014
DISCLAIMER:Pleasevisitwww.icicilombard.comforthepolicywordingsforcompletedetailsontermsandconditionsgoverningthecoverageand
NCB.Thisdocumentistobereadwiththepolicywordings.
GrievanceClause
Forresolutionofanyqueryorgrievance,InsuredmaycontacttherespectivebranchofficeoftheCompanyormaycalltollfreeno.18002666ormay
approachusatthesubsection"GrievanceRedressal"onourwebsitewww.icicilombard.com(CustomerSupportsection).However,iftheresolution
providedbyusisnotsatisfactoryyoumayapproachInsuranceRegulatoryandDevelopmentAuthority(IRDA)throughtheIntegratedGrievance
ManagementSection(IGMS)orIRDAGrievanceCallCentre(IGCC)attheirtollfreeno.155255.YoumayalsoapproachInsuranceOmbudsman,
subjecttovestedjurisdiction,fortheredressalofgrievance.DetailsofInsuranceOmbudsmanofficesareavailableatIRDAwebsite:
www.irdaindia.org,orontheCompany'swebsiteatwww.icicilombard.com.
Policyisvalidsubjecttorealizationofcheque.Weacceptpremiumonlyvialegallyrecognizedmodesexceptforcash.Ifourrepresentative
requestyoutopayincash,kindlyreportittous.
Forinformationonombudsmanyoumayvisitourwebsitewww.icicilombard.com
I/Weherebycertifythatthepolicytowhichthecertificaterelatesaswellasthecertificateofinsurance
areissuedinaccordancewiththeprovisionofchapterX,XIofM.VAct1988
ServiceTaxRegistrationNo.:GIS/MUMBAII/1528/2001
ServiceTaxCodeNumber:AAACI7904GST001
Category:GeneralInsuranceBusinessServices00440005.
InWitnesswhereofthispolicyhasbeensignedatMumbaithis23May2014inlieuofcovernoteNoW
27287184ThestampdutyofRs.0.50paidincashorbydemanddraftorbypayorder,vide
Receipt/Challanno.571161dated08May2014

ForICICILombardGeneralInsurance
CompanyLtd

DulyConstitutedAttorney(s)

ICICILombardGeneralInsuranceCompanyLtd.
MailingAdd.Office:
CorporateOffice:
ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,
ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,
414,VeerSavarkarMarg,NearSiddhiVinayakTemple,Prabhadevi,
414,VeerSavarkarMarg,NearSiddhiVinayakTemple,Prabhadevi,
Mumbai400025
Mumbai400025

TwoWheelerPAProposalForm
VehicleDetails
Registrationlocation(RTO)
Manufacturer

NEWDELHI
HONDAMOTORCYCLE

Registrationnumber
Enginenumber

DL5SBG3515
2063182

Model

CBUNICORN

Chassisnumber

8001346

Manufacturingyear
Color

2012

Purchase/Registrationdate
Registrationtype

14Apr2012
Individual

Currentshowroomprice(Rs.)

74421

Voluntarydeductible(Rs.)
ARAIapprovedantitheftdevice

0
No

Consumables

No

Returntoinvoicecover

No

Detailsofdiscounts&additionalcovers
Electricalaccessories(Rs.)
Nonelectricalaccessories(Rs.)

0
0

Automobileassociationmembership
ValueofLPG/CNGkitifany(Rs.)
Noclaimbonusprotectioncover

0
No

Garagecashcover

No

Insureddetails
NameoftheInsured

MRIMMANUELFERNANDEZG Relationship

29C,Pocket1Sunshine
AddressofTwoWheelerOwner(Policywill
AppartmentMayurVihar
besenthere)
Phase3
Pincode
110096

City

NEWDELHI

Newpolicydetails
Insurancevalue(IDV)(Rs.)

52095

NoClaimBonus(%)

25

Policystartdate

23May201412:00:00

Policyenddate

Midnightof22May2015

TotalPremiumAmount:

1102

I.OwnDamage
Thisproductprotectsyouagainstlossordamagetoyourmotorvehicleand/oraccessoriesdueto*Fire*SelfIgnition*Explosion*Lightning*Theft
*Burglary*Housebreaking*Riot*Strike*Earthquake*Floodandalliedperils*Accidentalexternalmeans*Maliciousacts*Terroristactivity*Transit
*Landslide/rockslide
II.ThirdPartyLiability
Inadditiontothecoveragenotedabove,thisproductcoversyouagainstlegalliabilitytowardsthirdparty,inrespectofthefollowing:*Deathofor
bodilyinjurytoanyperson*damagetopropertyaspertheprovisionsofMotorVehicleAct.Wearepleasedtoinformyouthatinaddition,the
productalsoincludesthefollowing:
l
l
l
l

PersonalaccidentbenefitsforownerdriveruptoavalueofRs.200,000.
Legalliabilitytowardsthepaiddriver.
CoverforRs.7.5Lacsthirdpartypropertydamage.
PAcoverforUnnamedpassengers.

SignificantExclusions:
Wewouldlikeyoutoknowthatthepolicydoesnotcoverconsequentialloss,depreciation,normalwearandtear,mechanicalorelectrical
breakdownfailuresorbreakages.Thevehicleisnotheldcoveredifusedforcommercialpurposesorifdrivenbyanunauthorizeddriver.Note:The
foregoingisonlyanindicationofthecoveroffered.Fordetailspleaserefertothepolicy.Itisourendeavortoprovideconsistentqualityserviceto
allourcustomers.WewouldliketoletyouknowthatinsuranceisacontractofUtmostGoodFaithrequiringthecustomertodiscloseallmaterial
facts.Ifinyouropinionanyfactismaterialandisnotcoveredbytheinformationsoughtintheapplicationform,werequestyoutodiscloseit.
Itisimportanttonotethatourliabilitywillcommenceonlyafterwehaveacceptedyourproposalandthepremiumhasbeenreceivedinfull.
Declaration:
I/Weherebydeclarethatthestatementsmadebyme/usinthisProposalFormaretruetothebestofmy/ourknowledgeandbeliefandnomaterial
information,whichmayberelevant,hasbeenwithheldornotdisclosedI/Weherebyagreethatthisdeclarationshallformthebasisofthecontract
betweenme/usandthe"ICICILombardGeneralInsuranceCo.Ltd."
I/Wealsodeclarethatanyadditionsoralterationsarecarriedoutafterthesubmissionofthisproposalformthenthesamewouldbeconveyedto
theinsurersimmediately.
I/WeagreethatthePolicyshallbecomevoidableattheoptionoftheInsurer,intheeventofanyuntrueorincorrectstatement,misrepresentation,
nondescriptionornondisclosureinanymaterialparticularintheproposalform/personalstatement,declarationandconnecteddocuments,or
anymaterialinformationhasbeenwithheldbymeoranyoneactingonmybehalftoobtainanybenefitunderthispolicy.I/Weherebydeclareand
warrantthattheabovestatementsaretrue,accurateandcomplete.I/WedesiretoeffectaninsuranceasdescribedhereinwiththeCompanyand
I/Weagreethatthisproposalanddeclarationsshallbethebasisofcontractbetweenme/usandtheCompanyandI/Weagreetoacceptapolicy
subjecttotheconditionsprescribedbytheCompany.

INSURANCEACT1938,SECTION41PROHIBITIONOFREBATES
1.Nopersonshallalloworoffertoallow,eitherdirectlyorindirectlyasaninducementtoanypersontotakeoutorreneworcontinueaninsurance
inrespectofanykindorriskrelatingtolivesorpropertyinIndia,anyrebateofthewholeorpartofthecommissionpayableoranyrebateofthe
premiumshownonthepolicy,norshallanypersontakingoutorrenewingorcontinuingapolicyacceptanyrebateexceptsuchrebateasmaybe
allowedinaccordancewiththeprospectusortablesoftheInsurer.
2.Anypersonmakingdefaultincomplyingwiththeprovisionsofthissectionshallbepunishablewithfine,whichmayextendtofivehundred
rupees.

AGEOFTHEVEHICLE

SCHEDULEOFDEPRECIATIONFORARRIVINGATIDV
%OFDEPRECIATIONFORFIXINGIDV

Notexceeding6months
5%
Exceeding6monthsbutnotexceeding1
15%
year
Exceeding1yearbutnotexceeding2years20%
Exceeding2yearsbutnotexceeding3
30%
years
Exceeding3yearsbutnotexceeding4
40%
years
Exceeding4yearsbutnotexceeding5
50%
years
Note.IDVofobsoletemodelsofvehicles(ie.Modelswhichthemanufacturershavediscontinuedtomanufacture)andvehiclesbeyond5yearsof
agewillbedeterminedonthebasisofandunderstandingunderstandingbetweentheinsurerandtheinsured.