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N Sure Policy

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TWO WHEELER CERTIFICATE-CUM-POLICY SCHEDULE

Cert. No. ICICI LOMBARD General Policy No


3005/6238119/00/000 Insurance Company Limited 3005/6238119/00/000
ICICI Bank Tower, Bandra Kurla
Complex,
Bandra(East) Mumbai -400 051
Insured Occupation Address Of The Insured Valid From To
VIMALKUMAR Service S NO 167/2 SAI PARADISE 30-10-2008 13:11:00.0 Midnight of 29-10-2009
AMARNATH KAMGARNAGAR PIMPRI
SHRIDHAR FLAT NO 12 HAVELI PUNE
Vehicle Regn No. Engine No. Chassis No. Make & Model Year Of Mfg Cubic Capacity
MH-14-BF-7942 07HBMM03800 07HBMC03434 Hero Honda – 2007 150
CBZ-
EXTREME DSS
Declared Value (IDV) Of Side Car IDV Non-Electrical Electrical CNG/LPG/Bi-Fuel IDV Total IDV
Vehicle Accessories IDV Accessories
52.999.00 NA NA NA NA 52.999.00
Place Of Regn. Body Type HP/Lease/Hire- Branch Office of Seating Capacity Premium
Purchase HP/Lease/Hire-
Agreement With Purchase
PCMC Solo CITI BANK NA 2 1200.00
LTD
A. Own Damage Premium Computation (Section 1) in Rs. B. Liability Premium Computation (Section II) in Rs.
Basic Premium Including Premium for TPPD
Basic Premium On Vehicle : 300.00
Vehicle : 718.00 CNG/LPG/Bi-Fuel Kit : 0.00
Accessories : 0.00 Total : 300.00
Electronic & Electrical
: Add
Accessories
Bi-Fuel Kit : a) PA Benefits : 50.00
Total : 718.00 b) : 0.00
Add Extras: Legal Liability
Geographical Extension : c) : 0.00
For any other extra : d) :
Sub Total : e) For any other extra :
Less Discounts
For ani-theft devices : Total Liablity Premium (B) : 362.00
Any other discount :
NCB : 20% Total Premium (A + B) : 968.00
Total Deductions : 0.0 Add Service Tax : 120.00
Net Own Damage Premium(A) : 718.00 :
Gross Premium : 1200.00
LIMITATIONS AS TO USE: The Policy covers use of the vehicle for any purpose other than: a) Hire Or Reward b) Carriage of goods
(other than samples or personal luggage) c) Organized Racing d) Pace Making e) Speed Testing f) Reliability Trials g) Any purpose in
connection with Motor Trade.
IMPORTANT NOTICE: The insured is not indemified if the vehicle is 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 RIGHTS OF RECOVERY'
DRIVER: Any person including insured: Provided that a person driving holds an effective driving licence at the time of the accident and
is not disqualified from Holding or obtaining such a licence.Provided also that the person holding an effective Learner's Licence may also
drive the vehicle and that such a person satisfies the requirements of Rule 3 of the Central Motor Vehicle Rules, 1989
LIMIT OF LIABILITY: Limit of the amount of the Company's liability under the Section II-I(i) in respect of any one accident as per
M.V. Act 1988. Limit of the amount of the Company's liability under Secion II-I(ii) in respect of any one claim or series of claims arising
out of one event : Upto Rs 100000/- 0.00
I/We certify that the policy to which the certificate relates as well the certificate of insurance are issued in accordance with the provisions
of Chapter X & XI of M.V. Act 1988
Dealer's Stamp & Issued through NsurePlus Application Software
Signature Received Via
Premium Of Rs. 1200.00 Cash/Cheque The policy is subject to a compulsory excess of Rs.
No. CASH 50/- & Depreciation is applicable as per policy terms
& conditions*
Dated Consolidted Stamp Duty Paid
IMT 22
Drawn On
Endorsements:
Acknowledgement
30-10-2007
Dated
FOR RENEWALS CONTACT:SEHGAL AUTORIDERS On behalf of ICICI Lombard General Insurance Co.
PVT LTD Ltd.
10-Oct-2008 D-II, 64/6, M.I.D.C CHINCHWAD, PUNE 020-24111213
Date & Signature of
proposer PUNE

411019
Duly Constituted Attorney
Service Tax Reg. No. G/S / Mumbai - 1/1528/2001 Visit us at www.icicilombard.com- Mail us at customersupport@icicilombard.com
Contact us at 1800-209-8888(Toll Free)
The stamp duty of fifty paise paid in cash or by demand draft or by pay order, vide Receipt/Challan No 19342, dated 19th July 2008
ICICI Lombard General Insurance Company Limited, Zenith house Keshavrao Khadye Marg,Opp. Race Course, Mahalaxmi, Mumbai
-400 034
Insurance underwritten by ICICI Lombard General Insurance Company Limited. Insurance is the subject matter of the solicitation.

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