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TWO WHEELER CERTIFICATE-CUM-POLICY SCHEDULE

Cert. No. ICICI Lombard General Insurance Prev. Policy No: ILG
3005/25956519/10961/000 Company Ltd 3005/2010833857/22/00000276
414,Veer Savarkar Marg,Near Siddhi
Vinayak Temple, Prabhadevi, Mumbai
400025

customersupport@icicilombard.com
Insured Business/Profession Address of The Insured Valid From To
D NO 5-142 ARTHAMURU
Mr RAJESWARA RAO Midnight of 07-01-
Employed BANTUMILLI MND Machilipatnam 08-01-2015 0:00:00
borra 2016
ANDHRA PRADESH 521369
Vehicle Regn No. Engine No. Frame No. Make & Model Year of Mfg Cubic Capacity
Hero
MotoCorp
AP-16-AY-1574 KC12EECGL07533 MBLKC12EHCGL05328 (formerly Hero 2012 150
Honda)
XTREME DSS
Declared Value (IDV) of Side Car IDV Non-Electrical Electrical CNG/LPG/Bi-Fuel IDV Total IDV
Vehicle Accessories IDV Accessories
IDV
46200.00 NA 0.00 0.00 NA 46200.00
Place of Regn. Body Type HP/Lease/Hire-Purchase Branch Office Seating Capacity Premium
Agreement With of
HP/Lease/Hire-
Purchase
Machilipatnam Solo --- --- 2 1347.00
A. Own Damage Premium Computation (Section 1) in Rs. B. Liability Premium Computation (Section II) in Rs.
Basic Premium On Basic Premium Including Premium for TPPD
Vehicle : 697.00 Vehicle : 464.00
Accessories : 0.00 CNG/LPG/Bi-Fuel Kit : 0.00
Electronic & Electrical Accessories : 0.00 Add
Bi-Fuel Kit : a) Compulsary PA Cover (Owner Driver) : 50.00
Total : 697.00 b) Optional PA Cover(Un Named Passenger) : 0.00
Add Extras: c) Optional PA Cover(Pillion Rider) : 0.00
Geographical Extension : 0.00 Legal Liability
ND Cover : 231.00 d) Legal Liability Cover (Paid Drivers, Cleaners) : 0.00
For any other extra : e) Legal Liability Cover (Other then Paid Drivers,
Cleaners) : 0.00
Sub Total : 928.00
Less Discounts Total Liablity Premium (B) : 514.00
For anti-theft devices : 0.00 Total Premium (A + B) : 1198.00
Any other discount : For any other extra : 0.00
NCB (35 %) : 244.00 Add Service Tax : 149.00
Total Deductions : 244.00 Gross Premium : 1347.00
Net Own Damage Premium(A) : 684.00

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/-
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

Issued through NsurePlus Application Software From 1st July 2014, Insured is Liable for a
Received Vide voluntary deductible of Rs. 250/- for each
Premium of Rs. 1347.00 CASH Claim,if policy having ND product.
Cash/Cheque No.
The policy is subject to a compulsory excess of
Dealer's Stamp & veera venkata Rs. 100/- & Depreciation is applicable as per
Dated Nominee Name
Signature gangadhara rao policy terms & conditions* (Please turn overleaf
Drawn on Nominee Age 58 for details)

07-01- Nominee Consolidted Stamp Duty Paid

Acknowledgement Dt Father Endorsements: IMT - 22
2015 Relation

08-Jan-2015 On behalf of ICICI Lombard General Insurance

Date & Signature of
Agent / Broker Details - Direct Company Ltd
proposer

http://www.nsureplus.com/Nsureplus/Policy/PolicySchedule.aspx 07-01-2015