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Ref. No. W6468789

Date: Sep 25, 2017
SAROJINI KOLLU
H. NO. 178/01 NARAYAN NAGAR, SATTARI
VALPOI
BICHOLIM
GOA 403506
Mobile No: 8605896717

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. 3001/107286243/02/000, which has been issued based on the below mentioned details:

Insured & Vehicle Details

Name of Insured SAROJINI KOLLU
Period of Insurance Sep 27, 2017 to Sep 26, 2018
Vehicle Make / Model MARUTI / RITZ VDI
RTO City GOA-BICHOLIM B
Vehicle Registration No. GA04C2830
Vehicle Registration Date Aug 26, 2010
Engine No. D13A1419799
Chassis No. MA3FDEB1S00200270FA
Previous Policy Details
Previous Policy No. 3001/107286243/01/000
Previous Policy Period 27-09-2016 to 26-09-2017
Previous Year NCB(%) 45%
Claims Made Under Previous Policy 0
Previous Insurer Name ICICI LOMBARD
Previous Policy Type Comprehensive Package

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.

If you require any changes in the Certificate of Insurance cum Policy Schedule, you are requested to inform us by writing to
customersupport@icicilombard.com 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. CORP/SUP/OPI/2014/1777

Mailing Address: 401 & 402, 4th Floor, Interface 11, New Linking Road, Malad (West), Mumbai - 400 064, IRDA Reg. No. 115, CIN: U67200MH2000PLC129408

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CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
Private Car Package Policy
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Insured Name : SAROJINI KOLLU Policy No : 3001/107286243/02/000

Address : H. NO. 178/01 NARAYAN NAGAR, SATTARI, VALPOI, Period of Insurance : Sep 27, 2017 00:00 to
BICHOLIM, GOA 403506 Midnight of Sep 26, 2018
Telephone No : - Mobile No: 8605896717 E-Policy No :
Email Address : Policy Issued On :
Sep 25, 2017
Nominee Name : - Named Passenger's Nominee: Covernote No :
107286243
Relationship : - - RTO Location :
GOA-BICHOLIM B
Age : - Hypothecated To :
DEENDAYAL NAGARI
SAHAKARI PS MARYAD,-
GSTIN Number (Customer) : Invoice Number : 100917532650
Servicing Branch Name : Panaji Servicing Branch Address : 101 First Kamat Tower Opp.
KTC Bus Stand, Panaji Goa
403001
Registration No. Make Model Type of Body CC Mfg Yr Seating Chassis No. Engine No.
Capacity
GA04C2830 MARUTI RITZ VDI Saloon 1248 2010 5 MA3FDEB1S00200270FA D13A1419799
Vehicle IDV Trailer Non Electrical Electrical / Electronic CNG / LPG Unit Total IDV
(`) (`) Accessories (`) Accessories (`) (`) (`)
215445 0 0 0 0 215445

Premium Details
OWN DAMAGE(A) (`) LIABILITY(B) (`)
Basic OD Premium 4332 Basic Third Party Liability 2863
Sub Total 4332 Total 2863
Less: Add:
Anti-theft Device Discount 108 Legal Liability to Paid Driver 50
Sub-Total Deductions 108 PA Cover for Owner Driver 100
Unnamed PA Cover for 5 Persons of ` 50000 each 125
Sub-Total 275
Total Own Damage Premium(A) 4224 Total Liability Premium(B) 3138
Total Package Premium(A+B): 7362
% 9
CGST
` 662.58
% 9
SGST
` 662.58
Total Tax Payable in ` 1325
Total Premium Payable In ` 8687
Geographical Area: India Applicable IMT Clauses: 16 , 28 , 10 , 22 , 7
Compulsory Deductible: ` 1000 Voluntary Deductible: ` 0

Premium Collection No. 1069632497 Premium Amount ` 8687 Receipt Date 25-09-2017
GSTIN Reg.No 30AAACI7904G1Z0 HSN/SAC code 9971 / 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 ` 750000/-; PA Cover for Owner-Driver under Section III: CSI ` 0/-. 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 is not indemnified 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 RIGHT OF RECOVERY". 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 is 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 is 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. 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 customersupport@icicilombard.com. 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 Sep 25, 2017 in lieu of Covernote no.
107286243. The stamp duty of ` 0.5 paid vide receipt/challan no. 5037788 dated Sep 04, 2017.
Policy Issuing Office: ICICI Lombard General Insurance Company Limited, ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple,
Prabhadevi, Mumbai 400 025.

Agency Code : 8159021

Agency Name : SHIRLEY EMILY DCUNHA

Agent's Contact No : 8087688102 Signature Not Verified

Digitally signed by
SANJAY DATTA
Date: 2017.09.27
17:09:45 IST
CORP/SUP/OPI/2014/1777

Mailing Address: 401 & 402, 4th Floor, Interface 11, New Linking Road, Malad (West), Mumbai - 400 064, IRDA Reg. No. 115, CIN: U67200MH2000PLC129408

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