COMPULSORY PERSONAL ACCIDENT OWNER DRIVER UNDER MOTOR INSURANCE POLICIES

Ref. No.: W345177380 Policy Number : 3012/357933354/00/000

Date: 04-Sep-2024

MR HARSHAL DAMODARE
S O SATISH KUMAR DAMODARE WARD N 06 WARD 06 FATEPUR GRAM FATEPUR FATEHPUR BURHANPUR MADHYA PRADESH,
BURHANPUR,
MADHYA PRADESH,
450331
Mobile: 8770423837
Dear Customer,

Subject: Risk Assumption Letter

We thank you for placing your confidence with ICICI Lombard for your Insurance needs.

Please find enclosed herewith Policy No. : 3012/357933354/00/000 which has been issued based on the details furnished by the applicant.

Details are:

Name of the Insured Mr HARSHAL DAMODARE Name & Relation of the Proposer with Insured Self
Period of Insurance From 04-Sep-2024 00:00 To Policy Duration (Year) 1
03-Sep-2025 23:59
Registration No. MP09ZW3460 Engine & Chassis No.
5287452
W287330
Date of Birth - Sum Insured 1500000
Product Name COMPULSORY PERSONAL ACCIDENT (OWNER-DRIVER) UNDER MOTOR INSURANCE POLICIES

Please go through the details as furnished in the format and the policy document. Please confirm that same are in order. In case there is any discrepancies/
variations, you are requested to write back to us immediately at customersupport@icicilombard.com or contact at 24 hour helpline number 1800 2666 for necessary
changes/ rectification

In the absence of any communication from you in this connection within a period of 15 days of receipt of this letter, we would take it that the issued policy is in order
and as per your proposal.

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 UIN : IRDAN115RP0034V01201819
Mailing Address: Registered Office: Toll free no.: 1800 2666
401 & 402, 4th Floor, Interface ICICI Lombard House, 414 Veer Savarkar Marg, Alternate No.: +918655 222 666 (chargeable)
11, New Linking Road, Malad Near Siddhi Vinayak Temple, Prabhadevi, Mumbai - Email: customersupport@icicilombard.com
(West), Mumbai - 400 064. 400 025. Website: www.icicilombard.com 1/3
 Policy Certificate
Compulsory Personal Accident (Owner-Driver) under Motor Insurance Policies
Product Code: 3012 UIN: IRDAN115RP0034V01201819

PREAMBLE:ICICI Lombard General Insurance Company Limited ("the Company"), having received a Proposal and the premium from the Policy holder named in
the Schedule referred to herein below, and the said Proposal and Declaration together with any statement, report or other document leading to the issue of this Policy
and referred to therein having been accepted and agreed to by the Company and the Policy holder as the basis of this contract do, by this Policy agree, in
consideration of and subject to the due receipt of the subsequent premiums, as set out in the Schedule with all its Parts, and further, subject to the terms and
conditions contained in this Policy, as set out in the Schedule with all its Parts that on proof to the satisfaction of the Company of the compensation having become
payable as set out in Part I of the Schedule to the title of the said person or persons claiming payment or upon the happening of an event upon which one or more
benefits become payable under this Policy, the Sum Insured/ appropriate benefit amount will be paid by the Company.

Part I of Policy Schedule

Proposer Name Mr HARSHAL DAMODARE Policy No. 3012/357933354/00/000

Address S O SATISH KUMAR DAMODARE WARD Period of Insurance From 04-Sep-2024 00:00
N 06 WARD 06 FATEPUR GRAM To 03-Sep-2025 23:59
FATEPUR FATEHPUR BURHANPUR
MADHYA PRADESH,
BURHANPUR,MADHYA
PRADESH,450331
Contact No. 8770423837 Policy Tenure 1
Email Address HARSHAL.DAMODARE56@GMAIL.COM Policy Issuing Office BARODA
Nominee Name Simaran damodare Policy Issued On 04-Sep-2024
Relationship With Policyholder SISTER Previous Policy No. -
Appointee Name - Nominee D.O.B -
GSTIN Number (Customer) - Servicing Branch Name BARODA
Servicing Branch Address 2nd floor, 204,205,206, Golden icon, Bird Invoice Number 1008242844208
circle Opp.BSNL, Baroda 390007,
Gujarat.BARODA GUJARAT - 390007

Politically Exposed Person (PEP)/close relative of PEP: No

Insured Name Date of Birth Age Gender Relationship with Proposer Beneficiary / Nominee Relation of Nominee with the Insured
Mr HARSHAL DAMODARE Self Simaran damodare SISTER

Benefit & Extension Table

Cover Sum Insured (`)
Compulsory Personal Accident Owner Driver Cover 1500000
Premium Details (`)
IGST
Basic Premium Total Tax Payable Total Premium
% `
375 18.0 67.50 67.5 443
GSTIN Reg.No HSN/SAC code The stamp duty of `0.5 paid vide deface no. CSD0220242018
24AAACI7904G1ZT 997134 / GENERAL INSURANCE SERVICES dated 10-Apr-2024
GSTIN Address
We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under
sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.

Point of Sale (POS) Details

POS Number POS Name Contact Details PAN Card No.
POSD00023303 GOPAL KANUBHAI PATEL 6355261648 AEHPP4357G

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
Important : Insurance benefit shall become voidable at the option of the company, in the event of any untrue or incorrect statement, misrepresentation non-description of
any material particular in the proposal form/ personal statement, declaration and connected documents, or any material information has been withheld by beneficiary or
anyone acting on beneficiary's behalf to obtain insurance benefit. Please note that any claims arising out of pre-existing illness/ injury/ symptoms is excluded from the
scope of this policy subject to applicable terms and conditions. Refer to policy wordings for the terms and conditions. All disputes are subject to the jurisdiction of
Mumbai High Court only. For claims, please call us at our toll free no. 1800 2666 or e-mail to us at customersupport@icicilombard.com or write to us at ICICI Lombard GIC,
ICICI Bank Tower, Plot no-12, Financial district Nanakramguda, Gachibowli, Hyderabad, Andhra Pradesh 500032.
This policy has been issued based on the details furnished by the policyholder. Please review the details furnished in the policy certificate and confirm that same are in
order. In case of any discrepancy/ variation, you are requested to call us immediately at our toll free no. 1800 2666 or write to us at customersupport@icicilombard.com. In

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 UIN : IRDAN115RP0034V01201819
Mailing Address: Registered Office: Toll free no.: 1800 2666
401 & 402, 4th Floor, Interface ICICI Lombard House, 414 Veer Savarkar Marg, Alternate No.: +918655 222 666 (chargeable)
11, New Linking Road, Malad Near Siddhi Vinayak Temple, Prabhadevi, Mumbai - Email: customersupport@icicilombard.com
(West), Mumbai - 400 064. 400 025. Website: www.icicilombard.com 2/3
order. In case of any discrepancy/ variation, you are requested to call us immediately at our toll free no. 1800 2666 or write to us at customersupport@icicilombard.com. In
the absence of any communication from you within the period of 15 days of receipt of this document, the policy would be deemed to be in order and issued as per your
proposal. All refunds and claim payment will be done through NEFT only. This policy certificate i s to be read with the policy wordings, as one contract or any word or
expression to which a specific meaning has been attached in any part of this policy shall bear the same meaning wherever it may appear.
Nature of injury Sum Insured Scale of compensation
I. Death 15 Lakh 100%
II. Loss of two limbs or sight of both eyes or one limb and sight of one eye 15 Lakh 100%
III. Loss of one limb or sight of one eye 15 Lakh 50%
IV. Permanent total disablement from injuries other than those named above. 15 Lakh 100%

For ICICI Lombard General Insurance Company Ltd.

Authorised Signatory

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2024.08.29 11:24:19 IST

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH20000PLC129408 UIN : IRDAN115RP0034V01201819
Mailing Address: Registered Office: Toll free no.: 1800 2666
401 & 402, 4th Floor, Interface ICICI Lombard House, 414 Veer Savarkar Marg, Alternate No.: +918655 222 666 (chargeable)
11, New Linking Road, Malad Near Siddhi Vinayak Temple, Prabhadevi, Mumbai - Email: customersupport@icicilombard.com
(West), Mumbai - 400 064. 400 025. Website: www.icicilombard.com 3/3