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Product Code: 3005 UIN: IRDAN115RP0015V04201415

Reference No.: W232639935

Date: Aug 02, 2023
PRABHAKAR KUMAR
S O R N BHAGAT
AT VEDANTA LIMITED SIBCO CAMP NISA SECURITY BHURKHAMUNDA
JHARSUGUDA
ORISSA 768201
Mobile No: 7654356324

Sub: Risk Assumption Letter

Dear PRABHAKAR KUMAR,

We value your relationship with ICICI Lombard General Insurance Company Limited and thank you for choosing us as your
preferred insurance provider.
Please find enclosed Policy No. 3005/177918428/04/000, The same has been issued based on below mentioned details, provided by you at the time of policy
purchase.

Insured & Vehicle Details

Name of the Insured PRABHAKAR KUMAR
Period of Insurance Aug 25, 2023 to Aug 24, 2024
Vehicle Make / Model HONDA MOTORCYCLE / ACTIVA 125
RTO City ORISSA-JHARSUGUDA
Vehicle Registration No. OD23F0428
Vehicle Registration Date Aug 19, 2017
Engine No. JF49E82167341
Chassis No. ME4JF497HH8037915
Current Year NCB(%) 50%
Previous Policy Details
Previous Policy No. 3005/177918428/03/000
Previous Policy Period 25-08-2022 to 24-08-2023
Previous Year NCB(%) 45%
Claims Made Under Previous Policy 0
Previous Insurer Name ICICI LOMBARD
Previous Policy Type Comprehensive Package
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The commencement of coverage of risk under the policy is subject to realisation of payment of premium in full. In case the premium is not realised due to
cheque dishonour or any other reason, the insurance cover shall be void ab-initio.
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We have issued the policy basis your confirmation that you hold a valid PUC and/or Fitness certificate, as applicable.
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Government of India has mandated electronic toll payments using FASTag to reduce vehicular traffic at toll plazas. Customers are advised to comply with the
direction of the government and get their FASTag from Point of Sale locations at Toll Plazas or from Issuer Agency. Please visit http://www.fastag.org/ for
details.

“Updating your bank details with us would help facilitating future transactions. Bank details can be easily updated using “IL – Take care” App.Download the app
now for all your insurance and wellness needs and for faster resolution”

Please check the policy details for accuracy. Should you find any discrepancy / require any changes in the Certificate of Insurance cum Policy Schedule, please
contact us immediately at our toll free number 1800 2666 or email us at customersupport@icicilombard.com, so that we can rectify the same. 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.

Important Points:
a. Any accidental loss, damage and/or liability caused, sustained or incurred, while vehicle not being registered permanently will not be covered.
b. Any minor scratches to the vehcile, paint fading, wear and tear arising out of normal use and requiring touch-up or minor repair under routine maintenance
will not be covered.
c. Any liability of whatsoever nature caused by, contributed by or arising due to the vehicle being driven by a person without having valid driving license will not
be covered.
( Please visist www.icicilombard.com for the policy wordings, for complete details on terms and conditions governing the coverage and NCB)

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

Aug 02, 2023

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CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
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Two Wheeler Vehicles Package Policy
Product Code: 3005 UIN: IRDAN115RP0015V04201415

Name of the Insured : PRABHAKAR KUMAR Policy No. : 3005/177918428/04/000

Address : S O R N BHAGAT, AT VEDANTA LIMITED SIBCO CAMP Period of Insurance : Aug 25, 2023 00:00:00 to
NISA SECURITY BHURKHAMUNDA, JHARSUGUDA, Midnight of Aug 24, 2024
ORISSA 768201
Telephone No : Mobile No: 7654356324 E-Policy No. : 3005/177918428/04/000
Email Address : PRABHAKARKUMAR7777@GMAIL.COM Policy Issued On : Aug 02, 2023
Nominee Name : NEEHAL KUMAR Named Passenger's Nominee: Covernote No. : 177918428
Relationship : SON - RTO Location : ORISSA-JHARSUGUDA
Age : 29 - Hypothecated To : -
GSTIN No. (Customer) : Invoice No. : 100823124831
Servicing Branch Name : Mumbai
Servicing Branch Address : 414, ICICI LOMBARD HOUSE, VEER SAVARKAR MARG, NEAR SIDDHI VINAYAK TEMPLE MAIN GATE, PRABHADEVI, MUMBAI,
400025, MAHARASHTRA

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

Vehicle Registration Make Model Type of Body CC/KW Mfg Yr Seating Chassis No. Engine No.
No. Capacity
HONDA Solo With
OD23F0428 ACTIVA 125 125 2017 2 ME4JF497HH8037915 JF49E82167341
MOTORCYCLE Pillion
Vehicle IDV Side Car Additional Accessories (`) Electrical / Electronic Non Electrical CNG / LPG Unit Total IDV
(`) (`) Accessories (`) Accessories (`) (`) (`)
20,426.00 0.00 0.00 0.00 0.00 0.00 20,426.00

Premium Details
OWN DAMAGE(A) (`) LIABILITY(B) (`)
Basic OD Premium 90.00 Basic Third Party Liability 714.00
Road Side Assistance (TW-199) 199.00 Total 714.00
Sub Total 289.00 Add:
Less: Unnamed PA Cover for 2 Persons of ` 100000 each 140.00
No Claim Bonus 50% 45.00 PA Cover for Owner Driver 450.00
Sub-Total Deductions 45.00 Sub-Total 590.00
Total Own Damage Premium(A) 244.00 Total Liability Premium(B) 1,304.00
Total Package Premium(A+B): 1548
% 0.00
CGST
` 0.00
% 0.00
SGST
` 0.00
% 0.00
UTGST
` 0.00
% 18.00
IGST
` 278.64
Total Tax Payable in ` 279.00
Total Premium Payable In ` 1,827.00
Unique Identification Number (UIN) Details
Road Side Assistance
IR
IRDAN115RP0015V01200607/A0002V01201213

Geographical Area: India Applicable IMT Clauses: 16 , 22

Compulsory Deductible: ` 100.00 Voluntary Deductible: ` 0.00

Premium Collection No. 1179416166 Premium Amount ` 1827 Receipt Date 02-08-2023
GSTIN Reg.No 27AAACI7904G1ZN HSN/SAC code 997134 / GENERAL
INSURANCE SERVICES
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.
Limits of Liability: (a) Under Section II-I(i) of the policy: Death of or bodily injury & (b) Under Section II-I(ii) of the policy: Damage to Third Party Property- Such amount as is
necessary to meet the requirements of the Motor Vehicles (Amendment) Act, 2019 ` 1,00,000.00/-; PA Cover for Owner-Driver under Section III: CSI ` 15,00,000.00/-.
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 i s 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".
In consideration of the premium for this extension being calculated at a pro-rata proportion of the annual premium, it is hereby declared and agreed by the insured that upon
expiry of this extension, this policy shall be renewed for a period of twelve months, failing which the difference between the extension premium now paid on pro rata basis
and the premium at short period rate shall become payable by the insured.For Legal interpretation, English version will hold good. Disclaimer: Please visit
CORP/SUP/OPI/2014/1777

Aug 02, 2023

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CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
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Two Wheeler Vehicles Package Policy
Product Code: 3005 UIN: IRDAN115RP0015V04201415
and the premium at short period rate shall become payable by the insured.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 i s 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 i s 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. On renewal, the benefits provided under the policy and/or terms and conditions of the policy including premium rate may be subject to change. 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.
The Company reserves the right to cancel this Policy immediately upon becoming aware of any mis-representation, fraud, non-disclosure of material facts or
non-cooperation by or on behalf of the Insured; the Company is not obliged to refund the premium paid under this Policy
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 Aug 02, 2023 in lieu of Covernote No. 177918428. The
stamp duty of ` 0.50 paid vide deface no. CSD6142023662 dated Feb 20, 2023.
Policy Issuing Office: ICICI Lombard General Insurance Company Limited, ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi,
Mumbai 400 025.
Warranted that the insured named herein/owner of the vehicle holds a valid Pollution Under Control (PUC) Certificate and/or valid fitness certificate, as applicable, on the
date of commencement of the Policy and undertakes to renew and maintain a valid and effective PUC and/or fitness Certificate, as applicable, during the subsistence of
the Policy. Further, the Company reserves the right to take appropriate action in case of any discrepancy in the PUC or fitness certificate.

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2023.08.02 17:51:37 IST
CORP/SUP/OPI/2014/1777

Aug 02, 2023