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Product Code: 3005 UIN: IRDAN115RP0015V05201415

Reference No.: W412086913

Date: Mar 28, 2025
MEHTAB ALAM
, WARD NO- 02, CHAMPARAN, BIHAR
CHAMPARAN
BIHAR 845455
Mobile No: 96******37

Sub: Risk Assumption Letter

Dear MEHTAB ALAM,

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. 3005/386694735/00/B00, 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 MEHTAB ALAM
Period of Insurance Mar 31, 2025 to Mar 30, 2026
Vehicle Make / Model YAMAHA / RX 100
RTO City MADHYA PRADESH-BHOPAL
Vehicle Registration No. MP04S1787
Vehicle Registration Date Apr 06, 1995
Engine No. 1L1488498
Chassis No. 1L1488498
Previous Policy Details
Previous Policy No. 123456789
Previous Policy Period 22-02-2022 to 21-02-2023
Previous Year NCB(%) 0%
Claims Made Under Previous Policy 0
Previous Insurer Name ICLB
Previous Policy Type Comprehensive Package
1 0
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.
1
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.
d. In case of total loss / constructive total loss / Total theft / cash loss of the vehicle, the claim will be settled at invoice price i.e amount paid by the insured /
policyholder at the time of purchasing the vehicle, excluding subsidy amount, if included in the invoice, or the Insured declared value (IDV) whichever is lower,
subject to terms and conditions of the policy and admissibility of claims.
( 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

Mar 28, 2025

 1 1
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
0
Two Wheeler Vehicles Package Policy 0
1
Product Code: 3005 UIN: IRDAN115RP0015V05201415

Name of the Insured : MEHTAB ALAM Policy No. : 3005/386694735/00/B00

Address : , WARD NO- 02, CHAMPARAN, BIHAR, CHAMPARAN, Period of Insurance : Mar 31, 2025 12:00:00 to
BIHAR 845455 Midnight of Mar 30, 2026
Telephone No : Mobile No: 96******37 E-Policy No. : 3005/386694735/00/B00
Email Address : ME***********@GMAIL.COM Policy Issued On : Mar 28, 2025
Nominee Name : SAHINA KHATOON Named Passenger's Nominee: Covernote No. : 386694735
Relationship : SPOUSE - RTO Location : MADHYA PRADESH-BHOPAL
Age : 25 - Hypothecated To : -
GSTIN No. (Customer) : Invoice No. : 1003252890044
Servicing Branch Name : Mumbai
Servicing Branch Address : 414, ICICI LOMBARD HOUSE, VEER SAVARKAR MARG, NEAR SIDDHI VINAYAK TEMPLE MAIN GATE, PRABHADEVI, MUMBAI,
400025, MAHARASHTRA

Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/ Close relatives/Associates of PEPs*? No
Vehicle Registration No. Make Model Type of Body CC/KW Mfg Yr Seating Capacity Chassis No. Engine No.
MP04S1787 YAMAHA RX 100 Solo 100 1995 2 1L1488498 1L1488498
Vehicle IDV Side Car Additional Accessories (`) Electrical / Electronic Accessories (`) Non Electrical Accessories (`) CNG / LPG Unit Total IDV
(`) (`) (`) (`)
26,000.00 0.00 0.00 0.00 0.00 0.00 26,000.00

Premium Details
OWN DAMAGE(A) (`) LIABILITY(B) (`)
Basic OD Premium 469.00 Basic Third Party Liability 714.00
Sub Total 469.00 Total 714.00
Add:
PA Cover for Owner Driver 525.00
Sub-Total 525.00
Total Own Damage Premium(A) 469.00 Total Liability Premium(B) 1,239.00
Total Package Premium(A+B): 1708
% 0.00
CGST
` 0.00
% 0.00
SGST
` 0.00
% 0.00
UTGST
` 0.00
% 18.00
IGST
` 307.44
Total Tax Payable in ` 307.00
Total Premium Payable In ` 2,015.00
Geographical Area: India Applicable IMT Clauses: 22
Compulsory Deductible: ` 100.00 Voluntary Deductible: ` 0.00

Premium Collection No. 1233585873 Premium Amount ` 2015 Receipt Date 28-03-2025
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 ; PA Cover for Owner-Driver under Section III: CSI 1500000/-. 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 i s 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 i s 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
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. 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
CORP/SUP/OPI/2014/1777

Mar 28, 2025

 1 1
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
0
Two Wheeler Vehicles Package Policy 0
1
Product Code: 3005 UIN: IRDAN115RP0015V05201415
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
In case of total loss / constructive total loss / Total theft / cash loss of the vehicle, the claim will be settled at invoice price i.e amount paid by the insured / policyholder at
the time of purchasing the vehicle, excluding subsidy amount, if included in the invoice, or the Insured declared value (IDV) whichever i s lower, subject to terms and
conditions of the policy and admissibility of claims.
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 Mar 28, 2025 in lieu of Covernote No. 386694735. The
stamp duty of ` 0.50 paid vide deface no. CSD10520244764 dated Oct 04, 2024.
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.

Click here or scan the QR code to view the Customer Information Sheet (CIS). It provides an overview
of the policy features, service and claim processes, as well as other important terms.

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2025.03.28 17:33:23 IST
CORP/SUP/OPI/2014/1777

Mar 28, 2025