TWOWHEELERVEHICLEPACKAGEPOLICY

CertificatecumPolicySchedule
CertificatecumPolicyNo:3005/W62113902/00/000
ForCLAIMS:Call18002666(Tollfreefromallphones)
ForRENEWALS:Visitwww.icicilombard.comorcall18002666
DETAILSOFPOLICYHOLDER POLICYDETAILS
InsuredName PHULCHANDNMUNDE ICICILombardGeneralInsurance
128,SHASTRINAGAR,WESTERNEXPRESS CompanyLtd.ICICILombardHouse,414,
PolicyIssuingOffice
InsuredAddress HIGHWAYROAD,VILEPARLEEAST,MUMBAI, VeerSavarkarMarg,NearSiddhiVinayak
MUMBAI,MAHARASHTRA,400099 Temple,Prabhadevi,Mumbai400025
ContactNo. 9773360379 From00:00:00hrsof24Aug2017to
PeriodofInsurance
Midnightof23Aug2018
EmailAddress MUNDESACHIN67@GMAIL.COM
PolicyIssuingon 21Aug2017
GSTINNumber
CoverNoteNo W62113902
InvoiceNumber 1327081700725569
RTOLocation MUMBAI
InvoiceDate 24Aug2017
Hypothecatedto N/A
TypeofAgreement None
NameoftheservicingIL
Mumbai
Branch
414,ICICILOMBARDHOUSE,VEER
SAVARKARMARG,NEARSIDDHIVINAYAK
AddressoftheILbranch
TEMPLEMAINGATE,PRABHADEVI,MUMBAI,
400025,MAHARASHTRA
GSTINReg.No 27AAACI7904G1ZN
VEHICLEDETAILS
RegistrationNumber Make Model Typeofbody C C Mfg.Year SeatingCapacity ChassisNumber EngineNumber
MH02DE4526 HONDAMOTORCYCLE ACTIVA Solo 102 2013 2 ME4JF501HD7382844 JF50E70382827
INSUREDDECLAREDVALUE
VehicleIDV(inRs.) SideCar NonElectricalAcc(inRs.) Elec/ElectronicAcc(inRs.) CNG/LPGUnit(inRs.) TotalValue(inRs.)
34894 0 0 0 0 34894
SCHEDULEOFPREMIUM(INRS.)
OwnDamage(A) Liability(B)
BasicPremium 536 BasicPremiumincludingpremiumforTPPDvehicle 720
Total: 536 Total: 720
Add Add
Less PAcoverforOwnerDriver 50
SubTotal(Additions): 50
Less
SubTotal(Deductions): 0
TotalOwnDamagePremium 536 TotalLiabilityPremium 770

TotalPackagePremium(A+B) 1306
Tax 235
CGST(9%onBasicPremium) 118
SGST(9%onBasicPremium) 118
UTGST(0%onBasicPremium) 0
IGST(0%onBasicPremium) 0
TotalPremiumPayable(inRs.)1541
Compulsorydeductibles:Rs.100/ GeographicalArea:India

PAToOwnerDriverNomineeDetails
NomineeName Age RelationShip
SUSHAMAMUNDE 47 Spouse
LIMITSOFLIABILITY:(a)UnderSectionII1(i)ofthepolicy>Deathoforbodilyinjury:Suchamountasisnecessarytomeetthere
requirementsofthemotorvehiclesAct.1988.
(b)UnderSectionII1(i)ofthepolicy>DamagetoThirdPartyPropertyRs1,00,000PACoverforOwnerDriverundersectionIIICSIRs
1,00,000
LIMITATIONSASTOUSE:Thepolicycoversuseofthevehicleforanypurposeotherthan:Hireorreward,Carriageofgoods(otherthansamples
orpersonalluggage),Organizedracing,Pacemaking,Speedtesting,Reliabilitytrials,AnypurposeinconnectionwithMotorTrade.
DRIVER'SCLAUSES:Anypersonincludingtheinsured:ProvidedthatapersondrivingholdsaneffectiveDrivingLicenseatthetimeofthe
accidentandisnotdisqualifiedfromholdingorobtainingsuchalicense.ProvidedalsothatthepersonholdinganeffectiveLearner'sLicensemay
alsodrivethevehicleandthatsuchapersonsatisfiestherequirementsofRule3oftheCentralMotorVehiclesRules,1989.
IMPORTANTNOTICE:TheInsuredisnotindemnifiedifthevehicleisusedordrivenotherwisethaninaccordancewiththisschedule.Anypayment
madebythecompanybyreasonofwidertermsappearinginthecertificateinordertocomplywiththeMotorVehicleAct,1988isrecoverablefrom
theinsured.Seetheclauseheaded'AVOIDANCEOFCERTAINTERMSANDRIGHTOFRECOVERY'.Forlegalinterpretation,Englishversionwillhold
good.
SubjecttoIMTEndorsementNos.&Memorandumprintedherein/attachedhereto:22
PremiumCollectionDetails:[CollectionNo/Amount/ReceiptDate]NA/Rs.1541/21/08/2017
DISCLAIMER:Pleasevisitwww.icicilombard.comforthepolicywordingsforcompletedetailsontermsandconditionsgoverningthecoverageandNCB.This
documentistobereadwiththepolicywordings.
GrievanceRedressal
Forresolutionofanyqueryorgrievanceyoumaycontactusonourtollfreeno.18002666,orvisitanyofourbranchoffices.Youcanalsowritetousat
customersupport@icicilombard.com.Fordetailedgrievanceredressalmechanismpleasevisitthe"GrievanceRedressal"sectiononourwebsite
www.icicilombard.com.
Policyisvalidsubjecttorealizationofcheque.Weacceptpremiumonlyvialegallyrecognizedmodesexceptforcash.Ifourrepresentativerequestyou
topayincash,kindlyreportittous.Forinformationonombudsmanyoumayvisitourwebsitewww.icicilombard.com
I/Weherebycertifythatthepolicytowhichthecertificaterelatesaswellasthecertificateofinsuranceare ForICICILombardGeneralInsurance
issuedinaccordancewiththeprovisionofchapterX,XIofM.VAct1988 CompanyLtd
GSTINReg.No.:27AAACI7904G1ZN
HSN/SACcode:440005,GENERALINSURANCESERVICES.
IRDARegistrationNo.115
InWitnesswhereofthispolicyhasbeensignedatMumbaithisinlieuofcovernoteNoThestampdutyofRs.
paidincashorbydemanddraftorbypayorder,videReceipt/Challanno.dated DulyConstitutedAttorney(s)
ICICILombardGeneralInsuranceCompanyLtd.
MailingAdd.Office: RegisteredOffice:
ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,414, ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,414,
VeerSavarkarMarg,NearSiddhiVinayakTemple,Prabhadevi,Mumbai400 VeerSavarkarMarg,NearSiddhiVinayakTemple,Prabhadevi,Mumbai400
025 025