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Product Code: 3005 UIN: IRDAN115RP0015V05201415

Reference No.: W439456067

Date: Jul 01, 2025
SARVAR KHAN SA
NO5, S V KOIL ST, CHINNA NATHAM KANCHIPURAM TAMIL NADU-603002, CITY,
603002
KANCHIPURAM
TAMIL NADU 603002
Mobile No: 95******76

Sub: Risk Assumption Letter

Dear SARVAR KHAN SA,

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. 3005/399165663/00/000, 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 SARVAR KHAN SA
Period of Insurance Jul 09, 2025 to Jul 08, 2026
Vehicle Make / Model HONDA MOTORCYCLE / ACTIVA STD
RTO City TAMILNADU-CHENGALPATTU
Vehicle Registration No. TN19P1974
Vehicle Registration Date Jul 28, 2014
Engine No. JF50ET1205026
Chassis No. ME4JF502GET203260
Current Year NCB(%) 20%
Previous Policy Details
Previous Policy No. D155010959
Previous Policy Period 09-07-2024 to 08-07-2025
Previous Year NCB(%) 0%
Claims Made Under Previous Policy 0
Previous Insurer Name GODI
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.
1
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 [Link] for
details.

“Updating your bank details with us would help facilitating future transactions. Bank details can be easily updated using “IL – Take care” [Link] 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@[Link], 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 [Link] for the policy wordings, for complete details on terms and conditions governing the coverage and NCB)
CORP/SUP/OPI/2014/1777

Jul 01, 2025

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

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.

The Compulsory Personal Accident cover has not been opted in this policy on account that, the Owner driver has a separate existing Personal Accident cover
against Death and Permanent Disability (Total and Partial) for Sum Insured of at least Rs.15 lacs.

CORP/SUP/OPI/2014/1777

Jul 01, 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 : SARVAR KHAN SA Policy No. : 3005/399165663/00/000

Address : NO5, S V KOIL ST, CHINNA NATHAM KANCHIPURAM TAMIL Period of Insurance : Jul 09, 2025 [Link] to
NADU-603002, CITY, 603002, KANCHIPURAM, TAMIL Midnight of Jul 08, 2026
NADU 603002
Telephone No : Mobile No: 95******76 E-Policy No. : 3005/399165663/00/000
Email Address : AS*********@[Link] Policy Issued On : Jul 01, 2025
Nominee Name : - Named Passenger's Nominee: Covernote No. : 399165663
Relationship : - - RTO Location : TAMILNADU-CHENGALPATTU
Age : - Hypothecated To : -
GSTIN No. (Customer) : Invoice No. : 10072558289
Servicing Branch Name : New Delhi
Servicing Branch Address : Fourth Parsavnath Capital Tower Bhai Veer Singh Marg, New Delhi New Delhi 110001

Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/ Close relatives/Associates of PEPs*? No
Vehicle Registration Make Model Type of Body CC/KW Mfg Yr Seating Chassis No. Engine No.
No. Capacity
HONDA ACTIVA STD Two Solo With ME4JF502GET2032
TN19P1974 110 2014 2 JF50ET1205026
MOTORCYCLE Wheeler Pillion 60
Vehicle IDV Side Car Additional Accessories Electrical / Electronic Non Electrical Accessories CNG / LPG Unit Total IDV
(`) (`) (`) Accessories (`) (`) (`) (`)
36,465.00 0.00 0.00 0.00 0.00 0.00 36,465.00

Premium Details
OWN DAMAGE(A) (`) LIABILITY(B) (`)
Basic OD Premium 33.00 Basic Third Party Liability 714.00
Sub Total 33.00 Total 714.00
Less:
No Claim Bonus 20% 7.00
Sub-Total Deductions 7.00
Total Own Damage Premium(A) 26.00 Total Liability Premium(B) 714.00
Total Package Premium(A+B): 740
% 0.00
CGST
` 0.00
% 0.00
SGST
` 0.00
% 0.00
UTGST
` 0.00
% 18.00
IGST
` 133.20
Total Tax Payable in ` 133.00
Total Premium Payable In ` 873.00
Geographical Area: India Applicable IMT Clauses: 22
Compulsory Deductible: ` 100.00 Voluntary Deductible: ` 0.00

Premium Collection No. 1241136192 Premium Amount ` 873 Receipt Date 09-07-2025
GSTIN [Link] 07AAACI7904G1ZP 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 0/-. The Compulsory Personal Accident
cover has not been opted in this policy on account that, the Owner driver has a separate existing Personal Accident cover against Death and Permanent Disability (Total and
Partial) for Sum Insured of at least Rs.15 lacs. 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 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".
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 [Link] Legal interpretation, English version will hold good. Disclaimer: Please visit
[Link] 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
CORP/SUP/OPI/2014/1777

Jul 01, 2025

 1 1
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
0
Two Wheeler Vehicles Package Policy 0
1
Product Code: 3005 UIN: IRDAN115RP0015V05201415
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@[Link]. For detailed grievance redressal mechanism please visit the "Grievance Redressal" section on our website [Link].
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 Jul 01, 2025 in lieu of Covernote No. 399165663. The
stamp duty of ` 0.50 paid vide deface no. CSD112025527 dated Jan 30, 2025.
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.

Agency Code CA0841 :

Agency Name :
DREAMPLUG ADVISORY
SOLUTIONS PVT LTD
Agent's Contact No 0000000000
:

Contact Person :

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: 2025.07.01 [Link] IST
CORP/SUP/OPI/2014/1777

Jul 01, 2025