RiskAssumptionLetter

Date:22/01/2016

ROOPALNPATEL

8,NewAsitAppt,,

InquilabSociety,GulbaiTekra,Naranpura

AHMEDABAD,GUJARAT380013

MobileNo.:9909004824

TelNo.:

DearSir/Madam,
WewelcomeyoutotheICICILombardInsurancefamily.
PleasefindenclosedPolicyNo.:3005/I40968775/00/000whichhasbeenissuedbasedonthedetailsfurnishedtousasbelow:

1. NameoftheInsured:ROOPALNPATEL
2. VehicleMake/Model:Suzuki/ACCESS
3. RTOCity:AHMEDABAD
4. VehicleRegistrationNumber:GJ01LM2176
5. EngineNumber:F486293600
6. ChassisNumber:MBCF4CAM98293531
7. Previouspolicydetailsprovided:Yes
8. PreviousPolicyperiod:From18/12/2014to17/12/2015
9. PeriodofInsurance:From:16:2631/12/2015To:30/12/2016midnight
10. PreviousYearNCB:50
11. Dateofregistration:17/12/2009
12. Claimsmadeinpreviouspolicy:NO
13. PreviousInsurerName:ICICILOMBARDGENERALINSURANCECOMPANYLTD.
14. PreviousPolicyNumber:3005/97295522/00/000
15. Previouspolicytype:ComprehensivePackage

Theinformationprovidedhereinaboveisbasedontheinformationreceivedfromyouandaccordingly,thepolicyhasbeenissued.Coverageofriskissubjecttorealisation
ofthepremiumbyus.Insurancecoverageunderthepolicywouldcommenceonlyonrealizationoffullpremium.Incasethepremiumisnotreceivedbyusduetodishonour
orwhatsoeverreason,theinsurancecovershallbevoidabinitio.

Shouldyoufeelthatthereareanychangesrequired,youarerequestedtoinformusimmediatelybyeitheremailingusatcustomersupport@icicilombard.comorcallingour
24hourtollfreehelplineon18002666.Intheabsenceofanycommunicationfromyouinthisconnectionwithinaperiodof15daysofreceiptofthisletter,wewouldtakeit
thattheissuedpolicyisinorderandasperyourproposal.

Theinformationprovidedaremerelyillustrativeandshallnotbeconstruedtobeanevidenceofexistenceofcontractofinsurance.TheRiskAssumptionLettershallbe
consideredasnullandvoidwithoutthepolicydocumentissuedbytheCompany.ThisRiskAssumptionLetteristobereadinconjunctionwiththepolicycopyattached
herewith.

ThankingYou,
YoursSincerely,

AuthorisedSignatory
ICICILombardGeneralInsuranceCo.Ltd


TWOWHEELERVEHICLEPACKAGEPOLICY
CertificatecumPolicySchedule
CertificatecumPolicyNo:3005/I40968775/00/000
ForCLAIMS:Call18002666(Tollfreefromallphones)
ForRENEWALS:Visitwww.icicilombard.comorcall18002666
DETAILSOFPOLICYHOLDER POLICYDETAILS

InsuredName R O O P A L N P A T E L ICICILombardGeneralInsuranceCompany
8,NewAsitAppt,InquilabSocietyGulbaiTekra, Ltd.ICICILombardHouse,414,VeerSavarkarMarg,
InsuredAddress PolicyIssuingOffice
N a r a n p u r a , A H M E D A B A D , G U J A R A T , 3 8 0 0 1 3 NearSiddhiVinayakTemple,Prabhadevi,Mumbai400
0 2 5
ContactNo. 9 9 0 9 0 0 4 8 2 4
From16:26:45hrsof31 D e c 2015toMidnightof
EmailAddress yogesh@reliableins.in PeriodofInsurance
3 0 D e c 2 0 1 6
PolicyIssuingon 3 1 / 1 2 / 2 0 1 5
CoverNoteNo I 4 0 9 6 8 7 7 5
RTOLocation A H M E D A B A D
Hypothecatedto N / A
TypeofAgreement N o n e
VEHICLEDETAILS
RegistrationNumber&RTOLocation Make&Model Typeofbody C C G V W Mfg.Year CarryingCapacity SubClass ChassisNumber EngineNumber
G J 0 1 L M 2 1 7 6 Suzuki&A C C E S S Solo 1 2 5 1 2 0 0 9 2 M B C F 4 C A M 9 8 2 9 3 5 3 1 F 4 8 6 2 9 3 6 0 0
INSUREDDECLAREDVALUE
VehicleIDV(inRs.) SideCar N o n ElectricalAcc(inRs.) Elec/ElectronicAcc(inRs.) CNG/LPGUnit(inRs.) TotalValue(inRs.)
2 3 5 7 3 0 0 0 0 2 3 5 7 3
SCHEDULEOFPREMIUM(INRS.)
OwnDamage(A) Liability(B)
BasicPremium 4 2 3 BasicPremiumincludingpremiumforTPPDvehicle 5 3 8
Total: 423 Total: 538
Add Add
Less PAcoverforOwnerDriver 5 0
Deduct5 0% forNCB 2 1 2 PAcoverforUnnamedPassenger 1 4 0
Total: 212 SubTotal(Additions): 190
Less
SubTotal(Deductions): 0

TotalOwnDamagePremium 211 TotalLiabilityPremium 728

TotalPackagePremium(A+B) 939

ServiceTax(includes0.5%ofSwachhBharatCess) 136

TotalPremiumPayable(inRs.)1075

Compulsorydeductibles:Rs.100/
GeographicalArea:India

LIMITSOFLIABILITY:(a)UnderSectionII 1(i)ofthepolicy >Deathoforbodilyinjury:SuchamountasisnecessarytomeetthererequirementsofthemotorvehiclesAct.1988.

(b)UnderSectionII 1(i)ofthepolicy >DamagetoThirdPartyPropertyRs1 , 0 0 , 0 0 0PACoverforOwner DriverundersectionIII C S I R s 1 , 0 0 , 0 0 0
LIMITATIONSASTOUSE:Thepolicycoversuseofthevehicleforanypurposeotherthan:Hireorreward,Carriageofgoods(otherthansamplesorpersonalluggage),Organizedracing,
Pacemaking,Speedtesting,Reliabilitytrials,AnypurposeinconnectionwithMotorTrade.
DRIVER'SCLAUSES:Anypersonincludingtheinsured:ProvidedthatapersondrivingholdsaneffectiveDrivingLicenseatthetimeoftheaccidentandisnotdisqualifiedfromholdingor
obtainingsuchalicense.ProvidedalsothatthepersonholdinganeffectiveLearner'sLicensemayalsodrivethevehicleandthatsuchapersonsatisfiestherequirementsofRule3ofthe
CentralMotorVehiclesRules,1989.
IMPORTANTNOTICE:TheInsuredisnotindemnifiedifthevehicleisusedordrivenotherwisethaninaccordancewiththisschedule.Anypaymentmadebythecompanybyreasonof
widertermsappearinginthecertificateinordertocomplywiththeMotorVehicleAct,1988isrecoverablefromtheinsured.Seethe c l a u s e h e a d e d ' A V O I D A N C E O F C E R T A I N T E R M S
ANDRIGHTOFRECOVERY'.Forlegalinterpretation,Englishversionwillholdgood.
SubjecttoIMTEndorsementNos.&Memorandumprintedherein/attachedhereto:22,16
PremiumCollectionDetails: [CollectionNo/Amount/ReceiptDate]NA/Rs.1 0 7 5/3 1 / 1 2 / 2 0 1 5

AgentCode 10241122 AgentName PRATIKHARSHADBHAIJANI

AgentMobileNo 917600007521 AgentTelephoneNo
EmailId pratikhj1@gmail.com
DISCLAIMER:Pleasevisitwww.icicilombard.comforthepolicywordingsforcompletedetailsontermsandconditionsgoverningthecoverageandNCB.Thisdocumentistobereadwiththepolicy
wordings.

ThispolicyisunderwrittenonthebasisoftheinformationprovidedbyyouandasdetailedintheRiskAssumptionLettersharedwithyoualongwiththepolicy.Incaseofanydiscrepancykindlyletusknow
within15daysfromthedateofreceiptofthisletter.
Policyisvalidsubjecttorealizationofcheque.Weacceptpremiumonlyvialegallyrecognizedmodes.
GrievanceClause
Forresolutionofanyqueryorgrievance,InsuredmaycontacttherespectivebranchofficeoftheCompanyormaycalltollfreeno.1800 2666ormayapproachusatthesubsection"Grievance
Redressal"onourwebsitewww.icicilombard.com(CustomerSupportsection).However,iftheresolutionprovidedbyusisnotsatisfactoryyoumayapproachInsuranceRegulatoryandDevelopment
Authority(IRDA)throughtheIntegratedGrievanceManagementSection(IGMS)orIRDAGrievanceCallCentre(IGCC)attheirtollfreeno.155255.YoumayalsoapproachInsuranceOmbudsman,
subjecttovestedjurisdiction,fortheredressalofgrievance.DetailsofInsuranceOmbudsmanofficesareavailableatIRDAwebsite:www.irdaindia.org,orontheCompany'swebsiteat
www.icicilombard.com.

I/Weherebycertifythatthepolicytowhichthecertificaterelatesaswellasthecertificateofinsuranceareissuedinaccordancewiththe ForICICILombardGeneralInsuranceCompanyLtd
provisionofchapterX,XIofM.VAct1988
ServiceTaxRegistrationNo.:GIS/MUMBAII/1528/2001
ServiceTaxCodeNumber:AAACI7904GST001
Category:GeneralInsuranceBusinessServices00440005.

IRDARegistrationNo.115
DulyConstitutedAttorney(s)
InWitnesswhereofthispolicyhasbeensignedatMumbaithisinlieuofcovernoteNoThestampdutyofRs.paidincashorbydemand
draftorbypayorder,videReceipt/Challanno.dated

ICICILombardGeneralInsuranceCompanyLtd.
MailingAdd.Office: CorporateOffice:
ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,414,VeerSavarkarMarg, ICICILombardGeneralInsuranceCompanyLtd.ICICILombardHouse,414,VeerSavarkarMarg,
NearSiddhiVinayakTemple,Prabhadevi,Mumbai400025 NearSiddhiVinayakTemple,Prabhadevi,Mumbai400025