no

Product Code: 3005/O UIN: IRDAN115RP0002V01201920

Ref. No. W101132979

Date: Jun 28, 2021

KARTHICK
3/823 LALIKAL VI UDDANAPALLI PO HOSUR TK KRISHNAGIRI DT
DHARMAPURI
TAMIL NADU 635119
Mobile No: 8423871234

Sub: Risk Assumption Letter

Dear Sir/Madam,

Thank you for choosing ICICI Lombard General Insurance Company Limited (ICICI Lombard) as your preferred service provider.

Please find enclosed Policy No. 3005/O/222699685/00/B00, which has been issued based on the below mentioned details:

Insured & Vehicle Details

Name of Insured KARTHICK
Period of Insurance - Own Damage Jun 28, 2021 to Jun 27, 2022
Vehicle Make / Model Suzuki / ACCESS
RTO City TAMILNADU-HOSUR
Vehicle Registration No. TN70AD9823
Vehicle Registration Date Jun 17, 2020
Engine No. AF212300175
Chassis No. MB8DP12DCL8215917
Current Year NCB(%) 25%
Previous Policy Details
Previous Policy No. 5268748474
Previous Policy Period 28-05-2020 to 27-05-2021
Previous Year NCB(%) 20%
Claims Made Under Previous Policy 0
Previous Insurer Name NIA
Previous Policy Type Bundled Package Policy
Third Party Insurance Details
Third Party Policy No. 5268748474
Third Party Period of Insurance May 28, 2020 to May 27, 2025
Third Party Insurer Name NIA
1
The information provided above is based on the information received from you and accordingly, the policy has been processed. Coverage of risk is subject to
realisation of the full premium, post which, insurance coverage under the policy would commence. In case the premium is not received by us 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.

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.

If you require any changes in the Certificate of Insurance cum Policy Schedule, you are requested to inform us by writing to
customersupport@icicilombard.com or calling our 24 hour toll free helpline on 1800 2666. 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.

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

Jun 28, 2021

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
no
Stand-Alone Own Damage Two wheeler Insurance Policy
Product Code: 3005/O UIN: IRDAN115RP0002V01201920

Insured Name : KARTHICK Policy No : 3005/O/222699685/00/B00

Address : 3/823 LALIKAL VI UDDANAPALLI PO HOSUR TK KRISHNAGIRI Period of Insurance - : Jun 28, 2021 16:40 to
DT, DHARMAPURI, TAMIL NADU 635119 Own Damage Midnight of Jun 27, 2022
Telephone No : Mobile No: 8423871234 Tenure : 1 year
Email Address : HARDWORKGURU@GMAIL.COM E-Policy No : 3005/O/222699685/00/B00
Nominee Name : - Named Passenger's Nominee: Policy Issued On : Jun 28, 2021
Relationship : - - Covernote No : 222699685
Age : - RTO Location : TAMILNADU-HOSUR
GSTIN Number (Customer) : Hypothecated To : -
Servicing Branch Name : Bangalore Invoice Number : 100621730314
:
This Policy covers only Own Damage Risk with no other liability in connection with Two Wheeler Vehicle including Third Party Cover and is issued basis the following:
Third Party Policy No. - 5268748474, valid from May 28, 2020 to May 27, 2025, Insured by NIA

Servicing Branch Address : Second SVR Complex Hosur Main road Bangalore Karnataka 560068 yes

Registration No. Make Model Type of Body CC/KW Mfg Yr Seating Chassis No. Engine No.
Capacity
Solo With
TN70AD9823 Suzuki ACCESS 125 2020 2 MB8DP12DCL8215917 AF212300175
Pillion
Vehicle IDV Side Car Additional Accessories (`) Electrical / Electronic Non Electrical CNG / LPG Unit Total IDV
(`) (`) Accessories (`) Accessories (`) (`) (`)
64000 0 0 0 0 0 64000

Premium Details
OWN DAMAGE(A) (`)
Basic OD Premium 858
Sub Total 858
Less:
No Claim Bonus 25% 215
Sub-Total Deductions 215
Total Own Damage Premium(A) 643
% 18
IGST
` 115.74
Total Tax Payable in ` 116
Total Premium Payable In ` 759

Geographical Area: India Applicable IMT Clauses: 22

Compulsory Deductible: ` 100 Voluntary Deductible: ` 0

Premium Collection No. 1128138888 Premium Amount ` 759 Receipt Date 28-06-2021
GSTIN Reg.No 29AAACI7904G1ZJ HSN/SAC code 997134 / GENERAL INSURANCE SERVICES

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". 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 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.
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 Jun 28, 2021 in lieu of Covernote no. 222699685. The
stamp duty of ` 0.5 paid vide deface no. CSD262021165121 dated May 05, 2021.
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 : CA0606

Agency Name : JANA SMALL FINANCE BANK

Agent's Contact No : 7022653867

Contact Person : Signature Not Verified
Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE COMPANY
LIMITED
Date: 2021.06.28 16:42:46 IST
CORP/SUP/OPI/2014/1777

Jun 28, 2021