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ICICI LOMBARD GENERAL INSURANCE COMPANY

IRDA Registraion No.115
MOTOR INSURANCE PROPOSAL FORM
TWO WHEELER PACKAGE POLICY
Proposal Form No: 3418657169

Registration Address (Where vehicle is

registered): My Occupation Details
Main Features:
Room No. / Block No. / House No.: L 502 Status Individual Proprietorship
I. Own Damage Tivoli Godrej Garden, City Jagatpur Off S G Partnership Pvt / Public Co's
This product Protects you Against loss or Highway Ahmedabad Gujarat 382470 Other(pl. specify)
damage to your motor vehicle and/or Building Name/ Wing/ Plot/ Occupation:
accessories due to Sector No./Floor No.: If Entity Urban Rural Social
Road No./ Street Name: Business Paid up Capital of Company in
•fire •selfignition •explosion •lightning
•theft •burglary •housebreaking Land Mark: Rupees
•riot •strike •earthquake •flood & allied Area/ Village: <10 Crore 10-25 Crore >25 Crore
perils •accidental external means City/ Town: Ahmedabad Category of Business Trading
•malicious acts •terrorist activity State: Gujarat Manufacturig Contracting
•transit •landslide •rockslide Pin Code: 382470 Hospitality Financial Services
Country: INDIA Other(pl. Specify)
II. Third Party Liability Annual Income :
In addition to the coverage noted above,
Correspondence Address Do you file Income Tax Return Yes
this
No
product covers you against legal liability Room No. / Block No. / House No.
towards ______________________________________ Do you own a Bank Account Yes No
third party, in respect of the following: Building Name/ Wing/ Plot/ Sector
Section II
No./Floor No. :
Death of bodily injury to any person.
Road No./ Street Name: My Vehicle Details
Damage to property as per the
Land Mark Date Of Purchase: 01/02/2017
provisions of Motor vehicle Act. We
are pleased to inform you that in City/Town Date Of Registration: 01/02/2017
addition, the product also include State Registration Number: GJ12DD2046
the following: GUJARAT
Registration Authority: GUJARAT-KUTCH
Personal accident benefits for Pin Code
Year of Manufacture: 2017
ownwer driver upto value of 382470
Country of Mfr. _______________________
Rs.2,00,000/ Rs. 1,00,000 (For Two Country :
Wheeler). Engine Number: JF50EU6131930
INDIA
Legal Liability towards the paid Chasis number: ME4JF509AHU131873
Preferred Mailing
driver. Make of Vehicle: HONDA MOTORCYCLE
Address Registration
Cover of Rs. 7.5 Lacs and Rs.1 Correspondence Model: ACTIVA 3G
Lac(for Two Wheelers) for third party Cubic capacity/ 109
If Corporate, vehicle used by: Mr./Ms.:
PropertyDamage gross vehicle weight: 1
Phone(with STD Code:(R)
Type Of Body: Solo With Pillion
Source Of Funds Mobile No.: 9879636496
Seating Capacity: 2
Fax No. :_____________________________
Carrying Capacity: 1
Salary Business Others Email Id:
JITENDRAGANDHI1@REDIFFMAIL.COM Fuel Type : Diesel Petrol CNG
In case of Others,Please specify: LPG Hybrid
Date Of Birth: 29 / 10 / 1980
Sex M F Colour Of Vehicle : NA
I/We hereby declare and confirm that
the premium has been paid out of Colour Finish : Metallic Non-Metallic
Marital Status:
legally acquired sources of income and Professional Qualification : Doctor Whether the vehicle is driven by
the subsequent premiums if any, will non- conventional source of power/CNG
MBA Engineer
continue to be paid out of legally /LPG /Bi-Fuel? Yes No
Lawyer Architect CA
declared and assessed source of If Yes, Please give details whether the use
Journalist IT Student
income. of vehicle is limited to own premises?
Graduate Post Graduate Other(pl.
Yes No
Specify)
Significant Exclusion Whether the use of vehicle is
used for commercial purpose? Yes
We would like you to know that the policy Declaration for PEP
No
does not cover consequential loss Are you or any of the proposed
depreciation, normal wear and tear, Whether the vehicle is used for driving
applicants/beneficial owner
mechanical or electrical breakdown tutions?
a PEP* or a close relative of a PEP*?
failures or breakages. The vehicle is not Yes No
Yes No
held covered if used for commercial If yes, please give details :
purposes or if driven by an unauthorized
driver.
*Politically Exposed Persons (PEPs) are
Note: The foregoing is only an indicaton
individuals who are or have been
of the cover offered. For details please
entrusted with prominent public functions
refer to the policy. It is our endeavour to
in a foreign country, e.g., Heads of
provide consistent quality service to all
States/Governments, senior politicians,
our customers. To enable us to deliver our
senior government/judicial/military
promise, we would appreciate if you would
officers, senior executives of state-owned
take some of your time to answer all
corporations, important political party
questions fully and correctly to the extent
officials, etc.
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possible. We would like to let you know
that insurance is a contract of Utmost CKYC ID:
Good Faith requiring the customer to CIN:
disclose all material facts without PAN of POS :
suppressing any vital information whether
material or otherwise. If in your opinion
any fact is material and is not covered by
the Information sought in the application
form, we request you to disclose it. It is
important to note that the liability will
commence only after we have accepted
yous proposal and the premium has been
received in full.

Section I

Personal Details

Name: Mr/Ms./M/s.: JITENDRA HIMATLAL

GANDHI

GSTIN Reg. No. Customer :

Vehicle Proposed for Insurance Personal Accident cover for Owner Driver is (If yes, reasons there
under hire purchase lease compulsory for__________________________)
agreement under hypothecation in the Liability Only Cover. C)Imposed special Condition or
none of above Please give details of nomination: excess: Yes No
In case the proposed vehicle is a)Name of the Nominee & 0
under hire purchase/lease Age: Declaration: We further
agreement / hypothecation, please b)Relationship: undertake that if this declaration is
provide following details of the c)Name of Appointee (If 0 found to be incorrect, all benefits
parties having a financial interest in Nominee is a Minor): under the policy in respect of
the Vehicle (s) Section I of the Policy will stand
d) Relationship to the
Name of the party: NA forfeited. Me, the undersigned
Nominee:
Address of the party: NA hereby declare that the above
statements and particulars are
Vehicle's Insurance Coverage If Yes , give name and Capital Sum Insured(CSI)
true, accurate and complete and
Details opted for:
IAVe declare that this declaration
Name CSI Nominee Relationship and the answer given above shall
Period of Insurance: Time :Midnight Opted be held to promissory and shall be
of 19 / 10 / 2024 13:03 TO (Rs.) the basis of the contract between
Midnight of 18 / 10 / 2025 1) me/us and ICICI Lombard. The
23:59:59 0 policy may however be continued
Coverage required for: PVT Car 2) at the sole discretion of ICICI
Two wheeler PCV 3) Lombard. subject to payment of
GVC Misc the amount payable as determined
Insured Declared value of Vehicle by ICICI Lombard. resulting from
(Provide bifurcation of body Do you wish to include Personal Accident cover for the difference in the bonus / malus
&chassis value, if applicable): Un-named Passenger/hire/pillion passengers (Two status. I shall endeavor to procure
Wheelers)? Yes No the renewal notice and pass on the
Body price:
same to ICICI Lombard
Chassis price:
If Yes, Give number of persons and Capital Sum immediately upon the receipt of
Value of non electrical accessories, such notice. I /We declare that the
if any Isured (CSI)
Opted.rblCovforConsmblItemsrblCovforConsmblItems rate of NCB claimed by me/us is
(Please attach bills): Rs. correct and that no claim as arisen
No. of Persons:C.S.I(Per Person):
Whether extension of geographical area to the in the expiring policy period (copy
Value of electrical/electronic
folllowing countries required? of the policy enclosed). I/We
accessories if any (Please attach
Bangladesh Bhutan Maldives Nepal further undertake that if this
bills):
declaration is found to be incorrect
Rs. Pakistan Sri Lanka
all benefits under the policy in
respect of Section I of the Policy
Value of non conventional source COMPULSARY PERSONAL ACCIDENT
will stand forfeited.
of power (CNG/LPG) if any: Rs. / COVER FOR OWNER DRIVER
Place : _________________
Rs. Do you have a Valid Driving Licence Yes No
Date: |__|__|/|__|__|/|__|__|__|__|
PAN of POS.:
Value of Trailer, if any: _________________
Rs. Do you have own Mutiple Vehicles Yes No ____________________
Trailer Chassis No.:
Signature of Proposer
Total Value: Rs. Vehicle's Insurance history
Whether extension of geographical Name and Address of ICLB OTHER INFORMATION
area to the folowing countries Previous Insurer: 0
required? Previous Policy Type: Liability only Cover
At the time of Purchase the vehicle
Bangladesh Bhutan Package Cover Others was: New Secondhand
Maldives Nepal Pakistan Previous Policy No.: 3005/308899124/00/B00
Will the vehicle be used
Sri Lanka Period of Insurance: 10/4/2023 12:00:00 AM -
exclusively for private,
Whether the vehicle is fitted with 10/3/2024 12:00:00 AM

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fibre glass tank? Existing bonus/ malus status: % social, domestic,pleasure &
Yes No (Please attach a copy of last policy/renewal notice professional
held) puroses: Yes No
Liabilty To Third Parties In the last three years. Is there any history of loss Will the vehicle be used for
Experinced by the proposer(s) or other drivers who carriage of goods other
Coverage for liability against Third
would by using this vehicle Yes No than samples or personal
Party risks (Death or Bodily Injury)
If Yes, deails are: lugguage: Yes No
required in respect of:
Date and Name of the Nature of loss Ammount The vehicle is in good condition:
i) Owner Driver only Yes No
time of loss driver at the Claimed Yes No
ii) Any person other than Paid timem of loss (Rs.)
Driver Yes No The vehicle is self owned: Yes
No
If Yes, Give details of such other
persons: The vehicle belongs to foreign
1.____________________________ embassy consulate? Yes No
2.____________________________ The car is certified as Vintage car
Has any Insurance company ever:
3.____________________________ by Vintage and
A)Declined the proposal: Yes No
Do you wish to have the statutory Classic Car Club of India: Yes
B) Cancelled/ refused to renew Yes No
Third party No
Property Damage (TPPD) liability The vehicle is designed for use of
of Rs. 6000/- only? Yes No Blind/Handicapped/mentally
The policy provides additional challenged persons
Third Party and duly endorsed as such by
Property Damage liability limits of RTA: Yes No
Rs. 1,00,000/- The vehicle is chauffeur driven:
for Two Wheelers and Yes No
Rs.7,50,000/- for other Are you a member of Automobile
Classes of Vehicles. Do you wish Association of India: Yes No
to cover the If Yes:
additional limit? Yes No
Legal liability to person employed
Is the vehicle fitted wth the any
in connection with operation of
Anti-theft device
the vehicle who are workmen.
approved by the AARI: Yes No
i) Drivers(No. of persons): 0
Do you wish to avail a voluntary
ii)Employees (Workmen) (No. of Excess?:
persons ): 0 Yes No
iii)Cleaner/Conductor (No. of
If Yes, Please indicate your choice:
persons):
Rs.2,500 Rs.5,000
iv)Non-Fare paying passenger(No. Rs.7,500 Rs.15,000
of persons):
Is the vehicle owned / hired /
Do you wish to cover wider legal
leased / permitted by the state ?
liablity to
Yes No
employees who are workmen?
Yes No
Do you wish to cover wider legal
liablity to
employees who are NOT
workmen? YES NO

Driver's Details I/We hereby declare and warrant that the

Motor Related Addon Covers Details of Driver above statements are true, accurate and
a. Age & Date of Birth of the Owner: complete. l/We
1.Do you wish to include Cover for Zero desire to effect an insurance as
Depreciation: Yes No Age______Yrs
DOB:|__|__|/|__|__|/|__|__|__|__| described herein
2. Do you wish to include Cover for with the Company and l/We agree that
Consumable Items: Yes No b. Age & Date of birth of the Driver:
this
Age______Yrs
3. Do you wish to include Cover for proposal and declarations shall be the
DOB:|__|__|/|__|__|/|__|__|__|__|
Return to Invoice Add-on: Yes No basis of
c. Does the driver suffer from defective contract between me/us and the
If Yes, please indicate Registraion +
vision or hearing or any physical Company and
Road Tax Charges Paid
infirmity: I/We agree to accept a policy subjet to
4. Do you wish to include Cover for NCB
_________________________________ the
Protect Add-on: Yes No
d. Has the driver ever been involved/ conditions prescribed by the Company.
If yes, please indicate the plan chosen
convicted for causing any accident of I/We
Number of claims to be considered
loss? Yes No hereby declare and undertake that the
eligible for this add-on 0
If Yes, give details as under including the amount
5.Do you wish to include Cover for
pending prosecutions: paid by me/us as premium for the
Garage Cash Add-on: Yes No
-Driver's Name: aforementioned
If Yes, Please indicate policy is out of my/our lawful and
-Date of Accident:
a) The Daily Allowance Opted for : 0 declared source
-Loss/Cost(Rs.):
b) The maximum Coverage Days opted of income.
-Circumstances of 3418657169
for : I hold a valid and effective PUC and/or
Accident/Loss:
c) Maximum amount payable in the fitness certificate,
event of the claim under this add-on: as applicable, for the vehicle mentioned
Declaration
d) The minimum number of days in herein and undertake
I/We hereby declare that the statements
excess of which the claim will be to renew the same during the policy
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 Page 4 of 4
payable from the day such vehicle was made by me/us in this Proposal Form are period.
delivered to the garage for : true to the best of my/our knowledge and
belief and I/We here by agree that this Subject to realisation of cheque
6. Do you wish to include cover for Road
side assistance: Yes No declaration shall form the basic of the
Place:__________________________
contract between me/us and the "ICICI
If Yes, Please provide you residence Date: |__|__|/|__|__|/|__|__|__|__|
Lombard General Insurance Col. Ltd."
address:
I/We also declare that any additions or
Name of the emergency service selected
alterations are carried out after the
are as below:
submission of this proposal from then the Statutory Warning
7. Do yopu wish to include Cover for same would be conveyed to the insurers
Engine Protect Plus: Yes No immediately. I agree that the Policy shall PROHIBITION OF REBATES
8.Do you wish to include Cover for Tyre become voidable at the option of the Under Section 41 of Insurance Law
Protect: Insurer, in the event of any untrue or Amendment Act 2015
Yes No incorrect statement, misrepresentation,
No person shall allow or offer to allow,
9. Do ou wish to include Cover for Loss nondescription or non-disclosure in any
either directly or indirectly as an
of Personal Belongings: material particular in the proposal
inducement to any person to take out or
Yes No form/personal statement, declaration and
renew or continue an insurance in
If yes please indicate the plan chosen connected documents, or any material
respect of any kind of risk relating to
.Sum Insured Rs. 0 information has been with held by me or
lives or property in India, any rebate of
anyone acting my behalf to obtain any
10. Do you wish to include Cover for Key the whole or part of the commission
benefit under this policy. I affirm and
Protect Add-on: Yes No payable or any rebate of the premium
undertake that I have read and
If yes, please indicate the sum insured shown on the policy, nor shall any person
understood the policy wordings, terms &
amount taking out or renewing or continuing a
conditions and exclusions governing the
0 policy accept any rebate except such
cover and agree to abide by them. I
rebate as may be allowed in accordance
agree to receive a One Page Motor
with the published prospectuses or tables
Insurance Policy in Physical Form Yes No
of the insurer. Any person making default
By agreeing to this, I understand that the
in complying with the provisions of this
same shall be read along the standard
section shall be liable for a penalty,
terms and conditions available on the
which may extend to ten lakhs rupees.
website (www.icicilombard.com)
Table1: This section shall be liable for a
penalty, which may extend to ten lakhs
I/We hereby give my/our consent to the
rupees. Table 1: Schedule of
Company to verify and obtain my/our
depreciation of arriving at IDV. The
identity/address proof through Central
Insured value (IDV) of the vehicle will be
KYC Registry or UIDAI or through any
deemed to be the 'Sum Insured'
other modes for the purpose of
undertaking KYC. IDV CALCULATION
AGE OF THE DEPRECIATION
VEHICLE
Upto 6 Months 5% 5%
6Months 1day to 15%
1Year 15%
1Year 1Day to 20%
2Years 20%
2Years 1Day to 30%
3Years 30%
3Years 1Day to 40%
4Years 40%
4Years 1Day to 50%
5Years 50%
NOTE: IDV of vehicles beyond 5 years of
age and obsolete models o the vehicles
(i.e. models which the manufacturers
have discontinue to manufacture) is to
be determined on the basis of the
understanding between insurer and the
insured.

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