Product Code: 3005/O UIN: IRDAN115RP0002V02201920

Reference No.: W373409370

Date: Nov 29, 2024

FOOLCHAND
VILL JITAPUR USARAWN POST DAUNI
MARIAHU JAUNPUR
UTTAR PRADESH 222161
Mobile No: 7985008925

Sub: Risk Assumption Letter

Dear FOOLCHAND,

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/O/370271249/00/B00, 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 FOOLCHAND
Period of Insurance - Own Dec 02, 2024 to Dec 01, 2025
Damage Vehicle Make / Model HERO MOTOCORP LTD / HF DELUXE DRUM
RTO City BSVI UTTAR PRADESH-VARANASI
Vehicle Registration No. UP65DW9054
Vehicle Registration Date Sep 17, 2020
Engine No. HA11ESLHB04713
Chassis No. MBLHAW14XLHB05111
Third Party Insurance Details
Third Party Policy No. 3005/48757033/64050/000
Third Party Period of Insurance Sep 01, 2020 to Aug 31,
Third Party Insurer Name 2025 ICICI LOMBARD

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.

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.

“Updating your bank details with us would help facilitating future transactions. Bank details can be easily updated using “IL – Take care” App.Download 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 [email protected], 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 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 www.icicilombard.com for the policy wordings, for complete details on terms and conditions governing the coverage and NCB)

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.
ORP/SUP/OPI/2014/1777

Nov 29, 2024

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
Stand-Alone Own Damage Two wheeler Insurance Policy
Product Code: 3005/O UIN: IRDAN115RP0002V02201920

Name of the Insured : SURAJ MISHRA Policy No. : 3005/O/33646787655/00/B00

Address : SIHULIYA, KATARI, CHOLAPUR, VARANASI 221101 Period of Insurance - : Jan15,2025 00:00:00 to
Own Damage Midnight of Jan14,2026
Telephone No : Mobile No: 7985753686 Tenure : 1 year
Email Address : [email protected] E-Policy No. : 3005/O/3654242865/00/B00
Nominee Name : - Named Passenger's Nominee: Policy Issued On : Jan14,2024
Relationship : - - Covernote No. : 370271249
Age : - RTO Location : UTTAR PRADESH-VARANASI
GSTIN No. (Customer) : Hypothecated To : -
Servicing Branch Name : New Delhi Invoice No. : 1011287899008

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. - 3005/48557033/73653/000, valid from Jul 28,2021 to Jul 27,2025, Insured by ICICI LOMBARD

Servicing Branch Address : Fourth Parsavnath Capital Tower Bhai Veer Singh Marg, New Delhi New Delhi 110001

Politically Exposed Person (PEP)/close relative of PEP: No

Vehicle Registration Make Model Type of Body CC/KW Mfg Yr Seating Chassis No. Engine No.
No. Capacity
HERO MOTOCORP PASSION PRO BSVI Solo With MBLJAW14XLHF1939 JA06EWLHF2079
UP65DW9828 110 2020 2
LTD Two Wheeler Pillion 3 4
Vehicle IDV Side Car Additional Accessories ( ) Electrical / Electronic Non Electrical Accessories CNG / LPG Unit Total IDV
() () Accessories ( ) () () ()
24,050.00 0.00 0.00 0.00 0.00 0.00 24,050.00

Premium Details
OWN DAMAGE(A) ()
Basic OD Premium 169.00
Sub Total 169.00
Total Own Damage Premium(A) 169.00
% 18
IGST
30.42
Total Tax Payable in 30.00
Total Premium Payable In 199.00

Geographical Area: India Applicable IMT Clauses: 22

Compulsory Deductible: 100.00 Voluntary Deductible: 0.00

Premium Collection No. 1222299991 Premium Amount (`) 199.00 Receipt Date 14-01-2025
GSTIN Reg.No 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.

CORP/SUP/OPI/2014/1777

Nov 29, 2024

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
Stand-Alone Own Damage Two wheeler Insurance Policy
Product Code: 3005/O UIN: IRDAN115RP0002V02201920

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 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 insured.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 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 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
[email protected]. For detailed grievance redressal mechanism please visit the "Grievance Redressal" section on our website www.icicilombard.com.
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 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.
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 Nov 29, 2024 in lieu of Covernote No.. 370271249. The
stamp duty of ` 0.50 paid vide deface no. CSD372024252885 dated Jul 15, 2024.
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 DB79719 :

Agency Name :
POLICYBAZAAR INSURANCE
BROKERS PRIVATE LIMITED
Agent's Contact No 9999999999
:

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: 2024.11.29 12:12:23 IST
CORP/SUP/OPI/2014/1777

Nov 29, 2024