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ICICI Lombard General Insurance Company
Second Floor, UMA Complex, Frazer Road, Patna, Bihar 800001 PATNA BIHAR State Code(10)
GSTIN: 10AAACI7904G1Z2
IRDA Registration Number : 115
Proposal Details
Proposal No. Policy Effective Date OD
PRDKIA11113525 22-Oct-2024
Policy Expiry Date OD Policy Tenure TP
21-Oct-2025 0 Year
Policy Effective Date TP Policy Expiry Date TP
26-Jul-2022 25-Jul-2025
Proposer Details
Proposer Type Proposer Name
Individual Mr. ANIL KUMAR MANDAL
Address of the Proposer Vehicle Class
S/O RAM LOCHAN MANDAL,HOUSE NO 7H F 4/29 WARD NO 46 HANUMAN Private
MANDIR,BAHADURPUR HOUSING COLONY,B.H COLONY, PATNA BIHAR 800026
Vehicle Details
Invoice Date Chassis No.
26-Jul-2022 MZBEU812LNN385710
Engine No. Make Model & Variant
G4FLNV319671 KIA SELTOS
CC Place of Registration
1497 PATNA
Registration No. Ex-showroom Price
BR-01-FT-6828 1546900
Year of Manufacture Seating Capacity
2022 5
Insured Declared Value (IDV)
Vehicle Electrical Accessories
1082830 0
Non-Electrical Accessories CNG/LPG
0 0
Total IDV
1082830
Other Details
HP/Lease/Hire Pur. Agreement with Branch/Office of HP/Lease/Hire Purchaser
STATE BANK OF INDIA PATNA
Agreement Type Branch City
Hypothecation EXHIBITION ROAD
Premium Calculation
Own Damage Premium Amount (Rs.)
Basic Premium Discounts
Vehicle 10366 Voluntary Discounts Rs. (0) 0
Non Electrical Accessories 0 Anti Theft Device 0
Electrical Accessories 0 AA Membership 0
Bi Fuel Kit 0 NCB (20%) 2074
Sub Total (Basic Premium) 10366 Handicapped Discount (0%) 0
Geographical Area Extension 0 Sub Total (Discounts) 2074
IMT 33 Premium 0 Add-Ons (Zero Depreciation ,Consumable ,Road Side Assistance ) 6255
IMT 23 Premium 0 Net Own Damage Premium(A) 14547
Sub Total 10366 Net Own Damage Premium
Total Premium 14547
SGST(9.00%) 1310
CGST(9.00%) 1310
Gross Premium 17167
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DECLARATION I/We hereby declare that the statements made by me/us in this proposal form, including document(s) attached, are true and correct, to the best of my/our knowledge and belief and nothing materially affecting the risk has/have been
concealed by me /us. I /We hereby agree that this declaration shall form the basis of the contract between me/us and the insurer and shall form part of the insurance contract. I/We also declare that if any additions or alterations are carried out after the submission
of this proposal form then the same would be conveyed to the insurer immediately.
DISCLAIMER
GRIEVANCE CLAUSE:
For resolution of any query or grievance, Insured may contact us 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 . Or You may also contact SMC Insurance Brokers Pvt. Ltd. Insurance Grievance Redressal No. : 1800-2666-9666
MANDATE:
I/we give my mandate for dealing of Insurance/Claims of my/our vehicle to SMC Insurance Brokers Pvt. Ltd. and request for insurance of my/our car with M/s ICICI Lombard General Insurance Company after having compared/verifying the quotations and benefits
offered by other insurers.
Date: 22-Oct-2024 Proposer Signature/ Thumb Impression
INSURANCE ACT 1938, SECTION 41, Amendment Act 2015 - PROHIBITION OF REBATES
1.No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property, in India, any rebate of the whole or part of the commission
payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a Policy accept any rebate, except such rebate as be allowed in accordance with the published prospectuses or tables of the Insurer.
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