yes

Product Code: 3005/O UIN: IRDAN115RP0002V01201920

Ref. No. W111646783

Date: Oct 03, 2021

UMESH PRABHAKAR PATIL

572 30 SHRINIVAS HOUSING SOC BHOI ALI BHOR
PUNE
MAHARASHTRA 412206
Mobile No: 9552631353

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/228228220/00/000, which has been issued based on the below mentioned details:

Insured & Vehicle Details

Name of Insured UMESH PRABHAKAR PATIL
Period of Insurance - Own Damage Oct 05, 2021 to Oct 04, 2022
Vehicle Make / Model HONDA MOTORCYCLE / ACTIVA 5G STD
RTO City MAHARASHTRA-PUNE
Vehicle Registration No. MH12SB8701
Vehicle Registration Date Oct 09, 2019
Engine No. JF50EG0228701
Chassis No. ME4JF50AHKG228643
Current Year NCB(%) 25%
Previous Policy Details
Previous Policy No. 3005/O/206319242/00/000
Previous Policy Period 05-10-2020 to 04-10-2021
Previous Year NCB(%) 20%
Claims Made Under Previous Policy 0
Previous Insurer Name 0
Previous Policy Type Bundled Package Policy
Third Party Insurance Details
Third Party Policy No. 170121923750044186
Third Party Period of Insurance Oct 05, 2019 to Oct 04, 2024
Third Party Insurer Name RELIANCE GENERAL INSURANCE COMPANY LTD.
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 1
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”

If you require any changes in the Certificate of Insurance cum Policy Schedule, you are requested to inform us by writing to
[email protected] 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

Oct 03, 2021

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
yes
Stand-Alone Own Damage Two wheeler Insurance Policy
Product Code: 3005/O UIN: IRDAN115RP0002V01201920

Insured Name : UMESH PRABHAKAR PATIL Policy No : 3005/O/228228220/00/000

Address : 572 30 SHRINIVAS HOUSING SOC BHOI ALI BHOR, PUNE, Period of Insurance - : Oct 05, 2021 00:00:00 to
MAHARASHTRA 412206 Own Damage Midnight of Oct 04, 2022
Telephone No : Mobile No: 9552631353 Tenure : 1 year
Email Address : [email protected] E-Policy No : 3005/O/228228220/00/000
Nominee Name : Radhika Umesh Patil Named Passenger's Nominee: Policy Issued On : Oct 03, 2021
Relationship : WIFE - Covernote No : 228228220
Age : 33 - RTO Location : MAHARASHTRA-PUNE
GSTIN Number (Customer) : Hypothecated To : -
Servicing Branch Name : Mumbai Invoice Number : 10102153612
:
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. - 170121923750044186, valid from Oct 05, 2019 to Oct 04, 2024, Insured by RELIANCE GENERAL INSURANCE COMPANY LTD.

Servicing Branch Address : 414, ICICI LOMBARD HOUSE, VEER SAVARKAR MARG, NEAR SIDDHI VINAYAK TEMPLE MAIN GATE, PRABHADEVI, MUMBAI, yes
400025, MAHARASHTRA

Registration No. Make Model Type of Body CC/KW Mfg Yr Seating Chassis No. Engine No.
Capacity
HONDA Solo With
MH12SB8701 ACTIVA 5G STD 109 2019 2 ME4JF50AHKG228643 JF50EG0228701
MOTORCYCLE Pillion
Vehicle IDV Side Car Additional Accessories (`) Electrical / Electronic Non Electrical CNG / LPG Unit Total IDV
(`) (`) Accessories (`) Accessories (`) (`) (`)
52000 0 0 0 0 0 52000

Premium Details
OWN DAMAGE(A) (`)
Basic OD Premium 908
Sub Total 908
Less:
No Claim Bonus 25% 227
Sub-Total Deductions 227
Total Own Damage Premium(A) 681
% 9
CGST
` 61.29
% 9
SGST
` 61.29
Total Tax Payable in ` 123
Total Premium Payable In ` 804

Geographical Area: India Applicable IMT Clauses: 22

Compulsory Deductible: ` 100 Voluntary Deductible: ` 0

Premium Collection No. 1131897490 Premium Amount ` 804 Receipt Date 03-10-2021
GSTIN Reg.No 27AAACI7904G1ZN 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 [email protected]. 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 Oct 03, 2021 in lieu of Covernote no. 228228220. The
stamp duty of ` 0.5 paid vide deface no. CSD1412021398321 dated Sep 29, 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.

Point of Sale (POS) Details

POS Number POS Name Contact Details PAN Card Number
201497436766 AMOL ARJUN SHEDGE 7507050051 DSQPS6704E
CORP/SUP/OPI/2014/1777

Oct 03, 2021

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
yes
Stand-Alone Own Damage Two wheeler Insurance Policy
Product Code: 3005/O UIN: IRDAN115RP0002V01201920

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE COMPANY
LIMITED
Date: 2021.10.03 11:56:11 IST
CORP/SUP/OPI/2014/1777

Oct 03, 2021