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Product Code: 3005 UIN: IRDAN115RP0019V01202122

Reference No.: W182392213

RAMAKRISHNAN M
NO.6, BAZZAR STREET, AMIRTHAPURAM, TIRUTTANI
CHENGALPATTU
TAMIL NADU 631209
Mobile No: 9786671321

Sub: Risk Assumption Letter

Dear RAMAKRISHNAN M,

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. 3005/270924602/00/000, The same has been issued based on below mentioned details, provided by you at the time of policy
purchase.

Insured & Vehicle Details

Name of Insured RAMAKRISHNAN M
Period of Insurance - Own Damage Dec 02, 2022 to Dec 01, 2023
Period of Insurance - Third Party Dec 02, 2022 to Dec 01, 2027
Vehicle Make / Model Suzuki / ACCESS 125 CBS
RTO City TAMILNADU-TIRUVALLUR
Vehicle Registration No. NEW
Vehicle Registration Date Dec 02, 2022
Engine No. AF217266172
Chassis No. MB8DP12DLN8E00500

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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.

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“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 chedule, please
contact us immediately at our toll free number 1800 2666 or email us at customersupport@icicilombard.com, 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.

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

Dec 02, 2022

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
1
Bundled – Two Wheeler Policy
Product Code: 3005 UIN: IRDAN115RP0019V01202122

Name of the Insured : RAMAKRISHNAN M Policy No. : 3005/270924602/00/000

Address : NO.6, BAZZAR STREET, AMIRTHAPURAM, TIRUTTANI, Tenure : Own Damage 1 Year & Third Party 5
CHENGALPATTU, TAMIL NADU 631209 Years
Telephone No : Mobile No: 9786671321 Period of Insurance - : Dec 02, 2022 17:37 to
Own Damage Midnight of Dec 01, 2023
Email Address : MANOJMOTORS.AKM@GMAIL.COM Period of Insurance - : Dec 02, 2022 17:37 to
Third Party Midnight of Dec 01, 2027
Nominee Name : V PREMA Named Passenger's Nominee: E-Policy No. : 3005/270924602/00/000
Relationship : SPOUSE - Policy Issued On :
Age : 61 - Covernote No. : 270924602
GSTIN No. (Customer) : RTO Location : TAMILNADU-TIRUVALLUR
Servicing Branch Name : Chennai Hypothecated To : -
Invoice No. : 101222157078
Servicing Branch Address : Unit No.684-690, Third Floor, Seethakathi Business Centre, 4 Moores Road Thousand Lights Anna Salai, Chennai, Tamil Nadu-600006

Vehicle Registration Make Model Type of Body CC/KW Mfg Yr Seating Chassis No. Engine No.
No. Capacity
Solo With
NEW Suzuki ACCESS 125 CBS 124 2022 2 MB8DP12DLN8E00500 AF217266172
Pillion
Vehicle IDV Side Car Additional Accessories (`) Electrical / Electronic Non Electrical CNG / LPG Unit Total IDV
(`) (`) Accessories (`) Accessories (`) (`) (`)
77,421.00 0.00 0.00 0.00 0.00 0.00 77,421.00

Premium Details
OWN DAMAGE(A) (`) LIABILITY(B) (`)
Basic OD Premium 649.00 Basic Third Party Liability 3,851.00
Sub Total 649.00 Total 3,851.00
Add:
PA Cover for Owner Driver 375.00
Sub-Total 375.00
Less:
TPPD Discount 250.00
Sub-Total Deductions 250.00
Total Own Damage Premium(A) 649.00 Total Liability Premium(B) 3,976.00
Total Package Premium(A+B): 4,625.00
% 9.00
CGST
` 416.25
% 9.00
SGST
` 416.25
Total Tax Payable in ` 833.00
Total Premium Payable In ` 5,458.00
Geographical Area: India Applicable IMT Clauses: 20 , 22
Compulsory Deductible: ` 100.00 Voluntary Deductible: ` 0.00

Premium Collection No. 1159712644 Premium Amount (`) ` 5,458.00 Receipt Date 02-12-2022
GSTIN Reg.No 33AAACI7904G2ZT HSN/SAC code 997134 / GENERAL INSURANCE SERVICES
We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards i s 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.
Limits of Liability: (a) Under Section II-I(i) of the policy: Death of or bodily injury - Such amount as is necessary to meet the requirements of the Motor Vehicles Act 1988. (b)
Under Section II-I(ii) of the policy: Damage to Third Party Property ` 6,000.00/-; PA Cover for Owner-Driver under Section III: CSI ` 15,00,000.00/- for 1 year. 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 i s 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 i s 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 i s 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 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 in lieu of Covernote No. 270924602. The stamp duty of `
0.50 paid vide deface no. CSD36420222395 dated Jun 03, 2022.
Policy Issuing Office: ICICI Lombard General Insurance Company Limited, ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi,
CORP/SUP/OPI/2014/1777

Dec 02, 2022

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
1
Bundled – Two Wheeler Policy
Product Code: 3005 UIN: IRDAN115RP0019V01202122
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
201877592976 MANOJ ... 9080067620 ATGPJ9377G

Agency Code : POS55601

Agency Name : R JAYACHANDRAN ...

Agent's Contact No : 9080067620

Contact Person :

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2022.12.02 17:38:13 IST
CORP/SUP/OPI/2014/1777

Dec 02, 2022