Bundled - Two Wheeler Policy (1 Yr OD + 5 Yrs TP)
Issued at
Policy No. ICICI Lombard General Insurance HERO INSURANCE BROKING INDIA PVT LTD.
3005/50034433/40756/000 Tenth floor, Unit no.1003 to 1008, Signature Towers, DC 2, IRDA Registration No.: 649
Lal Kothi Scheme ,District Shopping Centre ,Tonk road,Jaipur Toll-Free No.: 1800 102 4376
-302001,Rajasthan 264, Okhla Ind. Estate, Phase-III, Delhi-110020
Tel:1800 2666
customersupport@icicilombard.com
Insured Business/Profession Address of The Insured TP Valid From TP Valid To
Mr SANJAY VAIRAGI Self Employed S/O LAHRI DASS VERAGI R/O CHEEPI KHERA,KHE 27-02-2021 Midnight of 26-02-2026
MPUR TH.MAVLI Udaipur RAJASTHAN 313203 18:09:25
Cubic GSTIN No.
Vehicle Regn No. Engine No. Chassis No. Make & Model Year of Mfg
Capacity (Customer)
Hero MotoCorp
New HA11EDL4M00403 MBLHAW122L4M02392 SPLENDOR + BS6-I3S 2021 97
DRS
Declared Value (IDV) of Side Car IDV Non-Electrical Electrical Accessories CNG/LPG/Bi- Total IDV
Vehicle Accessories IDV IDV Fuel IDV
61879.00 NA 0.00 0.00 0.00 61879
Place of Regn. Body Type HP/Lease/Hire-Purchase Branch Office of Seating Premium
Agreement With HP/Lease/Hire-Purchase Capacity
HERO FINCORP LTD,
Udaipur Solo --- 2 4290.00
HPA (D)
Section A B. Liability Premium Computation (Section II) in Rs.
Basic OD Premium : 415.00 Basic Third Party Liability : 3285.00
Non-Electrical-Fitting Premium : 0.00 TPPD Discount : 250.00
Electronic & Electrical Accessories(IMT-24) : 0.00 Total : 3035.00
Bi-Fuel Kit : 0.00 CNG/LPG/Bi-Fuel Kit : 0.00
Geographical Extension : 0.00 Geographical Extension : 0.00
ND Cover : 186.00 Add
Less : Compulsory PA Cover (Owner Driver) : 0.00
Handicapped Discount : 0.00 Optional PA Cover(Un Named Passenger) : 0.00
For Anti-Theft Discount : 0.00 Optional PA Cover(Un Named Driver) : 0.00
NCB : 0.00 Legal Liability Cover (Paid Drivers, Cleaners) : 0.00
Total Own Damage Premium(A) : 601.00 Legal Liability Cover (Per Licensed Passenger) : 0.00
Total Liablity Premium (B) : 3035.00
Total Premium (A + B) : 3636.00
For any other extra : 0.00
CGST @ 9.00% : 327.24
SGST @ 9.00% : 327.24
Gross Premium : 4290.00
RegistrationNo.:115||CINNo.:L67200MH2000PLC29408||HSN/SAC:9971|| GSTIN No.:08AAACI7904G1ZN ||UIN No.-IRDAN115RP0005V01201819||IRDAN115RP0005V0120
1/A0017V01201819
27-02-2021 To 26-02- 27-02-2022 To 26-02- 27-02-2023 To 26-02- 27-02-2024 To 26-02- 27-02-2025 To 26-02-
OD Policy Period
2022 2023 2024 2025 2026
IDV 61879 NIL NIL NIL NIL
CPA Sum Insured(NODL) NIL NIL NIL NIL NIL
Sum Insured of Optional PA Cover:-Sum Insured of Optional PA Cover "Unnamed Passenger"-NA and "Unnamed Driver"-NA
LIMITATIONS AS TO USE:--The Policy covers use of the vehicle for any purpose other than: a) Hire Or Reward b) Carriage of goods (other than samples or
personal luggage) c) Organized Racing d) Pace Making e) Speed Testing f) Reliability Trials g) Any purpose in connection with Motor Trade.
DRIVER: Any person including insured: Provided that a person driving holds an effective driving licence at the time of the accident and is not disqualified from
Holding or obtaining such a licence.Provided also that the person holding an effective Learner's Licence may also drive the vehicle and that such a person
satisfies the requirements of Rule 3 of the Central Motor Vehicle Rules, 1989.
LIMIT OF LIABILITY: Limit of the amount of the Company's liability under the Section II-I(i) in respect of any one accident as per M.V. Act 1988. Limit of the
amount of the Company's liability under Secion II-I(ii) in respect of any one claim or series of claims arising out of one event : Upto Rs - 6000/
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 RIGHTS OF RECOVERY'
I/We certify that the policy to which the certificate relates as well the certificate of insurance are issued in accordance with this provisions of Chapter X & XI of M.V. Act 1988
Broker : Hero Insurance Broking India Pvt. Ltd.
Received Vide
Premium of Rs. 4290.00 CASH
Cash/Cheque No.
KALLA The policy is subject to a compulsory excess of Rs. 100/- &
Dated Nominee Name Depreciation is applicable as per policy terms & conditions*
DEVI
Drawn on Nominee Age 37 (Please turn overleaf for details)
Consolidated Stamp Duty Paid Endorsements : IMT - 22,20,7
Acknowledgement 27-02-
Nominee Relation Mother
Dt 2021
FOR RENEWALS CONTACT: NARESH KUMAR PALIWAL Ph.No- 097-85480965, On behalf of ICICI Lombard General Insurance
POS0203811 Company Ltd
27-Feb-2021
Date & Signature of
proposer
Dealer's Stamp & Signature Duly Constituted Attorney
# : Received with Thanks Rs 4290.00 from Mr SANJAY VAIRAGI as premium against the money receipt no 02180221350595
Regd. & Head Office : ICICI Lombard House, 414 Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai- 400025 The stamp duty of
Re. 0.5 paid in cash or by demand draft or pay order, vide Receipt / Challan No. CSD2162021218
For further information about motor insurance policy please also visit www.irdai.gov.in >> Grievances >> Policyholder Handbooks
