0

Product Code: 3001/O UIN: IRDAN115RP0001V01201920

Reference No.: W295654879

Date: Mar 19, 2024
MOIZ AZIZ RAMPURI
18/503, R- EUPHORIA NEAR KOTHARI SCHOOL, KONDHWHA BUDRUK PUNE
CITY, PUNE,
PUNE
MAHARASHTRA 411048
Mobile No: 73******57

Sub: Risk Assumption Letter

Dear MOIZ AZIZ RAMPURI,

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. 3001/O/334977903/00/000, The same has been issued based on below mentioned details, provided by you at the time of policy
purchase.

Insured & Vehicle Details

Name of the Insured MOIZ AZIZ RAMPURI
Period of Insurance - Own Damage Apr 13, 2024 to Apr 12, 2025
Vehicle Make / Model HYUNDAI / GRAND I10 NIOS MAGNA 1.2 CNG
RTO City MAHARASHTRA-PUNE
Vehicle Registration No. MH12UC9758
Vehicle Registration Date Apr 18, 2022
Engine No. G4LAMM044593
Chassis No. MALB251CLNM295940
Current Year NCB(%) 25%
Previous Policy Details
Previous Policy No. 3001/0/HY-18065821/00/000
Previous Policy Period 13-04-2023 to 12-04-2024
Previous Year NCB(%) 20%
Claims Made Under Previous Policy 0
Previous Insurer Name ICLB
Previous Policy Type Bundled Package Policy
Third Party Insurance Details
Third Party Policy No. 3001/HI-11644733/00/000
Third Party Insurance Period Apr 13, 2022 to Apr 12, 2025
Third Party Insurer Name ICLB
1
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.
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
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.

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 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.

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.

( 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.
CORP/SUP/OPI/2014/1777

Mar 19, 2024

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE 0

Stand-Alone Own Damage Private Car Insurance Policy

Product Code: 3001/O UIN: IRDAN115RP0001V01201920

Name of the Insured : MOIZ AZIZ RAMPURI Policy No. : 3001/O/334977903/00/000

Address : 18/503, R- EUPHORIA NEAR KOTHARI SCHOOL, Period of Insurance - Own : Apr 13, 2024 00:00 to
KONDHWHA BUDRUK PUNE CITY, PUNE,, PUNE, Damage Midnight of Apr 12, 2025
MAHARASHTRA 411048
Telephone No : - Mobile No: 73******57 Tenure : 1 Year
Email Address : HA******************@GMAIL.COM E-Policy No. :
Nominee Name : AZIZ RAMPURI Named Passenger's Nominee: Policy Issued On : Mar 19, 2024
Relationship : Father - Covernote No. : 334977903
Age : 55 - RTO Location : MAHARASHTRA-PUNE
GSTIN No. (Customer) : 27CWYPR1607L1ZP Hypothecated To : -
Servicing Branch Name : Mumbai Invoice No. : 1003242166974
:
This policy covers only Own Damage Risk with no other liability in connection with Private Car vehicle including third party cover and is issued basis following : Third Party
Policy No. - 3001/HI-11644733/00/000 valid from Apr 13, 2022 to Apr 12, 2025, Insured byICLB

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

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
GRAND I10 NIOS
MH12UC9758 HYUNDAI HATCHBACK 1197 2022 5 MALB251CLNM295940 G4LAMM044593
MAGNA 1.2 CNG
Vehicle IDV Trailer Non Electrical Electrical / Electronic Accessories CNG / LPG Unit Total IDV
(`) (`) Accessories (`) (`) (`) (`)
5,50,000.00 0.00 0.00 0.00 0.00 5,50,000.00

Premium Details
OWN DAMAGE(A) (`)
Basic OD Premium 3,766.00
Bi-fuel Kit 181.00
Zero Depreciation (ZD -) 1,925.00
Consumables 550.00
Engine Protect Plus 1,100.00
Road Side Assistance (RSA-With Key Protect) 599.00
Key Protect of ` 50000 499.00

Sub Total 8,620.00

Less:
No Claim Bonus 25% 987.00
Sub-Total Deductions 987.00
Total Own Damage Premium(A) 7,633.00
% 9.00
CGST
` 686.97
% 9.00
SGST
` 686.97
% 0.00
UTGST
` 0.00
% 0.00
IGST
` 0.00
Total Tax Payable in ` 1,374.00
Total Premium Payable In ` 9,007.00

Unique Identification Number (UIN) Details IR IR IR IR

Zero Depreciation Road Side Assistance Consumable Engine Protect Plus Key Protect
IR
IRDAN115RP0001V01201920/A IRDAN115RP0001V01201920/A IRDAN115RP0001V01201920/A IRDAN115RP0001V01201920/A IRDAN115RP0001V01201920/A
0035V01201819 0039V01201819 0008V01201920 0009V01201920 0010V01201920
Geographical Area: India Applicable IMT Clauses: 25 , 22.00
Compulsory Deductible: ` 1,000.00 Voluntary Deductible: ` 0.00
Features of Add-on Covers: 0 59 0 19 0 0 0

1.List of services for Road Side Assistance :Arrangement of keys,Towing on breakdown/accident upto 50 km,Accommodation Benefits,Arrangement/Supply of fuel,Battery
jump start,Message Relay,Flat Tyre support,Alternate Travel/Taxi Benefits,Minor on spot Repairs,Breakdown support over phone,Key Protect of Rs.10000
2.Zero Depreciation Coverage : Zero Depreciation covers only the depreciation on the replaced parts. Consumables and HydroStatic Lock are not coverd under Zero
Depreciation unless opted as separate add-on.

Premium Collection No. 1203349470 Premium Amount (`) ` 9,007.00 Receipt Date 19-03-2024
GSTIN Reg.No 27AAACI7904G1ZN 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.
CORP/SUP/OPI/2014/1777

Mar 19, 2024

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE 0

Stand-Alone Own Damage Private Car Insurance Policy

Product Code: 3001/O UIN: IRDAN115RP0001V01201920

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".
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 i s 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.
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
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 Mar 19, 2024 in lieu of Covernote No. 334977903. The
stamp duty of ` 0.50 paid vide deface no. CSD1820234850 dated Nov 30, 2023.
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 DB08903 :

LANDMARK INSURANCE
Agency Name :
BROKERS PVT LTD
Agent's Contact No 8850766009
:

Contact Person :

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2024.03.19 16:58:34 IST
CORP/SUP/OPI/2014/1777

Mar 19, 2024