Reference No.
: W357013063
Date: Oct 08, 2024
Dispatch Advice Letter
Dear Sir/Madam,
We value your relationship with ICICI Lombard General Insurance Company Limited and thank you
for choosing us as your preferred insurance provider.
Please find attached herewith Policy No. 4010/338756894/01/000 which has been issued based
on the previous year Policy No 4010/338756894/00/000 with us and the necessary endorsements
(if any) done in the same policy for the following insured:
MAHADEV ENGINEERING
ADANI POWER PLANT VILLAGE MOTIA
GODDA
JHARKHAND - 814133
Please go through the details as furnished in the format and also as provided in the policy
document to ensure that they are in order. If you feel that there are any discrepancies/variations,
please write to us immediately for the necessary changes/rectification. In the absence of any
communication from you in this regard within a period of 15 days of receipt of this letter, we would
understand that you have accepted the contents and the coverage to be in accordance with your
application.
Your renewed policy will be handed over to you shortly by your Relationship Manager / Agent /
Broker. In case you don't receive it within 10 days, please mail us at info@icicilombard.com
stating the renewed policy number.
Thank you once again and look forward to a lasting relationship.
D:/CLICK/images/Gaurav_Arora.png
Authorised Signatory
ICICI Lombard General Insurance Company Ltd.
Signature Not Verified
Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2024.10.08 12:10:43 IST
ICICI Lombard General Insurance Company Limited
IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : IRDAN115CP0017V02201920 EMPLOYEE'S COMPENSATION INSURANCE
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Savarkar Marg, Near Siddhi Vinayak E-mail : customersupport@icicilombard.com
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com 1/5
Reference No.: W357013063
Date: Oct 08, 2024
MAHADEV ENGINEERING
ADANI POWER PLANT VILLAGE MOTIA
GODDA
JHARKHAND - 814133
Risk Assumption Letter
Dear Sir/Madam,
We value your relationship with ICICI Lombard General Insurance Company Limited and thank you
for choosing us as your preferred insurance provider.
Please find attached herewith Policy No. 4010/338756894/01/000 which has been issued based
on the previous year’s policy No. 4010/338756894/00/000 with us and the necessary endorsements
(if any) done in the same policy.
Please go through the last year’s policy, endorsement documents and details provided in the
policy document to ensure that they are in order. If you feel that there are any
discrepancies/variations, please write to us immediately for the necessary changes / rectification.
In the absence of any communication from you in this regard within a period of 15 days of receipt
of this letter, we would understand that you have accepted the contents and the coverage to be in
accordance with your application.
Thank you once again and look forward to a lasting relationship.
Authorized Signatory
D:/CLICK/images/Gaurav_Arora.png
D:/CLICK/images/Gaurav_Arora.png
ICICI Lombard General Insurance Company Ltd.
ICICI Lombard General Insurance Company Limited
IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : IRDAN115CP0017V02201920 EMPLOYEE'S COMPENSATION INSURANCE
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Savarkar Marg, Near Siddhi Vinayak E-mail : customersupport@icicilombard.com
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com 2/5
EMPLOYEE'S COMPENSATION INSURANCE
Part 1 of the POLICY SCHEDULE
0
Policy No. 4010/338756894/01/000
Issued at: MUMBAI - CO
Name of the Insured: MAHADEV ENGINEERING
Address of the Insured: ADANI POWER PLANT VILLAGE MOTIA, GODDA, JHARKHAND -
814133
Period of Insurance: From: 11-Oct-2024 00:00 Hours To Midnight of 11-Apr-2025
Total Sum Insured: ₹ 16,80,000.00
UIN: IRDAN115CP0017V02201920
1.Premium Calculations:
Premium ₹ 17,510.00
Stamp Duty ₹ 9.00
CGST ₹ 0.00
SGST ₹ 0.00
IGST ₹ 3,151.80
UGST ₹ 0.00
Total GST ₹ 3,152.00
Total Premium* ₹ 20,671.00
*Premium value mentioned above is inclusive of taxes applicable
2. No. of lives: 40
3.Details of employees to be insured:
Estimated Occupation Estimated Estimated Place or Places of Industry Sub Industry Risk
Number of of Total Total Employment Classification Classification Classification
Employees Employees Salaries Earnings Code
Wages for the
and other Policy
money Duration
earnings
8 SKILLED 6000 336000 ADANI POWER Engineering NA 157A
PLANT VILLAGE workshop &
MOTIA--------JHARK Fabrication
HAND--GODDA--81 works (Above
4133 9 meters)
22 SEMISKILL 6000 924000 ADANI POWER Engineering NA 157A
ED PLANT VILLAGE workshop &
MOTIA--------JHARK Fabrication
HAND--GODDA--81 works (Above
4133 9 meters)
10 UNSKILLED 6000 420000 ADANI POWER Engineering NA 157A
PLANT VILLAGE workshop &
MOTIA--------JHARK Fabrication
HAND--GODDA--81 works (Above
4133 9 meters)
Total: 40 Total : ₹
1680000
4. Scope of cover
Main Coverage: EC Liability Cover Table 'A' 0
Extensions
ICICI Lombard General Insurance Company Limited
IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : IRDAN115CP0017V02201920 EMPLOYEE'S COMPENSATION INSURANCE
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Savarkar Marg, Near Siddhi Vinayak E-mail : customersupport@icicilombard.com
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com 3/5
Coverages:
1 Policy is issued on unnamed basis. 7
2 Entry age limit:As per WC Act
3 Policy for Table A only
4 Engineering workshop & Fabrication works (Above 9 meters):NA
5 Risk Classification code:157A
6 No. of lives:8
7 Risk Location Address:Adani power plant village Motia,GODDA,814133,JHARKHAND,INDIA
Exclusions:
19
1 Any employment compensation in excess of the actual sum insured for workmen compensation ordinance (not to apply
in\nrespect of common law awards)
2 Pandemics/epidemics as declared by WHO and / or Government of India
3 Any employment compensation in excess of the actual sum insured for workmen compensation ordinance (not to apply
in respect of common law awards).
4 Underground and/or underwater mines and/or underground services in connection therewith. However, this exclusion
shall only apply where more than 20 people are working at the same location at any one time.
5 Subaqueous work (underwater work).
6 Quarries, where explosives are used.
7 Contractors engaged exclusively in wrecking or demolition of building and/or scrap metal merchants.
8 Losses suffered on or in connection with offshore rigs.
9 Aircraft crews in respect of flight risk. However, this exclusion shall not apply to aircraft which are set aside for non
fare paying executive use and which are crewed by six persons or less.
10 Ship crews other than on inland vessels or on vessels operating within territorial waters. However, this exclusion shall
not apply to a vessel crewed by six persons or less.
11 Fire bridges other than those formed privately for loss prevention purposes.
12 Service in any kind of armed forces (including, but not limited to military, police, security services).
13 Operation of railways, other than sidings.
14 Employees employed on a permanent basis in USA and/or Canada.
15 Professional sports team.
16 Fire crackers manufacturing activity
17 Losses suffered in the course of manufacturing and /or supplying and/or producing storing, filling, breaking down,
transporting:- (a) Fireworks, ammunition, fuses, cartridges, powder, nitro-glycerine, or any explosives. (b) Gases and/or
air under pressure in containers. (c) Butane, methane, propane, and other liquefied gases. (d) Celluloid and pyroxylin.
(e) Petrochemicals and also chemicals of a toxic (as defined under India?s Public Liability Act 1991), noxious,
explosive and/or highly flammable nature. (f) Asbestos and/or asbestos products.\n(It is understood and agreed,
however, that the storage, transport and/or handling if any of the substances above mentioned other than f) which is
merely incidental to the operation and/or trade of the Insured not otherwise excluded, is covered.)
18 Any compensation in medical extension expenses if the injured is hospitalized for more than 12 month due to an
accident as per the coverage opted in WC policy
19 Communicable Disease Exclusion
Nature of work/activity
Policy type: Unnamed
Entry age limit As per EC Act
Policy cover Table A
Subject otherwise to terms and conditions of Employee’s Compensation Insurance Policy
Signed for and on behalf of the ICICI Lombard General Insurance Company limited, at Mumbai on this date Oct 07, 2024. The
Policy shall stand cancelled ab initio in the event of nonrealization of premium.
Authorised Signatory
ICICI Lombard General Insurance Company Ltd.
ICICI Lombard General Insurance Company Limited
IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : IRDAN115CP0017V02201920 EMPLOYEE'S COMPENSATION INSURANCE
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Savarkar Marg, Near Siddhi Vinayak E-mail : customersupport@icicilombard.com
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com 4/5
Click here or scan the QR code to view the Customer Information Sheet (CIS). It provides an
overview of the policy features, service and claim processes, as well as other important terms.
GSTIN Reg. No: 27AAACI7904G1ZN
IL GIC GSTIN Address: 414, ICICI LOMBARD HOUSE, VEER SAVARKAR MARG, NEAR SIDDHI VINAYAK TEMPLE MAIN
GATE, PRABHADEVI, MUMBAI, 400025, MAHARASHTRA
HSN/SAC code: 997139 GENERAL INSURANCE SERVICES
The stamp duty of ₹ 9 paid in cash or by demand draft or by pay order, vide Reciept/challan no. CSD0220242018 dated Apr 10,
2024.
Scan here for the Policy Terms and Conditions
ICICI Lombard General Insurance Company Limited
IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : IRDAN115CP0017V02201920 EMPLOYEE'S COMPENSATION INSURANCE
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Savarkar Marg, Near Siddhi Vinayak E-mail : customersupport@icicilombard.com
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com 5/5
