ICICI Lombard General Insurance Company Limited.

Servicing Office : Plot No 10 Second Floor, Alankar Palace, MP Nagar, Zone II, Bhopal, Madhya Pradesh - 462011,
, , BHOPAL, MADHYA PRADESH (State Code:23) -462011
Private Car Package Policy UIN --IRDAN115RP0017V01200102
Certificate Cum Policy Schedule (FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)
PAN :AAACI7904G GSTIN: 23AAACI7904G1ZV CIN :U67200MH2000PLC129408 IRDAI Reg:115

Policy No: 3001/HY-18591870/00/000 Proposal No. & Date: HIIB5465857, 28-OCT-2023

Policy Issued On: 28-OCT-2023 20:26 HRS Previous Policy No.: 3001/O/HI-11789929/00/000
Insured Name: MR. MUKESH VISHWAKARMA Previous Insurer: ICICI Lombard General Insurance Company Limited.
Period of Own Damage : 29-OCT-2023 (00:00) To 28-OCT-2024 (1 YEAR)
S/O MR.RAMPRASAD VISHWAKARMA 611 RAMANAND NAGAR,,
Period of Liability Cover: 29-OCT-2023 (00:00) To 28-OCT-2024 (1 YEAR)
Insured Address: INDORE CITY-2, INDORE , MADHYA PRADESH (State Code:23) -
452002 Period of Compulsory 29-OCT-2023 (00:00) To 28-OCT-2024 (1 YEAR)
Personal Accident Cover:
Customer Type PAN GSTIN Name Age (Yr.) Relation
Customer Details Nominee Details
INDIVIDUAL XXXXX0430C NA VANDANA VISHWAKARMA 32 SPOUSE

Vehicle Details
Make Model Variant Cubic Capacity Manufacturing Year Seating capacity
HYUNDAI GRAND I10 NIOS 1.2MT KAPPA SPORTZ 1197 2020 5
Body Type Registration No. RTO Hypothecation/Lease* Fuel Type VIN/Chassis No.
HATCHBACK MP 09 WF 8751 INDORE YES PETROL MALB351CLLM104625
Vehicle IDV Electrical Accessories Non-Electrical Accessories BI Fuel Kit Total IDV Engine No
448,648 0 0 0 448,648 G4LALM720684

Own Damage Premium (A) Amount(INR) Liability Premium (B) Amount(INR)

Basic Own Damage Premium Basic Third Party Liability Premium 3,416
Vehicle 4,296 Bi-Fuel Kit 0
Non-Elec. Accessories (IMT-24) 0 Geographical Area Extension (IMT-1) 0
Elec. Accessories (IMT-24) 0 Sub Total (Third Party Liability) 3,416
Bi-Fuel Kit (IMT-25) 0 Personal Accident (PA) Cover
Geographical Area Extension (IMT-1) 0 Compulsory PA Cover for Owner Driver Rs 1500000 (IMT-15) 475
IMT 23 Premium 0 PA Cover for 5 Unnamed Passengers Rs 50000 Each (IMT-16) 125
Sub Total (Basic Premium) 4,296 PA cover for Paid Driver of Rs 2 Lac (IMT-17) 0
Discount/Deductibles Sub Total PA Cover 600
Voluntary Deductibles (0) (IMT-22A) 0 Legal Liability
Anti Theft Device (IMT-10) 0 Paid Driver (IMT-28) 0
AA Membership (IMT-8) 0 Employees (for 0 persons) (IMT-29) 0

No Claim Bonus (20%) 860 Sub Total (Legal Liability) 0

Handicapped Discount (IMT-12) 0 Net Liability Premium (B) 4,016

Sub Total (Deductibles) 860 Total Premium (A+B) 11,340
Total Own Damage Premium 3,436 SGST(9%) 1,021
Add On Coverages ( ZD, KP, PB ) 3888 CGST(9%) 1021
Net Own Damage Premium (A) 7,324 Gross Premium Paid 13,382
Add-on Cover Opted in the Policy: Zero Depreciation(IRDAN115RP0017V01200102/A0368V01200910), Key Protect Cover(IRDAN115RP0017V01200102/A0019V01201213), Loss of Personal
Belongings Cover(IRDAN115RP0017V01200102/A0021V01201213)
Notes: 1. New Challan /Deface Number: CSD6920232872, Challan Date: 14/06/2023 Note: This challan number is not applicable for Jammu & Kashmir policies.
2.This policy has been issued upon declaration by the Insured that a valid Pollution Under Control (PUC) Certificate is held on the date of
commencement of the Policy. The insured undertakes to renew and maintain a valid and effective PUC and/or fitness Certificate, as applicable, 3.Geographical Area: India
during the subsistence of the Policy.
5.The policy is subject to compulsory deductible of INR 1000
4. Policy issuance is subject to realization of cheque if premium is paid by cheque
(IMT-22) & Voluntary Deductible of INR 0
6. This policy is to be read in conjunction with the Policy /Add-on wordings T&C available on the insurer website
http://www.icicilombard.com
*Hypothecation Details: STATE BANK OF INDIA - indore - Indore Payment Mode: Online
Limitations as to use:The policy covers use of the vehicle for any purpose other than (1) Hire or Reward (2) Carriage of goods (other than samples or personal luggage) (3) Organized racing (4) Pace
making (5) Speed testing (6) Reliability trials (7) Any purpose in connection with motor trade.
Driver's Clause: Any person including the insured: Provided that the person driving holds an effective driving license at the time of the accident and is not disqualified from holding or obtaining such
license. Provided also that the person holding an effective learners license may also drive the vehicle & that such a person satisfies the requirements of Rule 3 of the Central Motor Vehicle Rules, 1989.
Limits of Liability Clause: Under Section II-1(i) of the policy-Death of or bodily injury: Such amount as is necessary to meet the requirements of the Motor Vehicle Act 1988.Under Section II-1 (ii) of
the policy-Damage to third party property is INR 7.5 Lakhs, PA Cover Under Section III for Owner-Driver is INR 15 Lakhs.
No Claim Bonus: The insured is entitled for a No Claim Bonus (NCB) on the own damage section of the policy, if no claim is made or pending during the preceding year(s) - 20%, preceding
two consecutive years - 25%, preceding three consecutive years - 35%, preceding four consecutive years - 45%, preceding five consecutive years - 50% of NCB on OD Premium.
NCB is allowed provided the policy is renewed within 90 days of the expiry date of the previous policy.
Declaration on Tax Invoice We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is 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.
Important Notice: The insured is not indemnified if the vehicle is used or driven otherwise than in accordance with the schedule. Any payment made by the company by reasons 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 & RIGHT
OF RECOVERY" For legal interruption, English version will hold good.
Grievance Clause: For resolution of any query or grievance, Insured may check Grievance redressal policy at https://www.icicilombard.com/grievance-redressal or connect with the respective servicing
office of insurance company. In the event of unsatisfactory response,he/she may approach the insurance ombudsman for the redressal of grievance at www.irdai.gov.in or on website of General Insurance
Council: www.gicouncil.in
HSN/SAC : 997134, Description of Service : Motor Vehicle Insurance Services, Place of Supply : MADHYA PRADESH(State Code : 23), Insurer Invoice Number : HAP/181023402336
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 XI of Motor Vehicle Act, 1988.
Insurance Broker Name : Hyundai India Insurance Broking Pvt. Ltd. Scan for Renewal For & On Behalf of
Corporate Office:16th Floor, Building No. 9A, DLF Cybercity, Phase III, Gurugram, (Valid from 90 Days Prior to Expiry) ICICI Lombard General Insurance Company
Haryana 122001 Limited.
Broker Code: 822 (Valid UPTO:30/05/2025) MISP NAME-KRISHU MOTOR CRAFT
CIN No.: U67200HR2021PTC098982 PRIVATE LIMITED
GST: 06AAGCH0310P1ZP MISP CODE-HIIB-MHY-0356
Email ID: connect@hiib.in DP NAME-SACHIN SHARMA
Contact No: 0124-6833000
Authorized Signatory
For Claims, Policy Servicing & Renewal, Kindly contact (PRINCE HYUNDAI) at +91-8319484766