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Product Code: 3005 UIN: IRDAN115RP0015V05201415

Reference No.: W443321594

Date: Jul 14, 2025
SHYAM BABOO SRIVASTAVA
423/10, AVAS VIKAS COLONY AGRA UTTAR PRADESH, 999999
AGRA
UTTAR PRADESH 282001
Mobile No: 98******84

Sub: Risk Assumption Letter

Dear SHYAM BABOO SRIVASTAVA,

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. 3005/400206696/00/B00, 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 SHYAM BABOO SRIVASTAVA
Period of Insurance Jul 15, 2025 to Jul 14, 2026
Vehicle Make / Model HONDA MOTORCYCLE / ACTIVA 125
RTO City UTTAR PRADESH-AGRA
Vehicle Registration No. UP80EE5545
Vehicle Registration Date Aug 02, 2017
Engine No. JF50E85074996
Chassis No. ME4JF507FH8074960
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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.
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We have issued the policy basis your confirmation that you hold a valid PUC and/or Fitness certificate, as applicable.
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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.

“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
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.
d. In case of total loss / constructive total loss / Total theft / cash loss of the vehicle, the claim will be settled at invoice price i.e amount paid by
the insured / policyholder at the time of purchasing the vehicle, excluding subsidy amount, if included in the invoice, or the Insured declared
value (IDV) whichever is lower, subject to terms and conditions of the policy and admissibility of claims.
( 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.

The Compulsory Personal Accident cover has not been opted in this policy on account that, the Owner driver has a separate existing Personal
Accident cover against Death and Permanent Disability (Total and Partial) for Sum Insured of at least Rs.15 lacs.
CORP/SUP/OPI/2014/1777

Jul 14, 2025

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CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
0
Two Wheeler Vehicles Package Policy 0
1
Product Code: 3005 UIN: IRDAN115RP0015V05201415

Name of the Insured : SHYAM BABOO SRIVASTAVA Policy No. : 3005/400206696/00/B00

Address : 423/10, AVAS VIKAS COLONY AGRA UTTAR PRADESH, Period of Insurance : Jul 15, 2025 12:00:00 to
999999, AGRA, UTTAR PRADESH 282001 Midnight of Jul 14, 2026
Telephone No : Mobile No: 98******84 E-Policy No. : 3005/400206696/00/B00
Email Address : AX*******@GMAIL.COM Policy Issued On : Jul 14, 2025
Nominee Name : ASHISH SAXENA Named Passenger's Nominee: Covernote No. : 400206696
Relationship : Son - RTO Location : UTTAR PRADESH-AGRA
Age : 40 - Hypothecated To : -
GSTIN No. (Customer) : Invoice No. : 1007251013044
Servicing Branch Name : Gurgaon
Servicing Branch Address : Tower D, Twelth Global Business Park Mehrauli Gurgaon Road Gurgaon Haryana 122002

Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/ Close relatives/Associates of PEPs*? No
Vehicle Registration Make Model Type of Body CC/KW Mfg Yr Seating Chassis No. Engine No.
No. Capacity
HONDA Solo With ME4JF507FH807496
UP80EE5545 ACTIVA 125 125 2017 2 JF50E85074996
MOTORCYCLE Pillion 0
Vehicle IDV Side Car Additional Accessories Electrical / Electronic Non Electrical Accessories CNG / LPG Unit Total IDV
(`) (`) (`) Accessories (`) (`) (`) (`)
16,440.00 0.00 0.00 0.00 0.00 0.00 16,440.00

Premium Details
OWN DAMAGE(A) (`) LIABILITY(B) (`)
Basic OD Premium 257.00 Basic Third Party Liability 714.00
Total 714.00
Sub Total 257.00
Total Own Damage Premium(A) 257.00 Total Liability Premium(B) 714.00
Total Package Premium(A+B): 971
% 0.00
CGST
` 0.00
% 0.00
SGST
` 0.00
% 0.00
UTGST
` 0.00
% 18.00
IGST
` 174.78
Total Tax Payable in ` 175.00
Total Premium Payable In ` 1,146.00
Geographical Area: India Applicable IMT Clauses: 22
Compulsory Deductible: ` 100.00 Voluntary Deductible: ` 0.00

Premium Collection No. 1241980458 Premium Amount ` 1146 Receipt Date 14-07-2025
GSTIN Reg.No 06AAACI7904G1ZR HSN/SAC code 997134 / GENERAL
INSURANCE SERVICES
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.
Limits of Liability: (a) Under Section II-I(i) of the policy: Death of or bodily injury & (b) Under Section II-I(ii) of the policy: Damage to Third Party Property- Such amount as is
necessary to meet the requirements of the Motor Vehicles (Amendment) Act, 2019 ; PA Cover for Owner-Driver under Section III: CSI 0/-. The Compulsory Personal
Accident cover has not been opted in this policy on account that, the Owner driver has a separate existing Personal Accident cover against Death and Permanent Disability
(Total and Partial) for Sum Insured of at least Rs.15 lacs. 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 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 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.
The Company reserves the right to cancel this Policy immediately upon becoming aware of any mis-representation, fraud, non-disclosure of material facts or
CORP/SUP/OPI/2014/1777

Jul 14, 2025

 1 1
CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
0
Two Wheeler Vehicles Package Policy 0
1
Product Code: 3005 UIN: IRDAN115RP0015V05201415
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
In case of total loss / constructive total loss / Total theft / cash loss of the vehicle, the claim will be settled at invoice price i.e amount paid by the insured / policyholder at the
time of purchasing the vehicle, excluding subsidy amount, if included in the invoice, or the Insured declared value (IDV) whichever is lower, subject to terms and conditions
of the policy and admissibility of claims.
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 Jul 14, 2025 in lieu of Covernote No. 400206696. The
stamp duty of ` 0.50 paid vide deface no. CSD112025527 dated Jan 30, 2025.
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 DB79719 :

Agency Name :
POLICY BAZAAR INSURANCE
BROKERS PVT LTD
Agent's Contact No 1800120800
:

Contact Person :

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.

Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2025.07.14 17:55:43 IST
CORP/SUP/OPI/2014/1777

Jul 14, 2025