N Sure Policy

TWO WHEELER CERTIFICATE-CUM-POLICY SCHEDULE Cert. No. 3005/6238119/00/000

ICICI LOMBARD General Policy No Insurance Company Limited 3005/6238119/00/000 ICICI Bank Tower, Bandra Kurla Complex, Bandra(East) Mumbai -400 051

Insured

Occupation

Address Of The Insured

Valid From

To

VIMALKUMAR AMARNATH SHRIDHAR

Service

S NO 167/2 SAI PARADISE KAMGARNAGAR PIMPRI FLAT NO 12 HAVELI PUNE

30-10-2008 13:11:00.0

Midnight of 29-10-2009

Year Of Mfg

Cubic Capacity

2007

150

CNG/LPG/Bi-Fuel IDV

Total IDV

Vehicle Regn No.

Engine No.

MH-14-BF-7942

07HBMM03800

Declared Value (IDV) Of Vehicle

Side Car IDV

52.999.00

NA

Place Of Regn.

Body Type

PCMC

Solo

Chassis No.

Make & Model

07HBMC03434 Hero Honda – CBZEXTREME DSS Non-Electrical Accessories IDV

Electrical Accessories

NA

NA

HP/Lease/Hire- Branch Office of Purchase HP/Lease/HireAgreement With Purchase CITI BANK LTD

NA

52.999.00

Seating Capacity

Premium

2

1200.00

NA

A. Own Damage Premium Computation (Section 1) in Rs.

B. Liability Premium Computation (Section II) in Rs. Basic Premium Including Premium for TPPD Vehicle

Basic Premium On

: : :

300.00

: :

50.00

: : :

0.00

Vehicle Accessories Electronic & Electrical Accessories Bi-Fuel Kit Total Add Extras:

:

Geographical Extension

:

c)

For any other extra

:

d)

Sub Total

:

e) For any other extra

For ani-theft devices

:

Total Liablity Premium (B)

: 362.00

Any other discount NCB Total Deductions Net Own Damage Premium(A)

: : :

Total Premium (A + B) Add Service Tax

: 968.00 : 120.00

:

718.00 0.00

: : :

CNG/LPG/Bi-Fuel Kit Total

0.00 300.00

Add a) PA Benefits 718.00

b)

0.00

Legal Liability

Less Discounts

:

20% 0.0 718.00

: Gross Premium

:

1200.00

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. IMPORTANT NOTICE: The insured is not indemified 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' 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 100000/- 0.00 I/We certify that the policy to which the certificate relates as well the certificate of insurance are issued in accordance with the provisions of Chapter X & XI of M.V. Act 1988

Dealer's Stamp & Signature

Issued through NsurePlus Application Software Received Via Premium Of Rs. 1200.00 Cash/Cheque No. CASH Dated Drawn On

10-Oct-2008 Date & Signature of proposer

The policy is subject to a compulsory excess of Rs. 50/- & Depreciation is applicable as per policy terms & conditions* Consolidted Stamp Duty Paid IMT 22 Endorsements:

Acknowledgement 30-10-2007 Dated FOR RENEWALS CONTACT:SEHGAL AUTORIDERS On behalf of ICICI Lombard General Insurance Co. PVT LTD Ltd. D-II, 64/6, M.I.D.C CHINCHWAD, PUNE 020-24111213 PUNE 411019

Duly Constituted Attorney Service Tax Reg. No. G/S / Mumbai - 1/1528/2001 Visit us at www.icicilombard.com- Mail us at [email protected] Contact us at 1800-209-8888(Toll Free) The stamp duty of fifty paise paid in cash or by demand draft or by pay order, vide Receipt/Challan No 19342, dated 19th July 2008 ICICI Lombard General Insurance Company Limited, Zenith house Keshavrao Khadye Marg,Opp. Race Course, Mahalaxmi, Mumbai -400 034 Insurance underwritten by ICICI Lombard General Insurance Company Limited. Insurance is the subject matter of the solicitation.