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CERTIFICATE CUM POLICY SCHEDULE
Certificate cum Policy No:3001/134631183/00/000
MULPolicyNo:3001/MI04925346/00/000
For any assistance please call 1800 2 666 Please save the number for your reference
For RENEWALS : Visit www.icicilombard.com or call 1800 2 666
DETAILS OF THE POLICY HOLDER POLICY DETAILS
Insured Name NITHIN AITHAL G Policy Issuing Office ICICI Lombard General Insurance
Company LTD , ICICI LOMBARD
Insured Address NO 34, 2ND CROSS, RAMACHANDRA HOUSE , 414, Veer Savarkar Marg, Near
AGRAHARA, CHAMRAJPET BANGALORE Siddhi Vinayak Temple, Prabhadevi,
560018 INDIA KARNATAKA BANGALORE Mumbai 400 025
BANGALORE G P O PIN 560018
CHAMARAJPET BAZAR Period of Insurance From 00:00 14/09/2017 To
13/09/2018 midnight
Contact No. (s)
Policy Issued On 17/08/2017
Email Address
Cover Note No: 134631183
Intermediary ID 200027183990
VEHICLE DETAILS
Registration no & RTO Location Make & Model Engine No. Chassis No. MFG Year CC Seating capacity Type of body
KA05MS534 & KARNATAKABANGALORE MARUTI & CELERIO ZXI AT OPTIONAL 1876088 230053 2015 998 5 HATCHBACK
INSURED DECLARED VALUE
Vehicle IDV (In Rs.) Elec/Electronic Accessories (in Rs.) NonElec Accessories (in Rs.) CNG/LPG unit (in Rs.) Trailer (in Rs.) Total Value (in Rs.)
3,61,815.00 0.00 0.00 0.00 0.00 3,61,815.00
SCHEDULE OF PREMIUM(IN RS.)
Own Damage (A) Liability(B)
Basic Own Damage 6,223.00 Basic Third Party Liability 2,055.00
Zero Depreciation (ZD ) 2,533.00 Paid Driver (IMT28) 50.00
Total 8,756.00 PA Cover For OwnerDriver Of Rs. 2,00,000 100.00
Less Total 2,205.00
Anti Theft Device Discount 156.00
Sub Total(Deductions) 156.00
No Claim Bonus 25.00 % 1,517.00
Total 1,673.00
Total Own Damage Premium 7,083.00 Total Liability Premium 2,205.00
Total Package (A+B) 9,288.00
Total premium (in Rs.) 10,960.00
Geographical Area : India
Compulsory Deductibles : Rs.1000 Voluntary Deductible : Rs.0
LIMITS OF LIABILITY:(a)Under Section II 1 (i) of the policy > Death of or bodily injury : Such amount as is necessary to meet there requirements of the
Motor Vehicles Act, 1988.
(b)Under Section II 1 (ii) of the policy > Damage to Third Party Property Rs 7,50,000.00 ; PA Cover for OwnerDriver under section III: CSI Rs 2,00,000.00
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 or personal
luggage), organised racing, Pace making, reliability trails or speed testing any purpose in connection with Motor Trade.
DRIVER'S CLAUSES: Any person including the insured : Provided that a person driving holds and 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". For legal interpretation,English version will hold good
Subject to IMT Endorsement Nos. & Memorandum printed herein / attached hereto : 10,22,28
Premium Collection Details : [Collection No / Amount / ReceiptDate] 1068361536 / Rs.10,960.00 / 09/08/2017
Agency Code: DB47510 Agency Name: MARUTI INSURANCE BROKING PRIVATE LIMITED Agent's mobile no.: +911133774477 Agent's landline no.:
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.
Policy is valid subject to realization of cheque. We accept premium only via legally recognized modes.
In case of dishonour of premium cheque(s) the company shall not be liable under the policy and policy shall be void abinitio (from inception).
In case of any discrepancy with respect to the policy, please revert within 15 days from policy start date.
PA Owner driver Nominee details
Nominee name Age Relationship
H GOPALAKRISHNA AITHAL 56 Father
Grievance Clause:
For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call toll free no.18002666 or may approach
us at the sub section "Grievance Redressal" on our website www.icicilombard.com (Customer Support section). However, if the resolution provided by us is not
satisfactory you may approach Insurance Regulatory and Development Authority (IRDA) through the Integrated Grievance Management Section (IGMS) or IRDA
Grievance Call Centre(IGCC) at their toll free no.155255. You may also approach Insurance Ombudsman, subject to vested jurisdiction, for the redressal of
grievance. Details of Insurance Ombudsman offices are available at IRDA website: www.irdaindia.org, or on the Company's website at www.icicilombard.com.
For information on ombudsman you may visit our website www.icicilombard.com
I/We hereby certify that the policy to which the certificate relates as well as the certificate of insurance are For ICICI Lombard General Insurance
issued in accordance with the provision of chapter X,XI of M.V.Act 1988. Company Ltd
GSTIN Reg. No: 29AAACI7904G1ZJ
HSN/SAC code : 9971 GENERAL INSURANCE SERVICES
In Witness whereof this Policy has been signed at Mumbai this 18day of August of 2017 in lieu of covernote Duly Constituted Attorney(s)
No 134631183 Copy Of Policy
The stamp duty of Rs. 0.5 paid in cash or by demand draft or by pay order,vide receipt/challan no.
4045282 dated 31/07/2017
Dear Sir / Madam,
We thank you for placing your confidence with ICICI Lombard for your motor insurance needs. Please find attached herewith policy no. 3001/134631183/00/000, which has been
issued based on the details furnished by the applicant.
Based on the cover selected, below is a brief on the cover
1. Discount for anti theft devices (IMT10) :
It is hereby agreed and understood that the discount for anti theft device Rs. 156 in consideration of certification by has been given in the policy 3001/134631183/00/000. T h e
insured is eligible for a discount of 2.5% on the OD Component of premium subject to a maximum of Rs. 500/. Hence it is hereby understood & agreed that the insured shall
ensure at all times that anti theft device installed in the vehicle insured is maintained in efficient condition till the expiry of the policy. If at the time of claim, insured is asked to
provide supporting documents then the same has to be submitted mandatorily, failure of which will result in non admissibility of claim.