Ramesh Devram Gore
Content
Page 1 of 3
Two Wheeler Package Policy
CERTIFICATE CUM POLICY SCHEDULE
For all your insurance needs & query call us at our Toll free No.: 1800-2666(Accessible from your mobile also), you can also E-mail us at:
[email protected]
Certificate cum Policy No : 3005/2010845915/00/0000008422
Policy Issuing Office
ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025.
Period of Insurance
From 14:24 26/08/2015 To 25/08/2016 midnight
Insured Name
RTO Location
MAHARASHTRA-THANE
Intermediary Code
201336940149
RAMESH DEVRAM GORE
Policy Issued On
26/08/2015
Insured Address
AT.MHARAL AMBEDKAR NAGAR PIPE LINE POST VARAP TAL KALYAN421301 , THANE, MAHARASHTRA, Pin - 421301
Hypothecation With
SAMTANI
ENTERPRISE,MUMBAI
Primary Vertical Name
BANCASSURANCE-Motor Two Wheeler (M6)
Category
Contact No.
91-9820563252(Mobile No.)
Registration
Number
Make
NEW
HONDA
MOTORCYCLE
Vehicle IDV
Side Car
55100
Model
SHINE
Type of body
Mfg
Year
CC
Solo With Pillion
125
Additional Acc
NonElectrical Acc
Electrical/Electronic Acc
0
0
0
0
2015
Seat
Cap
2
Chassis
Number
Engine Number
43446
CNG/LPG Unit
43889
Total Value
0
55100
SCHEDULE OF PREMIUM
Own Damage(A)
Liability(B)
Basic Own Damage
Total
554.00
554.00
Total Own Damage Premium
554.00
Basic Third Party Liability
PA Cover For Owner-Driver Of Rs. 100000
Total
Total Liability Premium
538.00
50.00
588.00
588.00
Total Package Premium (A+B)
1142.00
Net Premium
1142.00
Service Tax
160.00
Total Premium
1302.00
For No claim Bonus (NCB), Coverages and exclusion of policy Please refer to the policy wordings attached with this schedule, in case of you have not received your
kindly write to us at the below mentioned mailing address.
Compulsory Deductibles : Rs.100
GeographicalArea India
*** All Premium figures are in Rupees
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 100000.00; PA Cover for Owner-Driver under section III: CSI Rs 100000.00
Voluntary Deductable Rs.0
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), Organized racing, Pace making, Speed testing, Reliability trials, Any purpose in connection with Motor Trade.
DRIVER'S CLAUSES: 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". For legal interpretation,English version will hold good
Subject to IMT Endorsement Nos. & Memorandum printed herein / attached hereto :
22,28
Premium Collection Details :
I/We hereby certify that the policy to which the certificate relates as well as the certificate of insurance are issued in accordance with the provision of chapter X,XI of
M.V.Act 1988.
Agency Code: 9539573
Agent's Mobile No.: 91-9223539392
Agency Name: MANSI MANISH SHAH
Agent's Landline No.:
Disclaimer: Policy is valid subject to Realization of Cheque.
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.1800-2666or 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.
The stamp duty of Re 0.5 paid in cash or by demand draft or by payorder,vide
receipt/challan no. 2286191 dated 15/07/2015
For
ICICI Lombard General Insurance Company Ltd
Service Tax Registration No. : GIS / MUMBAI-I / 1528 / 2001
Service Tax Code Number. :AAACI7904GST001
Category: General Insurance Business Services 00440005.
Duly Constituted Attorney(s)
IRDA Registration no. 115
COPY OF POLICY
ICICI Lombard General Insurance Company Ltd
Mailing Add. Office: ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025.
Corporate Office: ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025.
file://C:\Program Files\ILPOS Motor Insurance\PolicySchedule.html
8/26/2015
Page 2 of 3
TWO WHEELER
Proposal Form No. :3005/2010845915/00/0000008422
Main Features:
I. Own Damage : This product Protects you Against loss or damage to your motor vehicle and/or accessories due to
fire
self ignition
explosion
lightning
theft
burglary
housebreaking
riot
strike
earthquake
flood and allied perils
accidental external means
malicious acts
terrorist activity
transit
landslide, rockslide
II. Third Party Liability : In addition to the coverage noted above,this product covers you against legal liability towards third party, in respect of the following:
death of or bodily injury to any person
damage to property (as per the provision of Motor Vehicle Act.)
We are pleased to inform you that in addition, the product also includes the following:
Personal accident benefits for owner driver upto a value of Rs. 1 lakhs Legal liability towards the paid driver Cover for Rs.1 lakhs for third party property damage
Insured's
Year of
Cubic
Seating
Electrical
Non Electrical
Additional
Date of
Make of Vehicle
Model of Vehicle
Declared
Manufacturing
Capacity
Capacity
Accessories.
Accessories.
Accessories.
Registration
Value (IDV)
HONDA
MOTORCYCLE
SHINE|
Premium:
Rs. 1302.00
Engine No.
43889
Chassis No.
43446
2015
R. T .O Authority
125
2
Rs. 55100.00
Rs. 0.00
Rs. 0.00
Rs. 0.00
26/08/2015
MAHARASHTRA-THANE
Additional Risks, if any
Special Conditions : (Details of
HYP/HP/Lease)
SAMTANI ENTERPRISE,MUMBAI
1. Registration mark and number and description of vehicle insured
2. Name
NEW
RAMESH DEVRAM GORE
Flat/Building
AT.MHARAL AMBEDKAR NAGAR PIPE LINE POST VARAP TAL KALYAN-421301
Street/Road/Sector
Area/Village/Taluka
Landmark
City
THANE
State
PIN
421301
Telephone
Email
Mobile No.
MAHARASHTRA
9820563252
3. Effective date and time of commencement of insurance for the purpose of the Act
Time
4. Date of expiry of insurance
Midnight of : 25/08/2016
5. Are you entitled to No claim bonus?
Yes
Date
14:24
No
26/08/2015
if yes, please submit the proof
6. Liability to Third Parties - The Policy Provides Third Party property
Damage (TPPD) of Rs. 1 lakh/Do you wish to restrict the above limits to ICICI statutory TPPD liability limit
of Rs. 6000/-only?
Yes
No
7. Type of Cover
Package Policy
8. Do you wish to include P.A. Cover for Paid drivers, Cleaners and Conductors
Yes
Liability Only
Other Pls. Specify
No
9. Additional Covers
INSURANCE ACT 1938 SECTION 41-PROHIBITION OF REBATES
No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating
to lives or property in india, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy,nor shall any person taking out or renewing
or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the prospectuses or tables of the insurer.Any person making default in complying
with the provisions of this section shall be punishable with fine which may extend to five hundered rupees.
If corporate,vehicle used by Mr./Ms.
Phone(with STD Code) : (R)
(O)
Mobile Number :
Fax No. :
Email ID :
(For claim status and renewal reminders)
Date of birth :
Sex:
M
F
Marital status:
Single
Professional Qualification:
Doctor
MBA
Engineer
Lawyer
CA
Journalist
IT
Student
Post Graduate
Other (pl. specify)
Status
01/01/1981
Married
Architect
Graduate
:
Individual
Proprietorship
Partnerships
Pvt./Public Co's
Other (pl. specify)
Salaried
Self Employed
Professional
Retired
: Urban
Rural
Social
Paid up Capital of Company in Rupees :
< 10 Crores
10-25 Crores
>25 Crores
Category of Business
Trading
Manufacturing
Contracting
Financial Services Hospitality
Other (pl.specify)
Do you wish to cover Legal Liability to?
A) Driver (No.of persons )
Yes
No
B) Other employees (No.of persons )
Yes
No
C) Unnamed Passengers (No.of persons )
Yes
No
If Individual
:
If entity Business
Are you the ownerdriver*
Yes
No
Optioanl personal accident capital sum insured can be upto Rs 2 lakh per person. Number
of persons that can be covered is restricted to carrying capacity of the vehicle(excluding
driver)
Do you wish to include Personal Accident
(P.A.) Cover for named persons?
Yes
No
The vehicle is used for Commercial purposes
:
Yes
Use of my vehicle is limited to own premises
:
Yes
The vehicle is used for Personal purposes
:
Yes
The vehicle belongs to foreign embassy/consulate?
:
Yes
The car is certified as Vintage car by
Vintage and Classic Car Club of India
:
Yes
The vehicle is designed for use of Bind/Handicaped/mentally challenged persons
and duly endorsed as such by RTA
:
Yes
The vehicle is chauffeur driven
:
Yes
Are you a member of Automobile Association ofIndia :
Yes
No
If Yes : Association Name
Membership Number :
Date of expiry:
Is the vehicle fitted with the any Anti-theft
device approved by the ARRI
:
Yes
No
Whether you want to opt for a Voluntary Deductible
offered under the policy, whichwould be applied over
:
Yes
No
and above Complusory Deductible?
Voluntary Deductible Amount: Rs.0
If yes,please indicate your choice.Select Whichever Applicable
Private Car
2500
5000
7500
15000
Two-Wheeler
750
1000
1500
3000
Whether extension of grogrphical area to the following countries required?
:
Yes
Bangladesh,Bhutan,Maldives,Nepal,Pakistan & Sri Lanka.
If 'Yes' state the name of the countries. 1)
2)
3)
Whether the vehicle is driven by non-conventioanl source of power? :
Yes
If yes,please give details.
Whether the vehicle is fitted with fibre glass tank? :
Yes
Details of Hire Purchase/Hypothecation/Lease
A)Is the vehicle proposed for insurance:Under Hire Purchase: Yes
Under Lease agreement: Yes
file://C:\Program Files\ILPOS Motor Insurance\PolicySchedule.html
No
No
No
No
No
No
No
No
No
No
No
No
8/26/2015
Page 3 of 3
Do you wish to include P.A.Cover for
unnamed persons,
Yes
No
provide Details in the list below. You may include paid cover, in the list
Sr.No.
Name
CSI opted(Rs.)
Paid
Driver
1.
2.
3.
4.
5.
Under Hypothecation agreement: Yes
No
B)If yes,give name and address of cencerned partiesSAMTANI ENTERPRISE
MUMBAI
5. Are you entitled to No claim Bonus?
Yes No if yes,please submit the proof
6.Liability to Third Parties - The Policy Provides Third Party property
Damage(TPPD) of Rs. 1.0 lakhs/Do you wish to restrict the above limits to ICICI statutory TPPD liability limit
of Rs.6000/-only?
Yes No
7. Type of Cover
Package Policy
Liability Only
Other Pls.Specify
8. Do you wish to include P.A. Cover for Paid drivers, Cleaners and Conductors
Yes
No
(a)Age:Owner Driver
Other
Licence effective date :
Licence expiry date :
I or my driver of this vehicle suffer from defective vision, hearing or are physically
challenged in any manner.:
Yes
No
If yes, details are
There is a previous history of driving offences
by me or my drivers:
Yes
No
If yes, details are
We would like you to know that the policy does not cover consequential loss,
depriciation,normal wear and tear,mechanical or electrical breakdown failures or
breakages. The vehicle is not held covered if used for commercial purposes or if driven
by an unauthorised driver.
Note: The foregoing is only an indication of the cover offered. For details please refer to
the policy It is our endeavour to provide consistent quality service to all our customers.
To enable us to deliver our promise, we would appreciate if you take some of your
precious time to answer all questions fully and correctly to the extent possible.
We would like to let you know that insurance is a contract of Utmost Good Faith
Name and Address of Previous Insurer:
requiring the customer to disclose all material facts without supressing any vital
Date of purchase of vehicle
information whether material or otherwise.
Previous Policy Type
:Liability only Cover
Package Cover
Others
If in you opinion any fact is material and is not covered by the information sought in the
Previous Policy No.
:
application form, we request you to diclose it.
Period of Insurance
:
It is important to note that our liability will commence only after we have accepted your
Existing bonus/malus status : NA
proposal and the premium has been received in full.
(Please attach a copy of last policy/renewal notice held.)
Insured's Declared Value (IDV)
In the last three years, is there any history of loss experienced by the propose(s) or
Insured's Additional
Electrical &
Non
Side Car Value of Total
other drivers who would be using this vehicle
Yes
No
Declared accessories
electronic
Electrical
(Two CNG/LPG Value
If Yes, details are:
Value of fitted to the accessories Accessories Wheeler)
Kit
Date&Time of Name of the driver at the
Amount claimed
fitted to the
vehicle
vehicle
Trailer
Nature of Loss
loss
time of Loss
(Rs.)
vehicle
(Pvt.Cars)
Rs.55100 Rs.0
Rs.0
Rs.0
Rs.0
Rs.0
Rs.55100
Note:The IDV of the vehicle will be deemed to be the 'SUM INSURED' for the purpose
of this tariff and it will be fixed at the commencement of each policy period for each
Has any insurance company ever
:
insured vehicle. The IDV of the vehicle is to be fixed on the basis of manufacturers
A) declined the proposal
:
Yes
No
listed selling price of the brand and model as the vehicle proposed for insurance at the
B) Cancelled&refused to renew
:
Yes
No
commencement of insurance/renewal, and adjusted for depreciation (as per schedule
(If yes, reasons there for
) specified below).The IDV of this side car(s) and/ or accessories, if any, fitted to the
C) imposed special Condition or excess
:
Yes
No
vehicle but not included in the manufacturers listed selling price of the vehicle is / are
also likewise to be fixed. The schedule of age wise depreciation as shown below is
I/We hereby declare that the above statements and particulars are true, accurate and
applicable for the purpose of total loss/constructive total loss(TL/CTL) claims only. A
complete and I/We declare that this declaration and the answer given above shall be held to vehicle will be considered to be a CTL where the aggregate cost of retrieval and / or
promissory and shall be the basis of the contract between me/us and ICICI Lombard. The
repair of the vehicle subject to terms and conditions of the policy exceeds 75% of the
policy may however be continued at the sole discretion of ICICI Lombard , subject to the
IDV.
payment of the amount payable as determined by ICICI Lombard ,resulting from the
Table 1:Schedule of depriciation for arriving at IDV.
difference in the bonus/malus status. I shall endeavor to procure the renewal notice and
The Insured's declared value (IDV) of the vehicle will be deemed to be the 'Sum
pass the same to ICICI Lombard immediately upon receipt of such notice.
insured'.
IDV CALCULATION
AGE OF THE VEHICLE
Depreciation
Date: 26/08/2015
Signature of Proposer
Upto 6 Months
5%
At the time of Purchase the vehicle was
:
New
Secondhand
6Months 1day to 1Year
15%
Will the vehicle be used exclusively for private,social,
1Year 1day to 2Years
20%
domestic,pleasure&professional purposes
:
Yes
No
2Year 1day to 3Years
30%
Will the vehicle be used for carriage of
3Year 1day to 4Years
40%
goods other than samples or personal luggage
:
Yes
No
4Year 1day to 5Years
50%
The vehicle is in good condition
:
Yes
No
NOTE:IDV of vehicles beyond 5 years of age and of obsolete models of the vehicles
The vehicle is self owned
:
Yes
No
(i.e.models which the manufacturers have discontinued to manufacture) is to be
The vehicle is used for driving tutions
:
Yes
No
determined on the basis of an understanding between insurer and the insured.
*1 Owner driver is defined as "Owner of the Insured Vehicle holding an effective driving
license"
12 A vehicle in "Good Condition" means any vehicle which is in drivable condition
without structural and/or mechanical defects.
I/We hereby declare that the statements made by me/us in this Proposal Form are true to the best of my/our knowledge and belief and I/We hereby agree that this declaration shall
form the basis of the contract between me/us and the ICICI Lombard General Insurance Co. Ltd.
I/We also declare that any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the insurers immediately.
I agree that the Policy shall become voidable at the option of the Insurer, in the event of any untrue or incorrect statement, misrepresentation,non-description or non-disclosure in
any material particular in the proposal form/personal statement, declaration and connected documents, or any material information has been with held by me or anyone acting my
behalf to obtain any benefit under this policy. I affirm, and under take that have read and understood the terms and conditions for usage of Insurance online service of ICICI
Lombard General Insurance Company as displayed on the Web Site www.icicilombard.com and I agree to abide by them.
I/We hereby declare and warrant that the above statements are true, accurate and complete. I/We desire to effect an insurance as described herein with the Company and I/We
agree that this proposal and declarations shall be the basis of contract between me/us and the Company and I/We agree to accept a policy subject to the conditions prescribed by
the Company.
Note : In case of any discrepancy in the policy details, please revert back within 15 days from the date of issue of this policy.
Disclaimer : The Policy stands cancelled or void in the event of Cheque Dishonored.
Place
TELI GALLI
Proposal Date: 26/08/2015
Print Date: 26/08/2015
Signature of the Proposer
file://C:\Program Files\ILPOS Motor Insurance\PolicySchedule.html
8/26/2015
Two Wheeler Package Policy
CERTIFICATE CUM POLICY SCHEDULE
For all your insurance needs & query call us at our Toll free No.: 1800-2666(Accessible from your mobile also), you can also E-mail us at:
[email protected]
Certificate cum Policy No : 3005/2010845915/00/0000008422
Policy Issuing Office
ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025.
Period of Insurance
From 14:24 26/08/2015 To 25/08/2016 midnight
Insured Name
RTO Location
MAHARASHTRA-THANE
Intermediary Code
201336940149
RAMESH DEVRAM GORE
Policy Issued On
26/08/2015
Insured Address
AT.MHARAL AMBEDKAR NAGAR PIPE LINE POST VARAP TAL KALYAN421301 , THANE, MAHARASHTRA, Pin - 421301
Hypothecation With
SAMTANI
ENTERPRISE,MUMBAI
Primary Vertical Name
BANCASSURANCE-Motor Two Wheeler (M6)
Category
Contact No.
91-9820563252(Mobile No.)
Registration
Number
Make
NEW
HONDA
MOTORCYCLE
Vehicle IDV
Side Car
55100
Model
SHINE
Type of body
Mfg
Year
CC
Solo With Pillion
125
Additional Acc
NonElectrical Acc
Electrical/Electronic Acc
0
0
0
0
2015
Seat
Cap
2
Chassis
Number
Engine Number
43446
CNG/LPG Unit
43889
Total Value
0
55100
SCHEDULE OF PREMIUM
Own Damage(A)
Liability(B)
Basic Own Damage
Total
554.00
554.00
Total Own Damage Premium
554.00
Basic Third Party Liability
PA Cover For Owner-Driver Of Rs. 100000
Total
Total Liability Premium
538.00
50.00
588.00
588.00
Total Package Premium (A+B)
1142.00
Net Premium
1142.00
Service Tax
160.00
Total Premium
1302.00
For No claim Bonus (NCB), Coverages and exclusion of policy Please refer to the policy wordings attached with this schedule, in case of you have not received your
kindly write to us at the below mentioned mailing address.
Compulsory Deductibles : Rs.100
GeographicalArea India
*** All Premium figures are in Rupees
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 100000.00; PA Cover for Owner-Driver under section III: CSI Rs 100000.00
Voluntary Deductable Rs.0
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), Organized racing, Pace making, Speed testing, Reliability trials, Any purpose in connection with Motor Trade.
DRIVER'S CLAUSES: 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". For legal interpretation,English version will hold good
Subject to IMT Endorsement Nos. & Memorandum printed herein / attached hereto :
22,28
Premium Collection Details :
I/We hereby certify that the policy to which the certificate relates as well as the certificate of insurance are issued in accordance with the provision of chapter X,XI of
M.V.Act 1988.
Agency Code: 9539573
Agent's Mobile No.: 91-9223539392
Agency Name: MANSI MANISH SHAH
Agent's Landline No.:
Disclaimer: Policy is valid subject to Realization of Cheque.
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.1800-2666or 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.
The stamp duty of Re 0.5 paid in cash or by demand draft or by payorder,vide
receipt/challan no. 2286191 dated 15/07/2015
For
ICICI Lombard General Insurance Company Ltd
Service Tax Registration No. : GIS / MUMBAI-I / 1528 / 2001
Service Tax Code Number. :AAACI7904GST001
Category: General Insurance Business Services 00440005.
Duly Constituted Attorney(s)
IRDA Registration no. 115
COPY OF POLICY
ICICI Lombard General Insurance Company Ltd
Mailing Add. Office: ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025.
Corporate Office: ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025.
file://C:\Program Files\ILPOS Motor Insurance\PolicySchedule.html
8/26/2015
Page 2 of 3
TWO WHEELER
Proposal Form No. :3005/2010845915/00/0000008422
Main Features:
I. Own Damage : This product Protects you Against loss or damage to your motor vehicle and/or accessories due to
fire
self ignition
explosion
lightning
theft
burglary
housebreaking
riot
strike
earthquake
flood and allied perils
accidental external means
malicious acts
terrorist activity
transit
landslide, rockslide
II. Third Party Liability : In addition to the coverage noted above,this product covers you against legal liability towards third party, in respect of the following:
death of or bodily injury to any person
damage to property (as per the provision of Motor Vehicle Act.)
We are pleased to inform you that in addition, the product also includes the following:
Personal accident benefits for owner driver upto a value of Rs. 1 lakhs Legal liability towards the paid driver Cover for Rs.1 lakhs for third party property damage
Insured's
Year of
Cubic
Seating
Electrical
Non Electrical
Additional
Date of
Make of Vehicle
Model of Vehicle
Declared
Manufacturing
Capacity
Capacity
Accessories.
Accessories.
Accessories.
Registration
Value (IDV)
HONDA
MOTORCYCLE
SHINE|
Premium:
Rs. 1302.00
Engine No.
43889
Chassis No.
43446
2015
R. T .O Authority
125
2
Rs. 55100.00
Rs. 0.00
Rs. 0.00
Rs. 0.00
26/08/2015
MAHARASHTRA-THANE
Additional Risks, if any
Special Conditions : (Details of
HYP/HP/Lease)
SAMTANI ENTERPRISE,MUMBAI
1. Registration mark and number and description of vehicle insured
2. Name
NEW
RAMESH DEVRAM GORE
Flat/Building
AT.MHARAL AMBEDKAR NAGAR PIPE LINE POST VARAP TAL KALYAN-421301
Street/Road/Sector
Area/Village/Taluka
Landmark
City
THANE
State
PIN
421301
Telephone
Mobile No.
MAHARASHTRA
9820563252
3. Effective date and time of commencement of insurance for the purpose of the Act
Time
4. Date of expiry of insurance
Midnight of : 25/08/2016
5. Are you entitled to No claim bonus?
Yes
Date
14:24
No
26/08/2015
if yes, please submit the proof
6. Liability to Third Parties - The Policy Provides Third Party property
Damage (TPPD) of Rs. 1 lakh/Do you wish to restrict the above limits to ICICI statutory TPPD liability limit
of Rs. 6000/-only?
Yes
No
7. Type of Cover
Package Policy
8. Do you wish to include P.A. Cover for Paid drivers, Cleaners and Conductors
Yes
Liability Only
Other Pls. Specify
No
9. Additional Covers
INSURANCE ACT 1938 SECTION 41-PROHIBITION OF REBATES
No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating
to lives or property in india, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy,nor shall any person taking out or renewing
or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the prospectuses or tables of the insurer.Any person making default in complying
with the provisions of this section shall be punishable with fine which may extend to five hundered rupees.
If corporate,vehicle used by Mr./Ms.
Phone(with STD Code) : (R)
(O)
Mobile Number :
Fax No. :
Email ID :
(For claim status and renewal reminders)
Date of birth :
Sex:
M
F
Marital status:
Single
Professional Qualification:
Doctor
MBA
Engineer
Lawyer
CA
Journalist
IT
Student
Post Graduate
Other (pl. specify)
Status
01/01/1981
Married
Architect
Graduate
:
Individual
Proprietorship
Partnerships
Pvt./Public Co's
Other (pl. specify)
Salaried
Self Employed
Professional
Retired
: Urban
Rural
Social
Paid up Capital of Company in Rupees :
< 10 Crores
10-25 Crores
>25 Crores
Category of Business
Trading
Manufacturing
Contracting
Financial Services Hospitality
Other (pl.specify)
Do you wish to cover Legal Liability to?
A) Driver (No.of persons )
Yes
No
B) Other employees (No.of persons )
Yes
No
C) Unnamed Passengers (No.of persons )
Yes
No
If Individual
:
If entity Business
Are you the ownerdriver*
Yes
No
Optioanl personal accident capital sum insured can be upto Rs 2 lakh per person. Number
of persons that can be covered is restricted to carrying capacity of the vehicle(excluding
driver)
Do you wish to include Personal Accident
(P.A.) Cover for named persons?
Yes
No
The vehicle is used for Commercial purposes
:
Yes
Use of my vehicle is limited to own premises
:
Yes
The vehicle is used for Personal purposes
:
Yes
The vehicle belongs to foreign embassy/consulate?
:
Yes
The car is certified as Vintage car by
Vintage and Classic Car Club of India
:
Yes
The vehicle is designed for use of Bind/Handicaped/mentally challenged persons
and duly endorsed as such by RTA
:
Yes
The vehicle is chauffeur driven
:
Yes
Are you a member of Automobile Association ofIndia :
Yes
No
If Yes : Association Name
Membership Number :
Date of expiry:
Is the vehicle fitted with the any Anti-theft
device approved by the ARRI
:
Yes
No
Whether you want to opt for a Voluntary Deductible
offered under the policy, whichwould be applied over
:
Yes
No
and above Complusory Deductible?
Voluntary Deductible Amount: Rs.0
If yes,please indicate your choice.Select Whichever Applicable
Private Car
2500
5000
7500
15000
Two-Wheeler
750
1000
1500
3000
Whether extension of grogrphical area to the following countries required?
:
Yes
Bangladesh,Bhutan,Maldives,Nepal,Pakistan & Sri Lanka.
If 'Yes' state the name of the countries. 1)
2)
3)
Whether the vehicle is driven by non-conventioanl source of power? :
Yes
If yes,please give details.
Whether the vehicle is fitted with fibre glass tank? :
Yes
Details of Hire Purchase/Hypothecation/Lease
A)Is the vehicle proposed for insurance:Under Hire Purchase: Yes
Under Lease agreement: Yes
file://C:\Program Files\ILPOS Motor Insurance\PolicySchedule.html
No
No
No
No
No
No
No
No
No
No
No
No
8/26/2015
Page 3 of 3
Do you wish to include P.A.Cover for
unnamed persons,
Yes
No
provide Details in the list below. You may include paid cover, in the list
Sr.No.
Name
CSI opted(Rs.)
Paid
Driver
1.
2.
3.
4.
5.
Under Hypothecation agreement: Yes
No
B)If yes,give name and address of cencerned partiesSAMTANI ENTERPRISE
MUMBAI
5. Are you entitled to No claim Bonus?
Yes No if yes,please submit the proof
6.Liability to Third Parties - The Policy Provides Third Party property
Damage(TPPD) of Rs. 1.0 lakhs/Do you wish to restrict the above limits to ICICI statutory TPPD liability limit
of Rs.6000/-only?
Yes No
7. Type of Cover
Package Policy
Liability Only
Other Pls.Specify
8. Do you wish to include P.A. Cover for Paid drivers, Cleaners and Conductors
Yes
No
(a)Age:Owner Driver
Other
Licence effective date :
Licence expiry date :
I or my driver of this vehicle suffer from defective vision, hearing or are physically
challenged in any manner.:
Yes
No
If yes, details are
There is a previous history of driving offences
by me or my drivers:
Yes
No
If yes, details are
We would like you to know that the policy does not cover consequential loss,
depriciation,normal wear and tear,mechanical or electrical breakdown failures or
breakages. The vehicle is not held covered if used for commercial purposes or if driven
by an unauthorised driver.
Note: The foregoing is only an indication of the cover offered. For details please refer to
the policy It is our endeavour to provide consistent quality service to all our customers.
To enable us to deliver our promise, we would appreciate if you take some of your
precious time to answer all questions fully and correctly to the extent possible.
We would like to let you know that insurance is a contract of Utmost Good Faith
Name and Address of Previous Insurer:
requiring the customer to disclose all material facts without supressing any vital
Date of purchase of vehicle
information whether material or otherwise.
Previous Policy Type
:Liability only Cover
Package Cover
Others
If in you opinion any fact is material and is not covered by the information sought in the
Previous Policy No.
:
application form, we request you to diclose it.
Period of Insurance
:
It is important to note that our liability will commence only after we have accepted your
Existing bonus/malus status : NA
proposal and the premium has been received in full.
(Please attach a copy of last policy/renewal notice held.)
Insured's Declared Value (IDV)
In the last three years, is there any history of loss experienced by the propose(s) or
Insured's Additional
Electrical &
Non
Side Car Value of Total
other drivers who would be using this vehicle
Yes
No
Declared accessories
electronic
Electrical
(Two CNG/LPG Value
If Yes, details are:
Value of fitted to the accessories Accessories Wheeler)
Kit
Date&Time of Name of the driver at the
Amount claimed
fitted to the
vehicle
vehicle
Trailer
Nature of Loss
loss
time of Loss
(Rs.)
vehicle
(Pvt.Cars)
Rs.55100 Rs.0
Rs.0
Rs.0
Rs.0
Rs.0
Rs.55100
Note:The IDV of the vehicle will be deemed to be the 'SUM INSURED' for the purpose
of this tariff and it will be fixed at the commencement of each policy period for each
Has any insurance company ever
:
insured vehicle. The IDV of the vehicle is to be fixed on the basis of manufacturers
A) declined the proposal
:
Yes
No
listed selling price of the brand and model as the vehicle proposed for insurance at the
B) Cancelled&refused to renew
:
Yes
No
commencement of insurance/renewal, and adjusted for depreciation (as per schedule
(If yes, reasons there for
) specified below).The IDV of this side car(s) and/ or accessories, if any, fitted to the
C) imposed special Condition or excess
:
Yes
No
vehicle but not included in the manufacturers listed selling price of the vehicle is / are
also likewise to be fixed. The schedule of age wise depreciation as shown below is
I/We hereby declare that the above statements and particulars are true, accurate and
applicable for the purpose of total loss/constructive total loss(TL/CTL) claims only. A
complete and I/We declare that this declaration and the answer given above shall be held to vehicle will be considered to be a CTL where the aggregate cost of retrieval and / or
promissory and shall be the basis of the contract between me/us and ICICI Lombard. The
repair of the vehicle subject to terms and conditions of the policy exceeds 75% of the
policy may however be continued at the sole discretion of ICICI Lombard , subject to the
IDV.
payment of the amount payable as determined by ICICI Lombard ,resulting from the
Table 1:Schedule of depriciation for arriving at IDV.
difference in the bonus/malus status. I shall endeavor to procure the renewal notice and
The Insured's declared value (IDV) of the vehicle will be deemed to be the 'Sum
pass the same to ICICI Lombard immediately upon receipt of such notice.
insured'.
IDV CALCULATION
AGE OF THE VEHICLE
Depreciation
Date: 26/08/2015
Signature of Proposer
Upto 6 Months
5%
At the time of Purchase the vehicle was
:
New
Secondhand
6Months 1day to 1Year
15%
Will the vehicle be used exclusively for private,social,
1Year 1day to 2Years
20%
domestic,pleasure&professional purposes
:
Yes
No
2Year 1day to 3Years
30%
Will the vehicle be used for carriage of
3Year 1day to 4Years
40%
goods other than samples or personal luggage
:
Yes
No
4Year 1day to 5Years
50%
The vehicle is in good condition
:
Yes
No
NOTE:IDV of vehicles beyond 5 years of age and of obsolete models of the vehicles
The vehicle is self owned
:
Yes
No
(i.e.models which the manufacturers have discontinued to manufacture) is to be
The vehicle is used for driving tutions
:
Yes
No
determined on the basis of an understanding between insurer and the insured.
*1 Owner driver is defined as "Owner of the Insured Vehicle holding an effective driving
license"
12 A vehicle in "Good Condition" means any vehicle which is in drivable condition
without structural and/or mechanical defects.
I/We hereby declare that the statements made by me/us in this Proposal Form are true to the best of my/our knowledge and belief and I/We hereby agree that this declaration shall
form the basis of the contract between me/us and the ICICI Lombard General Insurance Co. Ltd.
I/We also declare that any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the insurers immediately.
I agree that the Policy shall become voidable at the option of the Insurer, in the event of any untrue or incorrect statement, misrepresentation,non-description or non-disclosure in
any material particular in the proposal form/personal statement, declaration and connected documents, or any material information has been with held by me or anyone acting my
behalf to obtain any benefit under this policy. I affirm, and under take that have read and understood the terms and conditions for usage of Insurance online service of ICICI
Lombard General Insurance Company as displayed on the Web Site www.icicilombard.com and I agree to abide by them.
I/We hereby declare and warrant that the above statements are true, accurate and complete. I/We desire to effect an insurance as described herein with the Company and I/We
agree that this proposal and declarations shall be the basis of contract between me/us and the Company and I/We agree to accept a policy subject to the conditions prescribed by
the Company.
Note : In case of any discrepancy in the policy details, please revert back within 15 days from the date of issue of this policy.
Disclaimer : The Policy stands cancelled or void in the event of Cheque Dishonored.
Place
TELI GALLI
Proposal Date: 26/08/2015
Print Date: 26/08/2015
Signature of the Proposer
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8/26/2015
