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TWO WHEELER CERTIFICATE-CUM-POLICY SCHEDULE

Cert. No.
3005/25956519/10961/000

ICICI Lombard General Insurance

Company Ltd
414,Veer Savarkar Marg,Near Siddhi
Vinayak Temple, Prabhadevi, Mumbai
400025

Prev. Policy No: ILG

3005/2010833857/22/00000276

customersupport@icicilombard.com
Insured

Business/Profession

Address of The Insured

Valid From

To

Mr RAJESWARA RAO
borra

Employed

D NO 5-142 ARTHAMURU
BANTUMILLI MND Machilipatnam
ANDHRA PRADESH 521369

08-01-2015 0:00:00

Midnight of 07-012016

Vehicle Regn No.

Engine No.

Year of Mfg

Cubic Capacity

2012

150

Frame No.

Make & Model

Hero
MotoCorp
MBLKC12EHCGL05328 (formerly Hero
Honda)
XTREME DSS

AP-16-AY-1574

KC12EECGL07533

Declared Value (IDV) of

Vehicle

Side Car IDV

Non-Electrical
Accessories IDV

Electrical
Accessories
IDV

CNG/LPG/Bi-Fuel IDV

Total IDV

46200.00

NA

0.00

0.00

NA

46200.00

Place of Regn.

Body Type

HP/Lease/Hire-Purchase
Agreement With

Branch Office
of
HP/Lease/HirePurchase

Seating Capacity

Premium

Machilipatnam

Solo

---

---

1347.00

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

B. Liability Premium Computation (Section II) in Rs.

Basic Premium Including Premium for TPPD

Basic Premium On
Vehicle

697.00

Accessories

0.00

CNG/LPG/Bi-Fuel Kit

Electronic & Electrical Accessories

0.00

Add

Bi-Fuel Kit

Total

:
:

464.00

:
:
:

50.00

:
:

0.00

e) Legal Liability Cover (Other then Paid Drivers,

Cleaners)

Less Discounts

Total Liablity Premium (B)

514.00

For anti-theft devices

Total Premium (A + B)

: 1198.00

Any other discount

For any other extra

: 0.00
: 149.00
: 1347.00

Vehicle

a) Compulsary PA Cover (Owner Driver)

697.00

Add Extras:

b) Optional PA Cover(Un Named Passenger)

c) Optional PA Cover(Pillion Rider)

Geographical Extension

0.00
231.00

ND Cover

For any other extra

Sub Total

928.00
0.00

d) Legal Liability Cover (Paid Drivers, Cleaners)

244.00

Total Deductions

244.00

Gross Premium

Net Own Damage Premium(A)

684.00

(35 %)

0.00
0.00

Legal Liability

Add Service Tax

NCB

0.00

0.00

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/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

Issued through NsurePlus Application Software

Premium of Rs.
Dealer's Stamp &
Signature

Dated

Nominee Name

Drawn on

Nominee Age

Acknowledgement Dt
08-Jan-2015
Date & Signature of
proposer

From 1st July 2014, Insured is Liable for a

voluntary deductible of Rs. 250/- for each
Claim,if policy having ND product.

Received Vide
1347.00
CASH
Cash/Cheque No.

07-012015

Nominee
Relation

Agent / Broker Details - Direct

The policy is subject to a compulsory excess of

veera venkata
Rs. 100/- & Depreciation is applicable as per
gangadhara rao policy terms & conditions* (Please turn overleaf
for details)
58
Consolidted Stamp Duty Paid
Endorsements: IMT - 22

Father

On behalf of ICICI Lombard General Insurance

Company Ltd

http://www.nsureplus.com/Nsureplus/Policy/PolicySchedule.aspx

07-01-2015