r

3005/37378957/10301/000
Tenure : 1 Year

Insured Business/Profession Address of The Insured Valid From To

Ms VISHAKHA F NO G 2 SWANAND APPT P NO 3 BAJAJ NAGAR NR SHRADHANAND 18-07-2017 Midnight of 17-
Self Employed
DESHMUKH PETH NAGPUR Nagpur MAHARASHTRA 440010 13:16:44 07-2018

Vehicle Regn No. Engine No. Chassis No. Make & Model Year of Mfg Cubic Capacity GSTIN No. (Customer)
Hero MotoCorp
--- JF16EGHGF11696 MBLJFN035HGF09453 Pleasure 2017 100 N/A
HPLNDRSMCR

Declared Value (IDV) Side Car IDV Non-Electrical Accessories IDV Electrical Accessories IDV CNG/LPG/Bi-Fuel Total IDV
of Vehicle IDV
45505.00 NA 0.00 0.00 0.00 45505.00
Place of Regn. Body Type HP/Lease/Hire-Purchase Branch Office of HP/Lease/Hire- Seating Capacity Premium
Agreement With Purchase
NAGPUR Solo , --- 2 2042.00
A. Own Damage Premium Computation (Section I) in Rs. B. Liability Premium Computation (Section II) in Rs.
Basic Premium On Basic Premium Including Premium for TP
Vehicle : 686.00 Vehicle : 720.00
Accessories : 0.00 CNG/LPG/Bi-Fuel Kit : 0.00
Electronic & Electrical Accessories : 0.00 Add
Bi-Fuel Kit : 0.00 a) Compulsary PA Cover (Owner Driver) : 50.00
Total : 686.00 b) Optional PA Cover(Un Named Passenger) : 0.00
Add Extras: c) Optional PA Cover(Un Named Driver) : 0.00
Geographical Extension : 0.00 Legal Liability
ND Cover : 137.00 d) Legal Liability Cover (Paid Drivers, Cleaners) : 0.00
RTI Cover : 137.00 e) Legal Liability Cover (Other then Paid Drivers,
: 0.00
For any other extra : Cleaners)
Sub Total : 960.00 Total Liablity Premium (B) : 770.00
Less Discounts Total Premium (A + B) : 1730.00
Handicapped Discount : 0.00 For any other extra : 0.00
For anti-theft devices : 0.00 CGST @ 9.00% : 156.00
Any other discount : SGST @ 9.00% : 156.00
NCB : 0.00 Gross Premium : 2042.00

Total Deductions : 0.00

Net Own Damage Premium(A) : 960.00
1. Registration No. : 115 || 2. CIN No. : U67200MH2000PLC29408 || 3. ST No. : GIS / MUMBAI-I / 1528 / 2001 || GST No. : 27AAACI7351P1Z3
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

Corporate Agent: Hero Corporate Service Pvt. Ltd. From 1st July 2014, Insured is Liable for a
Received Vide voluntary deductible of Rs. 250/- for each
Premium of Rs. 2042.00
Cash/Cheque No. Claim,if policy having ND product.
Dated Nominee Name DHANANJAY The policy is subject to a compulsory excess of
Drawn on Nominee Age 53 Rs. 100/- & Depreciation is applicable as per
policy terms & conditions* (Please turn overleaf
for details)
Acknowledgement Dt 18-07-2017 Nominee Relation Husband Consolidted Stamp Duty Paid
Endorsements: IMT - 22

On behalf of ICICI Lombard General

Registration No: CA0034 Tel No: 1800-102-4376 Insurance Company Ltd
18-Jul-2017 FOR RENEWALS CONTACT: ADITYA AUTO AGENCIES Ph.No- 0712-2431794
Date & Signature of
proposer Yashwant Stadium,Dhantoli,Nagpur.

Dealer's Stamp & Signature Duly Constituted Attorney