Registration Number Make Model Type of body CC Mfg.

Year Seating Capacity Chassis Number Engine Number

D!S"#$%&' ()ND" M)T)RCYCE "CT*+". Solo ,ith #illion -.! $.-& $ %$%!%-/ %.$%%/%0
+ehicle *D+ 1in Rs.2 Side Car NonElectrical "cc 1in Rs.2 Elec3Electronic "cc 1in Rs.2 CN4 3 #4 5nit 1in Rs.2 Total +alue 1in Rs.2
&00/' . . . . &00/'
Own Damage(A)
6asic #remium '7$
Tota l : 452
Add
Less
Deduct $. 8 for NC6 !.
Tota l : 90
Liability(B)
6asic #remium including premium for T##D 9ehicle '/'
Tota l : 464
Add
#" co9er for ):ner Dri9er 7.
#" co9er for 5nnamed #assenger -'.
Sb Total(Additions) : -!.
Less
Sb Total(Ded!tions) : 0
Total Own Damage "#emim $62 Total Liability "#emim 654
T,) ,(EEER +E(*CE #"C;"4E #)*CY
Certificate cum #olicy Schedule
Certificate cum #olicy No< &..73,$0!7$0/.3..3...
=or C"*MS < Call -%.. $/// 1Toll free from all phones2
=or RENE,"S < +isit :::.icicilombard.co m or call -%.. $///
D%TA&LS O' "OL&() *OLD%+ "OL&() D%TA&LS
*nsured Name >E=*N E"#EN
*nsured "ddress
&7-" ==?6 E 6)C; ("R* N"4"R ? NE,
DE(*? DE(*? --../'
(onta!t ,o- %$%7%7-/'!
%mail Add#ess
*C*C* ombard 4eneral *nsurance
"oli!y &ssing O..i!e
Company td.*C*C* ombard (ouse? '-'?
+eer Sa9arkar Marg? Near Siddhi +inayak
Temple? #rabhade9i? Mumbai '.. .$7
"e#iod o. &ns#an!e
=rom ..<..<.. hrs of -/>un$.-' to
Midnight of -7>un$.-7
"oli!y &ssing on -'>un$.-'
(o/e# ,ote ,o , $0!7$0/.
+TO Lo!ation NE, DE(*
*y0ot1e!ated to N3"
Ty0e o. Ag#eement None
2%*&(L% D%TA&LS
&,S3+%D D%(LA+%D 2AL3%
S(*%D3L% O' "+%4&34(&, +S-)
Total "a!5age "#emim ( A 6 B ) 7076
Se#/i!e Ta8(&n!l %d-(ess And *ig1e# %d-(ess) 726
Total "#emim "ayable(in +s-) 7742
(om0lso#y ded!tibles : +s- 7009
:eog#a01i!al A#ea : &ndia
L&4&TS O' L&AB&L&T): 1a2 5nder Section ** - 1i2 of the policy @ Death of or bodily inAury < Such amount as is necessary to meet there
reBuirements of the motor 9ehicles "ct.-!%%.
1b2 5nder Section ** - 1i2 of the policy @ Damage to Third #arty #roperty Rs -?..?... C #" Co9er for ):nerDri9er under section ***CS* Rs
-?..?...
L&4&TAT&O,S AS TO 3S%: The policy co9ers use of the 9ehicle for any purpose other than < (ire or re:ard?Carriage of goods1other than samples
or personal luggage2? )rganiDed racing? #ace making? Speed testing?Reliability trials?"ny purpose in connection :ith Motor Trade.
D+&2%+;S (LA3S%S : "ny person including the insured < #ro9ided that a person dri9ing holds an effecti9e Dri9ing icense at the time of the
accident and is not disBualified from holding or obtaining such a license. #ro9ided also that the person holding an effecti9e earnerEs icense may
also dri9e the 9ehicle and that such a person satisfies the reBuirements of Rule & of the Central Motor +ehicles Rules? -!%!.
&4"O+TA,T ,OT&(% : The *nsured is not indemnified if the 9ehicle is used or dri9en other:ise than in accordance :ith this schedule. "ny payment
made by the company by reason of :ider terms appearing in the certificate in order to comply :ith the Motor +ehicle "ct?-!%% is reco9erable from
the insured. See the clause headed E"+)*D"NCE )= CERT"*N TERMS "ND R*4(T )= REC)+ERYE.=or legal interpretation? English 9ersion :ill hold
good.
Sb<e!t to &4T %ndo#sement ,os- = 4emo#andm 0#inted 1e#ein 9 atta!1ed 1e#eto : 22>76
"#emim (olle!tion Details <FCollection No3"mount3ReceiptDateG N"3Rs. --'$ 3 -'3./3$.-'
D&S(LA&4%+: #lease 9isit :::.icicilombard.co m for the policy :ordings for complete details on terms and conditions go9erning the co9erage and
NC6. This document is to be read :ith the policy :ordings.
:#ie/an!e (lase
=or resolution of any Buery or grie9ance? *nsured may contact the respecti9e branch office of the Company or may call toll free no.-%..$/// or may
approach us at the sub section H4rie9ance RedressalH on our :ebsite :::.icicilombard.co m 1Customer Support section2. (o:e9er? if the resolution
pro9ided by us is not satisfactory you may approach *nsurance Regulatory and De9elopment "uthority 1*RD"2 through the *ntegrated 4rie9ance
Management Section 1*4MS2 or *RD" 4rie9ance Call Centre1*4CC2 at their toll free no.-77$77. You may also approach *nsurance )mbudsman? subAect
to 9ested Aurisdiction? for the redressal of grie9ance. Details of *nsurance )mbudsman offices are a9ailable at *RD" :ebsite< :::.irdaindia.org?o r on
the CompanyEs :ebsite at :::.icicilombard.com.
"oli!y is /alid sb<e!t to #eali?ation o. !1e@e- Ae a!!e0t 0#emim only /ia legally #e!ogni?ed modes e8!e0t .o# !as1- &. o# #e0#esentati/e
#e@est yo to 0ay in !as1> 5indly #e0o#t it to s-
'o# in.o#mation on ombdsman yo may /isit o# website www-i!i!ilomba#d-!om
*3,e here by certify that the policy to :hich the certificate relates as :ell as the certificate of insurance
are issued in accordance :ith the pro9ision of chapter I?I* of M.+ "ct -!%%
Se#/i!e Ta8 +egist#ation ,o- ::&S9 434BA&& 9752B 92007
Se#/i!e Ta8 (ode ,mbe# :AAA(&C904:ST007
(atego#y: :ene#al &ns#an!e Bsiness Se#/i!es 00440005-
*n ,itness :hereof this policy has been signed at Mumbai this -/>un$.-' in lieu of co9ernote No ,
$0!7$0/. The stamp duty of Rs. ..7. paid in cash or by demand draft or by pay order?9ide
Receipt3Challan no. 70--/- dated .%May$.-'
=or *C*C* ombard 4eneral *nsurance
Company td
Duly Constituted "ttorney1s2
Mailing "dd. )ffice<
*C*C* ombard 4eneral *nsurance Company td.
Corporate )ffice<
*C*C* ombard 4eneral *nsurance Company td.*C*C* ombard (ouse?
'-'? +eer Sa9arkar Marg? Near Siddhi +inayak Temple? #rabhade9i?
Mumbai '.. .$7
*C*C* ombard 4eneral *nsurance Company td.*C*C* ombard (ouse?
'-'? +eer Sa9arkar Marg? Near Siddhi +inayak Temple? #rabhade9i?
Mumbai '.. .$7
T:o ,heeler #" "#o0osal 'o#m
+ehicle Details
Registration location 1RT)2 NE, DE(* Registration number D!S"#$%&'
Manufacturer ()ND" M)T)RCYCE Engine number %.$%%/%0
Model "CT*+". Chassis number %$%!%-/
Manufacturing year $.-& #urchase 3 Registration date -/>un$.-&
Color Registration type *ndi9idual
Current sho:room price 1Rs.2 '0$.7
Electrical accessories 1Rs.2 . +oluntary deductible 1Rs.2 .
Nonelectrical accessories1Rs.2 . "R"* appro9ed antitheft de9ice No
"utomobile association membership Consumables No
+alue of #4 3 CN4 kit if any 1Rs.2 . Return to in9oice co9er No
No claim bonus protection co9er No
4arage cash co9er No
Name of the *nsured >E=*N E"#EN Relationship .
"ddress of T:o ,heeler ):ner 1#olicy :ill
be sent here2
&7-" ==?6 E 6)C; ("R*
N"4"R
City NE, DE(*
#incode --../'
*nsurance 9alue 1*D+2 1Rs.2 &00/' No Claim 6onus 182 $.
#olicy start date -/>un$.-' -$<..<.. #olicy end date Midnight of -7>un$.-7
Total "#emim Amont : --'$
*. ):n Damage
This product protects you against loss or damage to your motor 9ehicle and3or accessories due to J=ire JSelf *gnition JEKplosion Jightning JTheft
J 6urglary J(ousebreaking JRiot JStrike JEarthBuake J=lood and allied perils J"ccidental eKternal means JMalicious acts JTerrorist acti9ity JTransit
Jandslide 3 rockslide
**. Third #arty iability
*n addition to the co9erage noted abo9e? this product co9ers you against legal liability to:ards third party? in respect of the follo:ing< JDeath of or
bodily inAury to any person Jdamage to property as per the pro9isions of Motor +ehicle "ct. ,e are pleased to inform you that in addition? the
product also includes the follo:ing<
l #ersonal accident benefits for o:ner dri9er upto a 9alue of Rs.$..?....
l egal liability to:ards the paid dri9er.
l Co9er for Rs. 0.7 acs third party property damage.
l #" co9er for 5nnamed passengers.
Signi.i!ant %8!lsions:
,e :ould like you to kno: that the policy does not co9er conseBuential loss? depreciation? normal :ear and tear? mechanical or electrical
breakdo:n failures or breakages. The 9ehicle is not held co9ered if used for commercial purposes or if dri9en by an unauthoriDed dri9er. Note< The
foregoing is only an indication of the co9er offered. =or details please refer to the policy. *t is our endea9or to pro9ide consistent Buality ser9ice to
all our customers. ,e :ould like to let you kno: that insurance is a contract of 5tmost 4ood =aith reBuiring the customer to disclose all material
facts. *f in your opinion any fact is material and is not co9ered by the information sought in the application form? :e reBuest you to disclose it.
*t is important to note that our liability :ill commence only after :e ha9e accepted your proposal and the premium has been recei9ed in full.
De!la#ation:
*3,e hereby declare that the statements made by me3us in this #roposal =orm are true to the best of my3our kno:ledge and belief and no material
information? :hich may be rele9ant? has been :ithheld or not disclosed *3,e hereby agree that this declaration shall form the basis of the contract
bet:een me3us and the H*C*C* ombard 4eneral *nsurance Co. td.H
*3,e also declare that any additions or alterations are carried out after the submission of this proposal form then the same :ould be con9eyed to
the insurers immediately.
*3,e agree that the #olicy shall become 9oid able at the option of the *nsurer? in the e9ent of any untrue or incorrect statement? misrepresentation?
nondescription or nondisclosure in any material particular in the proposal form 3 personal statement? declaration and connected documents? or
any material information has been :ithheld by me or anyone acting on my behalf to obtain any benefit under this policy. *3,e hereby declare and
:arrant that the abo9e statements are true? accurate and complete. *3,e desire to effect an insurance as described herein :ith the Company and
*3,e agree that this proposal and declarations shall be the basis of contract bet:een me3us and the Company and *3,e agree to accept a policy
subAect to the conditions prescribed by the Company.
&,S3+A,(% A(T 79$B> S%(T&O, 47 "+O*&B&T&O, O' +%BAT%S
-. No person shall allo: or offer to allo:? either directly or indirectly as an inducement to any person to take out or rene: or continue an insurance
in respect of any kind or risk relating to li9es or property in *ndia? any rebate of the :hole or part of the commission payable or any rebate of the
premium sho:n on the policy? nor shall any person taking out or rene:ing or continuing a policy accept any rebate eKcept such rebate as may be
allo:ed in accordance :ith the prospectus or tables of the *nsurer.
$. "ny person making default in complying :ith the pro9isions of this section shall be punishable :ith fine? :hich may eKtend to fi9e hundred
rupees.
S(*%D3L% O' D%"+%(&AT&O, 'O+ A++&2&,: AT &D2
"4E )= T(E +E(*CE 8 )= DE#REC*"T*)N =)R =*I*N4 *D+
Not eKceeding / months 78
EKceeding / months but not eKceeding -
year
-78
EKceeding - year but not eKceeding $ years $.8
EKceeding $ years but not eKceeding &
years
&.8
EKceeding & years but not eKceeding '
years
'.8
EKceeding ' years but not eKceeding 7
years
7.8
Note. *D+ of obsolete models of 9ehicles 1ie. Models :hich the manufacturers ha9e discontinued to manufacture2 and 9ehicles beyond 7 years of
age :ill be determined on the basis of and understanding understanding bet:een the insurer and the insured.