TWO WHEELER VEHICLE PACKAGE POLICY Certificate Cum Policy Schedule Certificate cum Policy No :3005/W-2608465/00/000 For CLAIMS

: Call 1800-209-8888 (Toll free from all phones) For RENEWALS : Visit www.icicilombard.com or call 1800-209-8888
DETAILS OF THE POLICY HOLDER Insured Name HARSH PRIYA Insured Address ROOM NO 46,MBBS BOYS HOSTEL,HI TECH MEDICAL COLLEGE,PANDARA,BHUBANESWAR-751025 Contact No (s) Email Address 9439727310(Mobile No.) 91(Telephone No.) [email protected] POLICY DETAILS Policy Issuing Office Zenith House, Keshav Mumbai - 400034 Rao Khadye Marg, Mahalaxmi,

Period of Insurance Policy Issued On Cover Note No RTO Location Hypothecated to Category

From 00:00 :09-Apr-2011 to 08-Apr-2012 midnight 09-Apr-2011 00:00 W-2608465 ORISSA-BHUBANESWAR 0

VEHICLE DETAILS Registration Number OR02BE1187 Chassis Number Engine Number Make HONDA MOTORCYCLE Vehicle IDV (in Rs.) 49364 Side Car (in Rs.) 0 Model UNICORN Additional Acc (in Rs.) 0 Type of body Saloon Non-Electrical Acc.(in Rs.) 0 CC 150 Mfg. Year 2010 CNG / LPG Unit (in Rs.) 0 Seating capacity 2 Total Value (in Rs.) 49364

Elec/ Electronic Acc.(in Rs.) 0

ME4KC09CCA8000281 KC09E6000314 SCHEDULE OF PREMIUM (IN RS.) Own Damage(A)

Total Sub Total (Additions): Less Sub Total (Deductions) Bonus Percent 20 % Total Total Own Damage Premium Total package Premium(A+B) Service Tax(Incl Edu.Cess And Higher Edu.Cess)

Basic Own Damage

Liability (B) 580.00 Basic Third Party Liability 580.00 PA Cover for Owner-Driver of Rs. 1,00,000 0.00 Total Add 0.00 Unnamed PA cover for 2 persons of Rs.140.00 each 116.00 Sub Total (Additions) - 116.00 464.00 Total Liability Premium Total Premium Payable (in Rs.)

300.00 50.00 350.00

140.00
140.00 490.00 954.00 99.00 1,053.00

Geographical Area : India Compulsory deductibles : Rs. 50 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 (i) of the policy -> Damage to Third Party Property Rs 100,000; PA Cover for Owner-Driver under section III-CSI Rs 100,000 ;Voluntary Deductible 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 :-[Collection No/Amount/ReceiptDate] 0213551201/Rs.1053 / 17/03/2011 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 except for cash. If our representative request you to pay in cash, kindly report it to us. For information on ombudsman you may visit our website www.icicilombard.com I/We here by certify that the policy to which the certificate relates as well as the certificate of insurance are issued in For ICICI Lombard accordance with the provision of chapter X,XI of M.V Act 1988 General Insurance Service Tax Registration No. :GIS/ MUMBAI-I /1528 /2001, Service Tax Code Number.:AAACI7904GST001 Ltd Category: - General Insurance Business Services 00440005 In Witness whereof this policy has been signed at Mumbai this 9 day of April of 2011 in lieu of covernote No W-2608465 The stamp duty of Rs. 0.5 paid in cash or by demand draft or by pay order,vide Receipt/Challan no. 30155 dated 14/12/2009 Company

Duly Constituted Attorney(s) Copy of policy

ICICI Lombard General Insurance Company Ltd. Mailing Add. Office: ICICI Lombard General Insurance Company Ltd.Zenith House, Keshavrao Khadye Marg, 2nd Floor, Mahalaxmi, Mumbai - 400 034 Corporate Office: ICICI Lombard General Insurance Company Ltd.Zenith House, Keshavrao Khadye Marg, 2nd Floor, Mahalaxmi, Mumbai - 400 034

ICICI Lombard

Two Wheeler PA Proposal Form Vehicle details Registration location (RTO) Manufacturer Model Manufacturing year Color Current showroom price (Rs.) : BHUBANESWAR Registration number Engine number Chassis number Purchase / Registration date Registration type 61704 : OR02BE1187 : KC09E6000314 : ME4KC09CCA8000281 : 9/4/2010 : Individual

: HONDA MOTORCYCLE : UNICORN : : : 2010

Details of discounts & additional covers Electrical accessories (Rs.) Non-electrical accessories (Rs.) Automobile association membership Value of LPG / CNG kit if any (Rs.) Insured details Name of the Insured Address of Two Wheeler Owner (Policy will be sent here) Pincode New policy details Insurance value (IDV) (Rs.) : 49364 Policy start date : 09-Apr-2011 No Claim Bonus (%) Policy end date :0 : 08-Apr-2012 : HARSH PRIYA Relationship : : BHUBANESWAR :0 : : :0 0 Voluntary deductible (Rs.) ARAI approved anti-theft device : : No

: HI-TECH MEDICAL COLLEGE CAMPUS,PANDARA,RASULGARH City : 751010

Total Premium Amount : 1053

ICICI Lombard

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 provisions 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.200,000. Legal liability towards the paid driver. Cover for Rs. 7.5 Lacs third party property damage. PA cover for Un-named passengers. Significant Exclusions: We would like you to know that the policy does not cover consequential loss, depreciation, 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 unauthorized driver. Note: The foregoing is only an indication of the cover offered. For details please refer to the policy. It is our endeavor to provide consistent quality service to all our customers. We would like to let you know that insurance is a contract of Utmost Good Faith requiring the customer to disclose all material facts. If in your opinion any fact is material and is not covered by the information sought in the application form, we request you to disclose it. It is important to note that our liability will commence only after we have accepted your proposal and the premium has been received in full.
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Declaration: 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 no material information, which may be relevant, has been withheld or not disclosed 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/We agree that the Policy shall become void able 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 withheld by me or anyone acting on my behalf to obtain any benefit under this policy. 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. INSURANCE ACT 1938, SECTION 41 - PROHIBITION OF REBATES 1. 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 or 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 prospectus or tables of the Insurer. 2. Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to five hundred rupees. SCHEDULE OF DEPRECIATION FOR ARRIVING AT IDV AGE OF THE VEHICLE % OF DEPRECIATION FOR FIXING IDV Not exceeding 6 months 5% Exceeding 6 months but not exceeding 1 year 15% Exceeding 1 year but not exceeding 2 years 20% Exceeding 2 years but not exceeding 3 years 30% Exceeding 3 years but not exceeding 4 years 40% Exceeding 4 years but not exceeding 5 years 50% Note. IDV of obsolete models of vehicles (ie. Models which the manufacturers have discontinued to manufacture) and vehicles beyond 5 years of age will be determined on the basis of and understanding understanding between the insurer and the insured.