ICICI Lombard General Insurance Company Limited

Servicing Office: CHAMBER I, FOURTH FLOOR, ELDECO CORPORATE, GOMTI NAGAR, LUCKNOW, UTTAR PRADESH 226024 ,
LUCKNOW, UTTAR PRADESH -226024
Proposal Form
PAN: AAACI7904G, GSTIN: 09AAACI7904G1ZL, CIN: U67200MH2000PLC129408, IRDAI Reg. No.: 115

Proposal No: HIIB14137275 Proposal Date: 24-Feb-2025 (15:00)

Proposer Name: MR. HEMANT GUPTA Previous Policy No: 3001/O/HY-18965180/00/000
Vehicle Class: PRIVATE Previous Insurer: ICICI Lombard General Insurance Company Limited.
Period of Own Damage: 27-FEB-2025 (00:00) To 26-FEB-2026 (1 YEAR)
MANKAPUR SHABTRI NAGAR MANKAPUR GONDA Period of Liability Cover: NA
Proposer Address: MANKAPUR BAZAR , GONDA, UTTAR PRADESH-
271302 Period of Compulsory
Personal Accident Cover: NA To NA
Proposer Type PAN GSTIN Name Age Relation
Proposer Details: Nominee Details
INDIVIDUAL NA NA NA 0 NA
Previous TP Details
TP Insurance Company Name: The New India Assurance Company Limited. TP Policy No: 11300031220950065648
TP Risk Inception Date: 27-Feb-2023 TP Risk Expiry Date: 26-Feb-2026
Vehicle Details
Make Model Variant Cubic Capacity Manufacturing Year Seating Capacity
HYUNDAI CRETA CRETA 1.5 MPI MT E 1497 2023 5
Registration Date Registration No. RTO Hypothecation/Lease* Engine No. VIN / Chassis No.
27-FEB-2023 UP-43-BA-8384 GONDA YES G4FLPV495047 MALPA812LPM467446
Invoice Value Vehicle IDV Elec. Accessories Non-Elec. Accessories BI Fuel Kit Total IDV
1084100 758870 0 0 0 758870
Schedule of Premium (Amount in Rs.)
Own Damage Premium (A) Amount Liability Premium (B) Amount
Basic Own Damage Premium Basic Third Party Liability 0
Vehicle 4844 Bi-Fuel Kit 0
Non-Elec. Accessories (IMT-24) 0 Geographical Area Extension (IMT-1) 0
Elec. Accessories (IMT-24) 0 Sub Total (Third Party Liability Premium) 0
Bi-Fuel Kit (IMT-25) 0 Personal Accident (PA) Cover
Sub Total (Basic Premium) 4844 Compulsory PA Cover for Owner Driver Rs.0 (IMT-15) 0
Geographical Area Extension (IMT-1) 0 PA Cover for (0) Unnamed Passengers Rs.0 Each (IMT-16) 0
IMT 23 Premium 0 PA Cover for Paid Driver Rs. 2 Lac (IMT-17) 0
Sub Total 4844 Sub Total PA Cover 0
Discounts/Deductibles Legal Liability
Voluntary Deductible (IMT-22A) (0) 0 Paid Driver (IMT-28) 0
Anti-Theft Device (IMT-10) 0 Employees(IMT-29) (for 0 persons) 0
AA Membership (IMT-8) 0 Sub Total (Legal Liability) 0
No Claim Bonus – (25%) 1211 Net liability Premium (B) 0
Handicapped Discount (IMT-12) 0 Total Premium (A+B) 10763
Sub Total (Discounts/Deductibles) 1211 CGST (9%) 969
Add-on Coverage (ZD,CM,EP,KP,PB) 7130 SGST (9%) 969
Net Own Damage Premium (A) 10763 Gross Premium Paid 12701
Add-on Cover Opted in the Policy: ZERO DEPRECIATION,CONSUMABLES,ENGINE PROTECT,KEY PROTECT,PERSONAL BELONGING.
SAC: 997134, Description of Service: Motor Vehicle Insurance Services, Place of Supply: UTTAR PRADESH (State Code: 09)
*Hypothecation Details: HDFC BANK LTD - GONDA - GONDA Payment Mode:ONLINE
Break in Insurance Declaration “I/We hereby Declare and Undertake

That, the vehicle proposed to be insured had, during the period in which it was not covered by valid and effective insurance policy issued by any insurer/s, had NOT met with any accident (*Select the appropriate
check box and provide relevant information against selected entry)

That, the vehicle proposed to be insured had, during the period in which it was not covered by valid and effective insurance policy issued by any insurer/s, met with an accident on DD/MM/YYYY at DD/MM/YYYY
Add more date/s with time if vehicle had met with an accident more than once)
I/we understand that all and/or any kind of liabilities arising out of accident/s which had occurred prior to risk inception date and time as mentioned in the Policy Document issued by ICICI Lombard General Insurance
Company Limited. in consideration of these presents will be completely out of ambit of said Policy and said Company will not be in any manner liable or held responsible, therefore.
I/we further undertake that if this declaration and/or any of its part is found to be incorrect in any manner, all the benefits under the Policy will then stand forfeited and the contract of insurance will be treated as void
ab-initio”.
NCB Declaration I / We declare that the rate of NCB claimed by me/us is correct and that no claim has arisen in the expiring policy period (copy of the policy enclosed) I/We further undertake that if this declaration is
found to be incorrect, all benefits under policy respect of Section I of the policy will be forfeited.
Declaration “I am/we are aware that the complete terms and conditions of this insurance policy are available at the official website of the insurer [Link] I/We hereby consent to receive only the
certificate and schedule of insurance upon undertaking of the insurer that the complete policy terms & conditions will be made available free of cost upon my/our request”. I hereby declare and confirm that the PUC
certificate of the vehicle proposed for insurance is valid as on date. I hereby declare and confirm that the Fastage of the vehicle proposed for insurance is affix as on date.
Any other Material Information Declaration and Consent I/We hereby declare that the statements, answers given by me /us in this proposal form are true to the best of my knowledge and belief and I/We hereby
agree that this declaration shall form the basis of the contract between me/us and the It is hereby understood and agreed that all statements, details and particulars provided herein above are the basis on which this
Insurance is being granted and that if, after the insurance is affected, it is found that any of the statements, answers or particulars are incorrect or untrue in any respect, the company shall have no liability under this
Insurance. I/We agree and undertake to convey to any change / alterations carried out in the risk proposed for insurance after submission of this proposal form. “I/We have insurable interest in the subject matter of
this insurance, and we hereby declare that the Cost of the same and the premium for this insurance is paid from legal sources of funds. I, the undersigned proposer hereby declares and confirm that I have
understood the features, terms and conditions of the policy and details asked contained in the proposal form. I also understand that the reply to the details asked in the proposal form, forms the basis of the contract of
insurance. If any information/statement given in proposal is found to be untrue, the policy shall be treated as void ab initio and the premium paid shall be forfeited to the Company. Please give details if you are
politically exposed person or relative of politically exposed person. ------------------------------------------------------------ Please give details if you are no profit organization. ----------------------------------------------

I hereby agree to receive a one pager policy document I hereby confirm having a valid personal accident policy for sum Insured of minimum Rs.15 lakhs.
I hereby confirm that I have mandated Hyundai India Insurance Broking [Link]. to place my insurance risk and have read and agreed on the terms and conditions.

Insurance Broker Name: Hyundai India Insurance Broking Pvt. Ltd. Proposer Signature & Date:
Corporate Office: 16th Floor, Building No. 9A, DLF Cybercity, Phase III, Gurugram, Haryana 122001
Broker Code: 822 (Valid UPTO:30/05/2025) MISP NAME: GEETA AUTO SALES Proposal Form Created by:
CIN: U67200HR2021PTC098982 MISP CODE: HIIB-MHY-0246
GST: 06AAGCH0310P1ZP Designated Person NAME : Sakshi Kumari MISP Authorised Signatory
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 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 published prospectuses or tables of the Insurer 2) Any person making default in complying with the provisions of this section shall be liable for a penalty, which may extend to
ten lakh
Disclaimer: This Proposal is valid for today only. Price may vary subject to Terms & Conditions of Insurance Company at the time of policy issuance.