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Form 52 (See Rule 142 (1) of Central Motor Vehicle Rules, 1989) 

Toll Free no: 1800 209 8888TWO WHEELER - INSURANCE COVER NOTE

Cover Note No. : e-52339104

The insured, described in Form ‘52’ referred to below; having proposed for insurance in respectof Motor Vehicle (s) described therein and having paid the sum of Rs. 713.00/- as premium, therisk is hereby held covered under the terms of the Company’s usual form of Package policyapplicable thereto (subject to any Special Condition mentioned below) unless the cover be

terminated by the Company by notice in writing in which case the insurance will thereuponcease and a proportionate part of the premium otherwise payable for such insurance shall becharged for the time the Company had been at risk.

The Cover note wordings provided on theother side constitute the legal documentwith regard to the coverage. In order tohelp you understand the cover note better,

we are providing you with thiscommentary. The explanation,interpretation, commentary provided hereshall not be construed as part of the CoverNote attached alongside. We are not liableby any interpretation in this commentaryand the contract is restricted to thewordings provided alongside. For anyfurther clarifications, please contact ourCall Centres.As per your declaration in theproposal form with reference to yourvehicle described below and the premiumpaid by you, we are commencing aninsurance cover for your vehicle underTwo Wheeler Package Policy from the

date and time mentioned below (subject tospecial conditions described below, if applicable). The cover would be providedfor the duration described below unlessdue to some circumstances, we have tocancel the policy. In such a case, wewould send you a written notice andcancel the policy by proportionatelyrefunding premium to you for theunexpired period of cover.

Make & Reg. No.of the Vehicle

Year of Mfg.

CubicCapacityGrossVehicleWeight(GVW)(GoodCarryingVehicle)

LicensedCarryingCapacity(LCC)(PassengerCarryingVehicle)

Insured’s Declared Value(IDV)

For VehicleRs.

AccessoriesnotincludedinMfr’slistedsellingpriceRs.

SCOOTY PEPPLUS ,TVS,KA-03-EW-9897

2006 2 16,635.00 0

Engine No. : 01639 Chassis No.: 01186 N.B. In the event of an accident,theInsured should inform Company toarrange spot survey.The details of yourvehicle are as described alongside.

Additional Risks, if any : PA Cover for Owner-DriverSpecial Conditions :Hypothecated To : ,

Special conditions if applicable to yourpolicy are as described here.

1. Registration mark and number ordescription of thevehicle insured

KA-03-EW-9897 This represents your vehicle, for which we are providingthis insurance cover

2. Name and addressof insured

Mr. ANAND SUBRAMANIYAMA104 HABITAT SPLENDOUR, ITPL MAIN ROAD,KUNDALAHALLI, BANGALORE KUNDALAHALLI -BANGALORE KARNATAKA 560037,

Your name and address as mentioned by you in theproposal form

3. Effective date andtime of 

commencement of insurance for thepurpose of this Act

Time : 11:12:0Date :26-8-2010

The date and time of the commencement of thisinsurance cover.

4. Date of expiry of insurance

Midnight of 25-8-2011 The date and time of the expiry of this insurance cover.

5. Persons or classes of persons entitled todrive

Any person including the insured:Provided that a persondriving holds an effective Driving Licence at the time of the accident and is not disqualified from holding orobtaining such a licence. Provided also that the personholding an effective Learner’s Licence may also drive thevehicle and such a person satisfies the requirements of Rule3 of the Central Motor Vehicles Rules, 1989.

For the cover to be valid, the driver of your vehicle musthave a valid license.It also becomes void if the driver of your vehicle, at the time of accident was disqualifiedfrom holding or obtaining a driver’s license.This coveralso allows a driver of your vehicle holding a learner’slicense provided that such a driver satisfies therequirements of Central Motor Vehicle Rules asprescribed by the government.

6. Any limitations asto use of motor vehicle

The Policy covers use for any purpose other than (a)Hire orreward(b) Carriage of goods (other than samples or

personal luggage)(c) Organised racing (d) Pace making (e)Speed testing (f) Reliability trials (g) Any purpose inconnection with Motor Trade

This insurance cover is not valid if your vehicle is usedfor the purpose of (a)Hire or reward(b)Carriage of goods

(other than samples or personal luggage)(c) Organisedracing (d)Pace making (e) Speed testing (f) ReliabilityTrials (g) Any purpose in connection with Motor Trade

7. The period of validity of this covernote will expire on

25-Sep-2010 The validity of this Cover Note is till the date mentioned

I/We hereby certify that this Cover Note is issued in accordance with the provisions of Chapter XI of the Motor Vehicles Act, 1988.

It brings us pleasure in announcing that our operations function has been ISO 9001:2000 certified with effect from 7th September 2004. Thecertifying agency was Det Norske Veritas (DNV). This would mean that we would meet the service related promises that we make to ourcustomers.

Date of issue : 26-Aug-2010Time of issue : 11:12:0

For ICICI LOMBARD GENERALINSURANCE CO. LTD

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In the event of dishonour of cheque, insurance cover provided under this document automatically stands cancelled Ab-initio. The company isunder no obligation to send separate communication informing the said dishonour of cheque.Track your status online at www.icicilombard.com

Ahmedabad : 079-55309877 Andhra P'desh : 984957 7877 Bangalore : 080-5118 7464 Calcutta : 983137 7877 Chandigarh : 0172-505 5707

Chennai : 044-4201 7877Coimbatore : 0422-538 7877 Delhi : 0981817 7877 Gujarat : 989827 7877 Hyderabad : 040-23128511 Indore : 0731-502 7877 Karnataka :984557 7877Kerala : 989547 7877 Kochin : 0484-2384511 Lucknow : 0522-2294511M.P. : 989304 7877Maharashtra : 989001 7877 Mumbai : 022-28307711 Pune : 020- 26103511 Rajasthan : 9829796547 Tamil Nadu :989447 7877

ICICI Lombard General Insurance Company LimitedRegd. Office: ICICI Bank Towers, Bandra-Kurla Complex, Bandra (East), Mumbai - 400 051

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