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ICICI Lombard General Insurance Company Limited

Chamber I, Fourth Floor, Eldeco Corporate, Gomti Nagar, Lucknow, Uttar Pradesh 226024
Servicing Branch GSTIN Number. : 09AAACI7904G1ZL , PAN No. : AAACI7904G
IRDA Regn. No. : 115

PROPOSAL DETAILS
PROPOSAL NUMBER AND DATE PERIOD OF OWN DAMAGE(OD) COVER PREIOD OF LIABILITY(TP) COVER
P14000781 & 01-Dec-2021 02-Jan-2022 To 01-Jan-2023 02-Jan-2022 To 01-Jan-2023
PREVIOUS POLICY DETAILS
OD POLICY INSURER OD POLICY NUMBER PERIOD OF OD POLICY TP POLICY INSURER TP POLICY NUMBER PERIOD OF TP POLICY
02-Jan-2021 To 01-Jan-
ILG TIL/10717800 02-Jan-2021 To 01-Jan-2022 ILG TIL/10717800
2022

INSURED DETAILS Individual

DRIVER LICENSE
NAME GSTIN PANCARD NUMBER UIN
NUMBER
Mr. ABRAR AHMAD AHTPA9832E 0 .
ADDRESS DATE OF BIRTH
O-84, F/F, WELCOME SEELAMPUR-3 SEELAMPUR DELHI DELHI 110053 10-Jan-1979
NOMINEE
NOMINEE NAME NOMINEE AGE MOBILE NUMBER EMAIL ID
RELATIONSHIP
Mrs. ANJUM KHAN 36 SPOUSE 9891777228 [email protected]

VEHICLE DETAILS
YEAR OF
VARIANT MAKE / MODEL CHASSIS NUMBER ENGINE NUMBER
MANUFACTURE
TOYOTA FORTUNER 2WD 2.8L MT. Toyota / FORTUNER MBJGA3GS800376443 1GDA149614 2017
HYPOTHECATION / LEASE INVOICE DATE CUBIC CAPACITY SEATING CAPACITY FUEL TYPE
AXIS BANK LTD. / DELHI 02-Jan-2018 2755 7 DIESEL
REGISTRATION
GEOGRAPHICAL AREA EXTN. GEOGRAPHICAL AREA RTO CITY VEHICLE USAGE
NUMBER
NA India DELHI DL-1C-X-8475 Private

INSURED DECLARED VALUE (Rs.)

NON ELECTRICAL ELECTRICAL
VEHICLE CNG / LPG TOTAL
ACCESSORIES ACCESSORIES
1414501 0 0 0 1414501

PREMIUM CALCULATION
A. OWN DAMAGE (OD) SECTION Amount (Rs.) B. LIABILITY (TP) SECTION Amount (Rs.)
BASIC PREMIUM BASIC PREMIUM
THIRD PARTY LIABILITY ( INCLUDING
VEHICLE 38928 7890
TPPD )
NON ELECTRICAL ACCESSORIES (IMT-24) 0 GEOGRAPHICAL AREA EXT. ( IMT-1 ) 0
ELECTRICAL ACCESSORIES (IMT-24) 0 BI FUEL KIT 0
BI FUEL KIT (IMT-25) 0 SUB TOTAL (THIRD PARTY LIABILITY) 7890
SUB TOTAL (BASIC PREMIUM) 38928 PERSONAL ACCIDENT (PA) COVER
COMPULSORY PA COVER FOR OWNER
GEOGRAPHICAL AREA EXT (IMT-1) 0 325
DRIVER (IMT-15) Rs. 15 LAC
PA COVER FOR PAID DRIVER (IMT-17) Rs. 2
IMT 23 0 0
LAC
PA COVER (100000 FOR 7 UNNAMED
SUB TOTAL 38928 350
PERSONS) (IMT-16)
DISCOUNTS SUB TOTAL (PA COVER) 675
VOLUNTARY DEDUCTIBLE (IMT-22A) 0 LEGAL LIABILITY
ANTI THEFT DEVICE (IMT-10) 500 PAID DRIVER (IMT-28) 50
AA MEMBERSHIP (IMT-8) 0 EMPLOYEE (FOR 0 PERSON) (IMT-29)
NON-FARE PAYING 0 PASSENGER (IMT-
HANDICAPPED DISCOUNT (IMT-12) 0
37)
UNNAMED 0 PASSENGER ON
NCB (20%) 7786 0
AMBULANCE/HEARSES (IMT- 46)
SUB TOTAL (DISCOUNTS) 8286 SUB TOTAL (LEGAL LIABILITY) 50
NET LIABILITY PREMIUM (B) 8615
ADD-ONS 33492 TOTAL PREMIUM (A+B) 72749
CGST (0%) 0
THEFT AND CONVERSION RISK (IMT-43) 0 SGST (0%) 0
INDEMNITY TO HIRER (IMT-44) 0 IGST (18%) 13095
UTGST (0%) 0
NET OWN DAMAGE PREMIUM (A) 64134 GROSS PREMIUM PAID 85844

ADD-ON COVERS OPTED IN THE PROPOSAL

CONSUMABLES NIL DEPRECIATION ENGINE PROTECT
RETURN TO INVOICE - KEY PROTECT
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http://toyota.ttibi.co.in/LV/Policy/VSProposalPreviewFW.aspx 01-12-2021