ICICI Lombard General Insurance Company Limited
Plot No 10 Second Floor, Alankar Palace, MP Nagar, Zone II, Bhopal, Madhya Pradesh - 462011
Servicing Branch GSTIN Number. : 23AAACI7904G1ZV , PAN No. : AAACI7904G
IRDA Regn. No. : 115
PROPOSAL DETAILS
PROPOSAL NUMBER AND DATE PERIOD OF OWN DAMAGE(OD) COVER PERIOD OF LIABILITY(TP) COVER
P31560753 & 17-May-2025 23-May-2025 To 22-May-2026 To
PREVIOUS POLICY DETAILS
PERIOD OF OD TP POLICY
OD POLICY INSURER OD POLICY NUMBER TP POLICY INSURER PERIOD OF TP POLICY
POLICY NUMBER
23-May-2024 To 22-May- 23-May-2023 To 22-May-
ITG TIT/92404909 ITG TIT/92301975
2025 2026
INSURED DETAILS Individual
PAY AS YOU DRIVE /
NAME GSTIN PANCARD NUMBER UIN
USE
Mr. MANOJ BANSAL AHGPB3017P 0 0 KM
ADDRESS DATE OF BIRTH
S/O OM PRAKASH BANSAL BHIND DR LUMBA JATAV MOHALLA HOSPITAL ROAD, LASHKAR, LASHKAR CITY,, GWALIOR
15-Jun-1975
MADHYA PRADESH 474009
NOMINEE
NOMINEE NAME NOMINEE AGE MOBILE NUMBER EMAIL ID
RELATIONSHIP
Mrs. RADHA BANSAL 47 SPOUSE 9827669227 BANTI21JK@GMAIL.COM
VEHICLE DETAILS
YEAR OF
VARIANT MAKE / MODEL CHASSIS NUMBER ENGINE NUMBER
MANUFACTURE
Toyota / URBAN
URBAN CRUISER HYRYDER E MT D22AH MBJUYML1SPE106138 K15CN7137552 2023
CRUISER HYRYDER
SEATING
HYPOTHECATION / LEASE INVOICE DATE CC/KW/GVW FUEL TYPE
CAPACITY
-- / - 23-May-2023 1462 5 PETROL
REGISTRATION
GEOGRAPHICAL AREA EXTN. GEOGRAPHICAL AREA RTO CITY VEHICLE USAGE
NUMBER
NA India GWALIOR MP-07-ZG-0766 Private
INSURED DECLARED VALUE (Rs.)
NON ELECTRICAL ELECTRICAL CNG /
AGE VEHICLE BODY TOTAL
ACCESSORIES ACCESSORIES LPG
2 760200 0 70 0 0 760270
PREMIUM CALCULATION
A. OWN DAMAGE (OD) SECTION Amount (Rs.) B. LIABILITY (TP) SECTION Amount (Rs.)
BASIC PREMIUM BASIC PREMIUM
VEHICLE 4852 THIRD PARTY LIABILITY ( INCLUDING TPPD ) 0
NON ELECTRICAL ACCESSORIES 3 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) 0
BODY PREMIUM 0
SUB TOTAL (BASIC PREMIUM) 4855 PERSONAL ACCIDENT (PA) COVER
COMPULSORY PA COVER FOR OWNER DRIVER (IMT-
GEOGRAPHICAL AREA EXT (IMT-1) 0 0
15) Rs. 15 LAC
IMT 23 0 PA COVER FOR PAID DRIVER (IMT-17) Rs. 2 LAC 0
PA COVER (200000 FOR 5 UNNAMED PERSONS) (IMT-
SUB TOTAL 4855 0
16)
DISCOUNTS SUB TOTAL (PA COVER) 0
VOLUNTARY DEDUCTIBLE (IMT-22A) 0 LEGAL LIABILITY
ANTI THEFT DEVICE (IMT-10) 0 PAID DRIVER (IMT-28) 0
AA MEMBERSHIP (IMT-8) 0 EMPLOYEE (FOR 5 PERSON) (IMT-29) 0
HANDICAPPED DISCOUNT (IMT-12) 0 NON-FARE PAYING 0 PASSENGER (IMT-37) 0
UNNAMED 0 PASSENGER ON AMBULANCE/HEARSES
NCB (25%) 1214 0
(IMT- 46)
SUB TOTAL (DISCOUNTS) 1214 SUB TOTAL (LEGAL LIABILITY) 0
NET LIABILITY PREMIUM (B) 0
ADD-ONS 7984 TOTAL PREMIUM (A+B) 11625
THEFT AND CONVERSION RISK (IMT-43) 0 CGST (9%) 1046
INDEMNITY TO HIRER (IMT-44) 0 SGST (9%) 1046
PAY AS YOU DRIVE / USE DISCOUNT 0
NET OWN DAMAGE PREMIUM (A) 11625 GROSS PREMIUM PAID 13717
ADD-ON COVERS OPTED IN THE PROPOSAL
CONSUMABLES NIL DEPRECIATION -
RETURN TO INVOICE - -
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Proposal Validty:This proposal is valid for only 7 days from the date of generation.
