Proposal Form No.

________________

ICICI LOMBARD GENERAL INSURANCE COMPANY LTD

Registered Office Address: ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.
Visit us at www.icicilombard.com • Mail us at [email protected] • Our toll free number is 1800 2666.
Insurance underwritten by ICICI Lombard General Insurance Company Limited. Insurance is the subject matter of solicitation. CIN: L67200MH2000PLC129408. IRDA Reg. No. 115.
PLEASE WRITE IN BLOCK LETTERS MOTOR PACKAGE PROPOSAL FORM STAND-ALONE OWN DAMAGE PROPOSAL FORM
Product Two Wheeler Vehicle Package Policy Stand-Alone Own Damage Two wheeler Insurance Policy Private Car package policy Bundled - Private Car Policy
UIN IRDAN115RP0015V05201415 IRDAN115RP0002V02201920 IRDAN115RP0017V01200102 IRDAN115RP0021V02202122
Product 5 Years - Two Wheeler Package Policy 2 Years - StandAlone Own Damage Two Wheeler Insurance Policy 3 years - Private Car Package Policy Goods Carrying Vehicle Package Policy
UIN IRDAN115RPMT0004V01202425 IRDAN115RPMT0006V01202425 IRDAN115RPMT0003V01202425 IRDAN115RP0013V01200203
Product Bundled - Two wheeler Policy 3 Years - StandAlone Own Damage Two Wheeler Insurance Policy Stand-Alone Own Damage Private Car Insurance Policy Passenger Carrying Vehicle Package Policy
UIN IRDAN115RP0019V01202122 IRDAN115RPMT0007V01202425 IRDAN115RP0001V02201920 IRDAN115RP0014V01200203
Product Long term Two Wheeler Package Policy 4 Years - StandAlone Own Damage Two Wheeler Insurance Policy 2 Years - StandAlone Own Damage Private Car Insurance Policy Miscellaneous Vehicle Package Policy
UIN IRDAN115RP0015V05201415 IRDAN115RPMT0008V01202425 IRDAN115RPMT0005V01202425 IRDAN115RP0015V01200203
Product Motor trade road risk package policy Motor Trade Internal Risk Package Policy Motor trade road transit risk package policy Trailer package policy
UIN IRDAN115RP0002V01200203 IRDAN115RP0001V01200203 IRDAN115RP0008V01202223 IRDAN115RP0006V01202223
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 Act • 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) • Personal accident benefits (Death or Bodily injury) in respect of owner driver only/ any person other than paid drivers.
Coverage required for : Pvt Car Two Wheeler PCV GCV Misc D Type of Policy: New Roll Over Renewal Used Endorsement

Year of Cubic Seating Date of

Make of Vehicle Model of Vehicle Capacity (CC) Capacity Insured's Declared Value (IDV) Registration
Manufacture
`

Premium: ` GVW kg R.T.O. Authority

Body Price: (if applicable) ` Chassis Price: (if applicable) Value of Non Electrical Accessories, if any (Please attach bills)

Value of Non Conventional source of Power (CNG/LPG) if any ` Value of Electrical Accessories, if any (Please attach bills)

Engine No.: Side Cars (Two Wheeler)

Chassis No.: _____________________________ Value of Trailer, if any ` ____________________________ Date of Purchase of Vehicle:
Additional Risks, if any: _____________________ Trailer Chassis No.: _______________________________ Seating Capacity for PCV: Type of Body: ____________________________
Deal No.: ________________________________ Vehicle Usage: __________________________________ Vehicle Driven By: ___________________________ Area of Operation: _________________________
Vehicle sub-class: __________________________ Policy Class: ____________________________________
Fuel Type: Diesel Petrol CNG LPG Hybrid Electric • Colour of the Vehicle : _______________________ • Colour Finish : Metallic Non-Metallic
Your policy will be dispatched to the below mentioned correspondence address.

(Use Block Letters) Form 52 (India) (See Rule 142 (i) of Central Motor Vehicle Rules 1989)
1. Registration mark, number and description of the vehicle insured
CORRESPONDENCE ADDRESS (Where the vehicle is normally kept) PERMANENT ADDRESS / GST REGISTERED ADDRESS
2. Name:
Flat/Building:
Street/Road/Sector:
Area/Village/Taluka:
Landmark:
City: Pincode: City: Pincode:
State: State:
Mobile Telephone: Email:

For Non-Individual – Other details (Authorised Signatory)

Name: __________________________________________________________________________________________________________________________________________________________________
Current residential address: __________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________
Any officially valid document containing photographs of Authorized Signatory: _____________________________________________________________________________________________________________

For Non-Individual – Details of Beneficial Owner

Mention the details of individual persons who has/have the Beneficial Ownership in the captioned entity:

Nationality % share holding Politically Exposed Person

Full Name Date of birth Address PAN (PED) Declaration
PEP Family member/
Close relatives/
No Associates to PEP

PEP Family member/

Close relatives/
No Associates to PEP

3. Are you or any of the proposed applicants a PEP* or Family member/ Close relatives/Associates of PEPs*? Yes No
If yes, please give details (Nature of relationship and position held by PEP): _______________________________________________________________________________________________________________
“*Politically Exposed Persons” (PEPs) are individuals who have been entrusted with prominent public functions by a foreign country, including the heads of States or Governments, senior politicians, senior government or judicial
or military officers, senior executives of state-owned corporations and important political party officials.
4. GSTIN (If customer is registered for GST): 5. Date of Incorporation 6. Place of Incorporation
7. PAN No. 8. Date of Birth 9. Sex : M F T
10. CKYC No 11. CIN 12. PAN of POS
13. Voter ID 14. Passport no 15. Driving license
16. DARPAN Portal Reg No.:
17. Effective date & time of commencement of insurance for the purpose of the Act. Tenure- Own Damage ______ Period of Insurance: Own Damage TO
In case of long term Policy Tenure: (Only Two Wheeler Policy) 2 years 3years Tenure- Third Party________ Period of Insurance: Third Party TO
Endorsement Effective date (only for endorsements) Date:
18. Mandatory Third Party Details for Stand-Alone Own Damage Insurance Policy (Applicable only for Stand-Alone products)
Third Party Policy Number __________________ Third Party Start Date Third Party Insurer Name ___________________ Third Party End Date

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19. Compulsory Personal Accident (PA) Cover for owner-driver Tenure: _____ TO
I hereby declare that the owner driver does not require Compulsory Personal Accident cover as:
Owner driver has a separate existing Personal Accident cover against Death and Permanent Disability (Total and Partial) for Sum Insured of at least ` 15 lacs.
The owner does not have a valid driving license. The vehicle to be insured is not owned by an individual.
Personal Accident Cover for driver is compulsory for Sum Insured for 15,00,000 for Two Wheeler, Private Cars and Commercial Vehicles. Cars and Commercial Vehicles. Compulsory PA cover to owner-driver cannot be granted
where a vehicle is owned by a company, a partnership firm or a similar body corporate or where the owner driver does not hold an effective driving license.
Nominee Details
1st Nominee 2nd Nominee 3rd Nominee 4th Nominee
Nominee Name and Relationship
Date of birth of nominee DD/MM/YY DD/MM/YY DD/MM/YY DD/MM/YY
Percentage of nomination (%) (%) (%) (%)
Mobile no. of nominee
Email id of nominee
Present and Permanent address
of Nominee
Bank Account Details:
Beneficiary Name:
Bank Name:
Bank Account Number:
IFSC CODE
MICR NUMBER
BRANCH
Appointee details: Please write the Appointee name also in case the nominee is a minor . * Please provide the details of the guardian in case of nominee is a minor
1st Appointee 2nd Appointee 3rd Appointee 4th Appointee
Appointee Name and Relationship
Date of birth of Appointee DD/MM/YY DD/MM/YY DD/MM/YY DD/MM/YY
Mobile no. of Appointee
Email id of Appointee
Present and Permanent address
of Appointee
Bank Account Details:
Beneficiary Name:
Bank Name:
Bank Account Number:
IFSC CODE
MICR NUMBER
BRANCH

Source of Funds
Salary Business Others (In case of others, please specify: __________________________________________.
I/We hereby declare and confirm that the premium has been paid out of legally acquired sources of income and the subsequent premiums if any, will continue to be paid out of legally declared and assessed source of income.
Is the vehicle proposed for insurance under: Hire-Purchase Lease Agreement Hypothecation Agreement None of the above LAN No.: _______________________________
Name and address of the financier

Significant Exclusion
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. For private car/two wheeler, the vehicle is not held covered if
used for commercial purpose or if driven by an unauthorised driver. Note: The foregoing is only an indication of the cover offered. For details, please refer to the policy. It is our endeavour to provide consistent quality service to all our
customers. To enable us to deliver our promise, we would appreciate if you take some of your precious time to answer all questions fully and correctly to the extent possible. We would like to let you know that insurance is a contract of
Utmost Good Faith requiring the customer to disclose all material facts without suppressing any vital information whether material, or otherwise. 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.

Declaration
I/We hereby agree that this declaration shall form the basis of the contract between me/us and "ICICI Lombard General Insurance Co. Ltd." I/We also declare that if 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 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. I/We agree to accept a policy subject to the conditions prescribed by the Company. I/We further undertake that if this declaration is found to be incorrect, all benefits under the policy in respect of the
Section I of the Policy will stand forfeited. The policy may however be continued at the sole discretion of ICICI Lombard, subject to payment of the amount payable as determined by the ICICI Lombard, resulting from the difference in the
bonus / malus status. I affirm and undertake that I have read and understood the policy wordings, terms, conditions and exclusions governing the cover and agree to abide by them.
I/We hereby give my/our consent to the Company to verify and obtain my/our identity/address proof for the purpose of undertaking KYC.
• I/We hereby declare and confirm that the premium has been paid out of legally acquired sources of income and the subsequent premiums if any, will continue to be paid out of legally declared and assessed source of income.
• I/We understand that the Company has right to call for documents to establish source of funds
• I/We hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I/we undertake to inform you of any changes therein, immediately and not later than 30 days.
• In case any of the above information is found to be false or untrue or misleading or misrepresenting, I/We am/are aware that I/We may be held liable for it. Further, the Company has a right to cancel the insurance contract in case, I
am/have been found guilty by any competent court of law under any statutes, directly or indirectly governing the prevention of money laundering.
I hold a valid and effective PUC and/or fitness certificate, as applicable, for the vehicle mentioned herein and undertake to renew the same during the policy period.
I agree to receive a One Page Motor Insurance policy in physical form. (By agreeing to this, I understand that this shall be read alongwith the standard terms, conditions available on the website www.icicilombard.com)
I wish to avail physical policy documents
I wish to get policy related communications on My WhatsApp number.

Agent Declaration
I, _________________________________________________________<full name> in my capacity as an Insurance Advisor/ Specified Person of the Corporate Agent/ Insurance Sales Persons of Insurance Marketing Firm
/ Broker Qualified Person/ Point of Sale Person/ Rural Authorized Person (RAP) and Village Level Entrepreneur – Ins (VLE-Ins) of Common Public Service Centre do hereby declare that I have explained all the contents of this
Proposal Form, including the nature of the questions contained in this Proposal Form to the Proposer including statement(s), information and response(s) submitted by him/her in this Proposal Form to questions contained herein
or any details sought herein will form the basis of the Contract of Insurance between the Company and the Proposer, if this Proposal is accepted by the Company for issuance of the Policy. I have further explained that if any
untrue statement(s)/ information/response(s) is/are contained in this Proposal Form/including addendum(s), affidavits, statements, submissions, furnished/to be furnished, the Company shall have the right to cancel the policy at
its discretion. Further, this declaration does not confirm issuance of policy or assumption of risk thereof.
I hereby confirm to the best of my knowledge and belief that there is no inconsistency or adverse habits that may affect the underwriting of this proposal except as mentioned below: _____________________________(to be
filled in, only in case there is some disclosure to be made)
Intermediary Name and Code:________________________ Date: ________________________________ Place: _____________________ Intermediary License / Registration Number: ________________________

Bank Details
Direct Fund Transfer / EFT Mandate Form (Please attach an Original Blank Cancelled Cheque signed by payee)
Payee Name (As per bank records) Payee Account No.
Name of Bank : Type of Account: Savings Current IFSC Code No.
Cheque / DD Date: Amount: ` ______________ Cheque / DD No.: _______________________ Bank Name: ______________________________ Deposit Slip No.: ____________
Credit Card No. Expiry Date: Issuing Bank ________________________________ Amount: _________________________________

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If Corporate, vehicle used by, Mr./Ms. ______________________________________________________________ 11) The vehicle is designed for use of blind/handicapped/ mentally challenged person
Phone (with STD Code): ___________________________________ (O) __________________________________ and duly endorsed as such by RTO: Yes No
Mobile No.: ____________________ Email ID: ______________________________________________________ 12) The vehicle is chauffeur driven: Yes No
(For claim status and renewal reminders) Date of Birth : __________________________ 13) Are you a member of Automobile Association of India: Yes No
Sex : M F T Marital status : Single Married If yes, Association Name: ___________________________________
Membership Number: ___________________________ Date of expiry:
My Occupation Details
14) Is the vehicle fitted with the any Anti-theft device approved by the ARAI: Yes No
Type of Customer: Private Limited Co. Public Ltd. Co. Unincorporated Association or Body of Individuals If yes, attach Certificate of Installation in the vehicle issued by Automobile Association of India
Partnership/LLP Trust/ Foundation Government 15) Whether extension of geographical area to the following countries required?
NGO/NPO (Provide DARPAN Portal Registration number above) Bangladesh, Bhutan, Maldives, Nepal, Pakistan & Sri Lanka: Yes No
Others (please specify) ______________________________________________________ If yes, state the name of the countries
If Individual Salaried Self Employed Professional Retired 1)______________ 2)_______________ 3) __________________
If Non Individual Urban Rural 16) Whether the vehicle is driven by non-conventional source of power: Yes No
Paidup Capital of Company in ` < 10 Crores 10-25 Crores > 25 Crores If yes, CNG LPG Bi-fuel Electric If yes, please give details _____________________________________________

Category/ Nature of Business: Training Manufacturing Contracting Others ________________ 17) Whether the vehicle is fitted with fibre glass tank?: Yes No

Financial Services Hospitality Other (pl. specify) 18) Will the vehicle be used exclusively for Private, Social, Domestic, Pleasure & Professional Purpose?
Vehicle in “Good condition” means any vehicle which is in drivable condition without structural line and/ or mechanical defects
Annual Income in ` : ______________________
Agent Code: _______________________________ Agent Name: ___________________________________________
Do you File an Income Tax Return Yes No Do you own a bank account Yes No
Office Use: IM Name ________________________ IM Code: ______________________________________________
Optional Personal Accident Cover MO Name: ________________________________ Branch Name: __________________________________________
Do you wish to include Personal Accident cover for named persons? Yes No (Note: Copies of RC Book, Permit & Fitness Certificate should be submitted along with the proposal form)
If yes, provide name and Capital Sum Insured (CSI) opted for : If the Vehicle owned / hired / leased / permitted by the State Transport authorities for the purpose of their operation for
Name CSI Opted (`) Nominee Relationship public transport Yes No
1. Additional coverages, if any ______________________________________________________________________
If yes, please submit the proof: ___________________________________________________________________
2.
• Do you wish to include PA Cover for paid drivers, cleaners and conductors? Yes No
Do you wish to include PA cover for unnamed Passengers / Hirer / Pillion Passengers (Two Wheeler) Yes No
If yes, provide number of persons and Capital Sum Insured (CSI) opted for : Name CSI Opted (`) Nominee Relationship
No. of persons : ________________ CSI (per person) : ________________
1.
Details of Driver 2.
a. Age & Date of Birth of the Owner : Age ___________ Yrs DOB : Coverage for liability against Third Party Risks (Death or Bodily Injury) required in respect of:
b. Age & Date of Birth of the Driver : Age ___________ Yrs DOB : i) Owner-Driver only Yes No
Does the driver suffer from defective vision or hearing or any physical infirmity? Yes No ii) Any person other than Paid Driver Yes No If yes, provide details of such other persons
If yes, please provide details of such infirmity: _____________________________________________________ 1 ____________________________ 2 ______________________________
d. Has the driver ever been involved / convicted for causing any accidental loss? Yes No Note:
If yes, provide details as under including the pending prosecutions 1. Section 146 of Motor Vehicle Act - 1988 makes it mandatory for the owner of the vehicle to ensure that he or any
Drivers Name :_________________________________ Date of Accident : other person authorized by him to drive a vehicle in public place has insurance against third party risks.

Circumstances of Accident / Loss : _____________________________________________________________ The explanation to Section 146 exempts the paid driver.

_________________________________________________________ Loss / Cost (`) :___________________ 2. As per Section 147 (2)(a) the liability is ‘as incurred’ in the case of death / bodily injury of a third party.
Legal Liability to persons employed in connection with operation of the vehicle who are ‘workmen’. The liability of the
Vehicle Insurance History employee under the Workmens Compensation Act-1923 is covered under the Motor Vehicle Act - 1988.
1) Drivers : (No. of persons:___________) 2) Employees (Workmen)(No. of persons:___________)
Name and Address of Previous Insurer: _____________________________________________________________
(Note: The Motor Vehicles Act-1988 under Sec. 141(1)(ii)(I)covers liability to employees who are workmen within the
Previous Policy Type: Liability only Cover Package Cover Others meaning of the Workmen’s Compensation Act-1923.)
Previous Policy No. Do you wish to cover wider legal liability to employees who are ‘workmen’? [This information is sought to cover in
addition to liability under the Workmens Compensation Act-1923, also liability under the fatal Accidents Act-1855 and
Period of Insurance TO the Common Law] Yes No
Existing bonus/malus status: % (Note: The additional liability under Common Law and Fatal Accidents Act in respect of employees who are workmen is
covered under this endorsement)
Are you entitled to No Claim Bonus? Yes No
Do you wish to cover wider legal liability to employees who are NOT ‘workmen’? Yes No
In the last three years, is there any history of loss experienced by the proposer(s) or other drivers who would be using
(Note: The Liability under Common Law and Fatal Accidents Act - 1855 in respect of employees who are not workmen
this vehicle Yes No If yes, details are:
can be covered under this endorsement)
Name of the Driver Amount claimed
Date & Time of Loss at the time f loss Nature of Loss (`) Motor Related Add-on Covers
1) Do you wish to include Cover for Pay As You Use (PAYU - Telematics) Yes No
2) Do you wish to include cover for Zero Depreciation? Yes No
Has any insurance company ever If yes, please select 2 Claim Limit No Claim Limit
A) declined the proposal : Yes No Note- Above claim limit is applicable for 3 Years- Private Car Package Policy & 5 Years- Two Wheeler Package
Policy
B) cancelled & refused to renew : Yes No (If yes, reasons for the same ________________)
3) Do you wish to include cover for Road Side Assistance Yes No
C) imposed special condition or excess : Yes No (If yes, reasons and details thereof : ________________)
If yes, please provide your residence address:______________________________________________________
Declaration: I/We further undertake that if this declaration is found to be incorrect, all benefits under the policy in
respect of Section I of the policy will stand forfeited. I/We, the undersigned hereby declare that the above statements Names of the emergency services selected are as below: ____________________________________________
and particulars are true, accurate and complete and I/We declare that this declaration and the answer given above shall
4) Do you wish to include Cover for Pay How You Use (PHYU- Telematics) Yes No
be held to promissory and shall be the basis of the contract between me/us and ICICI Lombard. The policy may however
be continued at the sole discretion of ICICI Lombard, subject to payment of the amount payable as determined by ICICI 5) Do you wish to include Cover for Both - Pay As You Use (PAYU - Telematics)
Lombard, resulting from the difference in the bonus/malus status. I shall endeavour to procure the renewal notice and & Pay How You Use (PHYU - Telematics) Yes No
pass on the same to ICICI Lombard immediately upon the receipt of such notice. “I/We declare that the rate of NCB
6) Do you wish to avail discount for Voluntary Deductibles for this Add-on*? Yes No
claimed by me/us is correct and that no claim as 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 the policy in respect of Section I of the If yes, please indicate the amount: ` _____________________ * You can opt for a Voluntary Deductible specifically
policy will stand forfeited.” for this add-on, which would be over and above the basic Policy Deductible.
Place: ______________ Date: Signature of Proposer____________________
7) Do you wish to include cover for consumable items? Yes No
Other Vehicle Information If yes, please indicate the plan chosen______________
1) At the time of purchase the vehicle was : New Used 8) Do you wish to include cover for Return to Invoice add-on: Yes No
Date of purchase of the Vehicle (if current owner purchased the used vehicle): If yes, please indicate, Registration+Road Tax Charges Paid ` ____________
2) Will the vehicle be used for carriage of goods other than samples or personal luggage: Yes No 9) Do you wish to include cover for NCB Protect add-on: Yes No
3) The vehicle is in good condition* : Yes No If 'No' please give full details _______________________________
If yes, please indicate the plan chosen________ Number of claims to be considered eligible for this add-on : _____
4) The vehicle is self owned: Yes No
10) Do you wish to include cover for Garage Cash add-on: Yes No
5) The vehicle is used for driving tution: Yes No
If yes, please indicate
6) The vehicle is used for commercial purposes: Yes No
7) Use of my vehicle is limited to own premises: Yes No A. The Daily Allowance opted for ` _________________________________
8) The vehicle is used for Personal purposes: Yes No (excluding use for hire or reward) B. The Maximum Coverage Days opted for____________________________
9) The vehicle belongs to foreign embassy/consulate?: Yes No C. Maximum amount payable in the event of a claim under this add-on ` ________________________________
10) The car is certified as Vintage car by: Yes No Vintage and Classic Car Club of India D. The minimum number of days in excess of which the claim will be payable from the day such vehicle was
delivered to the garage ____________________________________________________________________

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11) Whether you want to opt for Voluntary Deductible offered under the Policy, which would be applied over the Statutory Warning
Compulsory Deductible? Yes No
Prohibition of Rebates Under Section 41of Insurance Law (Amendment Act 2015)
If yes, please state the amount: ` ____________________________________
No person shall allow or offer or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or
12) Do you wish to include cover for Engine Protect Plus: Yes No 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
13) Do you wish to include cover for Loss of Personal belongings: Yes No policy accept any rebate except such rebate as may be allowed in accordance with the prospectuses or tables of the insurer. Any
person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.
If yes, please indicate the plan chosen ___________________ Sum Insured ` ___________________
Note: The IDV of the vehicle will be deemed to be the 'SUM INSURED' for the purpose of this tariff and it will be fixed at the
14) Do you wish to include cover for Key Protect add on : Yes No commencement of each policy period for each insured vehicle. The IDV of the vehicle is to be fixed on the basis of manufacturer
listed selling price of the brand and model as the vehicle proposed for insurance at the commencement of insurance/renewal, and
If yes, please indicate the Sum Insured ` ___________________ adjusted for depreciation (as per schedule specified below). The IDV of side car(s) and/ or accessories, if any, fitted to the vehicle
but not included in the manufacturers listed selling price of the vehicle is / are also likewise to be fixed. The schedule of age wise
15) Do you wish to include cover for Tyre Protect add on: Yes No depreciation, as shown below, is applicable for the purpose of total loss/constructive total loss / or repair of the vehicle subject to
terms and conditions of the policy exceed 75% of the IDV
16) Do you wish to include Cover for EMI Protect : Yes No
Table 1 : Schedule of depreciation for arriving at IDV
If yes, please mention the EMI amount (sum insured) / ` ___________________ The Insured’s declared value (IDV) of the vehicle will be deemed to be the ‘Sum insured’.
No. of EMI opted _______________ (Kindly select one option from below table) Time excess ________ (Kindly
IDV CALCULATION
select one option from below table)
AGE OF THE VEHICLE Depreciation
No of EMI: 1 2 3 4 5 6 Upto 6 Months 5%
For Pvt. Car - Time Excess (Minimum No of Days): 7 days 10 days 14 days 21 days 28 days 6 Months 1 day to 1 Year 15%
For CV - Time Excess (Minimum No of Days): 30 days 40 days 50 days 60 days 80 days 100 days 1 Year 1 day to 2 years 20%
2 Year 1 day to 3 Years 30%
17) Do you wish to include Cover for Emergency Medical Expenses: Yes No
3 Years 1 day to 4 Years 40%
If yes, please mention below details: 4 Years 1 day to 5 Years 50%
Accidental Hospitalization Sum Insured ` ________________. Ambulance Cover Sum Insured ` ______________.
Note: IDV of vehicles beyond 5 years of age and of obsolete of the vehicle (i.e. models which the manufacturer have discontinued is to
Hospital Daily Cash: 1) No of occupants to be covered ____________. 2) Per Day Sum Insured _______________. be determined on the basis of an understanding between insurer and the insured.

Tele Consultation No. of service __________________________ In case of total loss / constructive total loss / total theft / cash loss of the vehicle, the claim will be settled at invoice price i.e
amount paid by the insured / policyholder at the time of purchasing the vehicle, excluding subsidy amount, if included in the invoice,
18) Do you wish to include Cover for Battery Protect Cover: Yes No or the Insured declared value (IDV) whichever is lower, subject to terms and conditions of the policy and admissibility of claims.
19) Do you wish to include Cover for Motor Floater Add-on: Yes No Note: Denial of “Third Party Liability Only Cover” by Insurer, for reasons other than fraud / misrepresentation by proposer,
will entail Regulatory action.
20) Do you wish to include Driving Accessories Cover: Yes No
• I hereby confirm that I am aware that enrolment to this product is purely voluntary and is not linked to me availing of any other
21) Do you wish to include Tyre & Wheel Rim Protect: Yes No facility from the bank.
22) Do you wish to include Smart Saver: Yes No • I hereby confirm that the premium towards my insurance cover will not be borne by any third party entity / person(s), with the
exception of my spouse, parents, grandparents, children, siblings or employer
23) Do you wish to include Smart Saver Plus: Yes No
Note: Smart Saver & Smart Saver Plus, both cannot be opted together.
Signature of the Proposer: ________________________________

20240624001-Motor Package Proposal and Annexure-FORMS-12/08/2024

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