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Bajaj Allianz General Insurance Company Ltd.Registered and Head Office: GE Plaza, Airport Road, Yerwada, Pune

Transcript of Proposal for Private Car - Package Policy

Dear MR RAJENDRASINH JORUBHAI SISODIYA,

We wish to inform you that the contract under policy number 'OG-14-2202-1801-00054071' has been finalized based on the information and

declaration given by you, the transcript whereof is mentioned below. You are requested to reconfirm the same. In case of any disagreement or

objection or any changes with respect to information mentioned below, we request you to please revert back within a period of 15 days from

date of your receipt of this, failing which it will be deemed that you are satisfied with the correctness of the details mentioned below. Kindly note

that as the contents and declarations contained in this transcript is the basis on which we have issued the policy to you, we advise you to please

ensure that you have provided/disclosed and or not withheld any material facts/information and declarations, as Policy becomes Void ab initio if

material facts are not provided/disclosed and or withheld and in such case no claim, if any, will be considered by us apart from forfeiture of the

premium.

Details provided by you:

A. Proposer details

1. Proposer Name : MR RAJENDRASINH JORUBHAI SISODIYA

2. Proposer Address : AT PO PETHAPUR, TA DIST GANDHINAGAR

GANDHINAGAR (GUJARAT), , GANDHI NAGAR-382010

3. Proposer Mobile Number :

4. Proposer Residential Number : NA

5. Proposer e-mail id : NA

6. Proposer Profession : NA

B.Vehicle Details

Registration

Number

Month / Year of

Regn

Vehicle Make Vehicle Model Vehicle Sub

Type

Cubic Capacity Fuel Type Year of Manu-

facture

Seating Capacity

GJ18BA1580 DEC/2011 MAHINDRA

AND

MAHINDRA

SCORPIO M

HAWK

VLX 8 SEAT-

ER

2179 Diesel 2011 8

Engine Number Chassis Number Vehicle IDV (in Rs.) Electrical

Accessories IDV

(in Rs.)

Non-Electrical

Accessories IDV

(in Rs.)

CNG/LPG Unit

(Extra fitted) IDV

(in Rs.)

Total IDV (in Rs.)

92741 43826 720000 0 0 0 720000


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C. Coverage opted

1. Period of Insurance : From 10-JAN-2014 00:00 (Hrs) To 09-JAN-2015 Midnight

2. Is your vehicle fitted with external LPG/CNG kit : No.

3. Electrical Accessories cover Opted (If Applicable) : No.

4. Non - Electrical Accessories cover Opted (If Applicable): : No.

5. Is Voluntary Excess opted : No.

Amount of voluntary excess opted : Rs.NA.

6. Whether PA cover is opted for owner-driver : Yes.

7. Is any additional compulsory deductible imposed and agreed upon : No.

Amount of additional compulsory deductible imposed : NA.

8. Whether geographical area extension is opted : No.

Details of Countries to which geographical area extension cover is given : NA.

9. Is LL to person for Paid driver/Operation/Maintenance opted : Yes.

10. Whether PA cover is opted for paid driver other than owner driver : No.

Sum Insured for Paid Driver : Rs.NA.

11. Whether PA cover is opted for passengers : Yes.

Sum Insured per Passenger : Rs.40000.

12. Is TPPD restricted to statutory limit of Rs.6000? : No.

13. Pre Existing damages in the vehicle : NA.

14. Premium for Liability coverage, quoted and agreed upon is : Rs.3734.

15. Premium for OD coverage, quoted and agreed upon is : Rs.11663.

16. Total Premium (excluding Service Tax and Education Cess) for Liability and OD coverages, quoted and agreed upon is : Rs.15397

17. NCB (No Claim Bonus) claimed by you and granted by us based on your declaration of no claim during your previous policy : -25 %.

18. About the last insurance company

(i) Insurance Provider : New India Assurance Co Ltd.

(ii) Previous Policy No : 21260031120100023662, Previous Policy Expiry Date :09-JAN-14

19. Whether your vehicle is Hypothecated and if so the details of Pledgee whose name is registered by us : Yes.

Name of Pledgee : MMFSL.

20. Add on Cover(s) opted : No.Plan name:NA

Please note Cover Note No. issued to you basing on the above information.

In case of Disagreement or objection or any changes with respect to information and contents mentioned hereinabove, please contact our tollfree number & register your objections/changes/disagreement to the contents of this transcript or you may also send us email or writtencorrespondence at the following details within a period of 15 days from date of your receipt of this transcript along with Policy:

Toll free Number : 1800-22-5858, 1800-102-5858 ,1800-102-5858,1800-209-5959

Email address : [email protected].

Website : www.bajajallianz.com.

Contact our policy servicing branch at: 4th Floor, Turquoise, Nr. Panchvati Circle, C.G Road, Ellisbridge, Ahmedabad-380006PH:079-26408006/40028866.

For Bajaj Allianz General Insurance Co Ltd

Authorized signatory


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BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LTD.Policy Servicing Office 4th Floor, Turquoise, Nr. Panchvati Circle, C.G Road, Ellisbridge, Ahmedabad-380006

PH:079-26408006/40028866

Policy Number OG-14-2202-1801-00054071 Product Private Car - Package Policy

Period Of Insurance From: 10-JAN-2014 00:00 (Hrs) Policy issued on 07-JAN-2014

To: 09-JAN-2015 Midnight Cover Note No.

Insured Name MR RAJENDRASINH JORUBHAI SISODIYA Zone B

Insured Address AT PO PETHAPUR, TA DIST GANDHIN-AGAR GANDHINAGAR (GUJARAT), ,GANDHI NAGAR-382010

Customer Id 54952336 Premium Payer Id 54952336

Application No 0 Scrutiny No 31230556

HYPOTHECATED WITH : MMFSL Policy Status ISSUED

Coinsurance Details :NA.

Registration No Make Model SubType CC Year Of Mfg Seat Cap Chassis number. Engine No.

GJ18BA1580 MAHINDRA ANDMAHINDRA

SCORPIO MHAWK

VLX 8 SEATER 2179 2011 8 43826 92741

Vehicle IDV Elec. Accessories Non-Elec. Acc. Trailer Trailer Reg No CNG/LPG Unit Total Sum Insured

720000 0 0 0 -,- 0 720000

SCHEDULE OF PREMIUM

Own Damage Liability

Total Own Damage Premium 11663 Basic Third Party Liability 3424

PA Cover for Owner-Driver of Rs. 200000 100PA Cover For 8 Passanger Of Rs. 40000 each 160

LL to person for Paid driver/Operation/Maintenance 50

Total Act Premium: 3734

Total Premium 15397

Special Discount 0

Net Premium 15396

Service Tax 1848

Edu Cess 55

Final Premium Rs. 17299 *** All Premium Figures are in Rupees

Geographical Area :India No Claim Bonus :-25% Voluntary Excess :Nil

Compulsory Deductible :Rs. 2000 Additional Compulsory Deductible :Rs. 0

Previous Insurer - New India Assurance Co Ltd Previous Policy No - 21260031120100023662 Expiry On - 09-JAN-14

The above Total OD Premium is inclusive of all applicable Loading/Discounts viz (Automobile Association Membership,Voluntary Excess,Anti-Theft,Handicap Per-son,Driver Tution,Fibre Glass,Cng/Lpg Unit,Geographical Extn,Imported Vehicle etc wherever applicable)

LIMITS OF LIABILITY: Under section II-I(i) of the policy -> Death of or bodily injury : Such amount is necessary to meet there requirements of the Motor Vehicles Act,1988. Undersection II-I(ii) of the policy -> Damage to Third Party Property : Rs. 750000

LIMITATION AS TO USE : The Policy covers use of the vehicle for any purpose other than : Hire or reward, Carriage of goods(other than samples or personal luggage), Organised ra-cing, Pace making, Speed testing, Reliability trials, Any purpose in connection with Motor Trade.

DRIVER : Any person including the insured Provided that a person driving holds an effective driving licence at the time of the accident and is not disqualified from holding or obtainingsuch a licence. Provided also that the person holding an effective Learner's licence may also drive the vehicle and that such a person satisfies the requirements of Rule 3 of the CentralMotor Vehicles Rules, 1989.

Past Claim Reference :

IMPORTANT NOTICE : The Insured is not indemnified if the vehicle is used or driven otherwise than in accordance with this schedule. Any payment made by the Company by reasonof wider terms appearing in the Certificate in order to comply with the Motor Vehicle Act, 1988 is recoverable from the Insured. See the clause headed AVOIDANCE OF CERTAINTERMS AND RIGHT OF RECOVERY.

Subject to IMT Endorsement Nos: 22, 7, 16, 28 & Policy wordings attached herewith

Broker Code 10029148 Channel Name : MLBroker Name : Bajaj Capital Insurance Broking Ltd

Contact No : 011-61111111/18602661226 Email - [email protected]

Premium Collection Details :- [Receipt No/Collection No/Amount] 2202-01281868,/31230556,/ Rs.17299,

*** If premium paid through cheque, the policy is void ab-initio in case of dishonor of cheque.

This certificate of insurance is issued in accordance with the provision of Chapter X and Chapter XI of M.V.Act, 1988.

In case of any claim, please contact our 24 Hour Call centre at 1800-22-5858, 1800-102-5858 ,1800-102-5858,1800-209-5959(Toll Free) /91-020-30305858 (chargeable, add area code before this number in case of mobile call) or email us at '[email protected]'31230556/-/10029148/0/-

PIN NO : NA Damage Details:null

Remarks :

Kindly contact our nearest / local office(s) for No Claim Bonus Confirmations.

This is the 'Digital Print' and original Policy would follow and the Original policy, duly countersigned, to be relied on for all legal purposes.

For & On Behalf of Bajaj Allianz General Insurance Company Ltd.

Stamp

Duty Rs.

0.5

Authorized Signatory

Consolidated stamp Duty paid vide Receipt No: .13 dated 11-NOV-13

Regd Office : GE Plaza,Airport Road, Yerwada Pune-411006 (India)

Regd. Office : GE Plaza, Airport Road, Yerawada,Pune - 411006 (India) Service Tax Reg. No. AABCB5730G-ST-001

-Latest Schedule- 08-Jan-2014 12:49:39 PM (Web)

Generated by bajacapital2202@general bajajallianz co in


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.

Bajaj Allianz General Insurance Company Ltd.4th Floor, Turquoise, Nr. Panchvati Circle, C.G Road, Ellisbridge, Ahmedabad-380006 Contact

No:079-26408006/40028866,

COPY RECEIPT

Receipt Number 2202-01281868

Receipt Date 03/01/2014

Business Channel ML

Received with thanks from MR RAJENDRASINH JORUBHAI SISODIYA

(Customer ID : 54952336 ) a total sum of Rupees Seventeen Thousand Two Hundred NinetyNine Only by,

InstrumentType

Instrument No. InstrumentDate

Bank Name Branch Name Amount

Cash 17,299

Total Amount Rs. 17,299.00

Note : 31230556

Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General In-surance Company Limited. The insurance cover for the risk shall be as per the terms and con-ditions of the Insurance Policy if and when issued.

* Cheque/DD/PO receipt is valid subject to realisation of the instrument.

For & on behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory

Regd.Office: GE Plaza,Airport Road, Yerwada, Pune - 411006

Regd. Office : GE Plaza, Airport Road, Yerawada,Pune - 411006 (India) Service Tax Reg. No. AABCB5730G-ST-001

-Latest Schedule- 08-Jan-2014 12:49:39 PM (Web)

Generated by bajacapital2202@general bajajallianz co in

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Rajendrasinh Sisodiya (1)