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 SANJEEV BHISE,
We wish to inform you that the contract under policy number 'OG-15-2001-1801-00017036' 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 : SANJEEV BHISE
2. Proposer Address : BLOCK NO.14/A BHIMDEEP SOC,
GOKHALE NAGAR, ., PUNE, MAHARASHTRA-411016
3. Proposer Mobile Number : 8975803500
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
MH12GF0562 AUG/2010 SKODA FABIA 1.2 MPI AMBI-
ENTE
1198 Petrol 2010 5
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.)
CEV008967 TMBBHF5J2AG013883 280858 0 0 0 280858
C. Coverage opted
1. Period of Insurance : From 29-JUL-2014 00:00 (Hrs) To 28-JUL-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.100000.
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.1732.
15. Premium for OD coverage, quoted and agreed upon is : Rs.4980.
16. Total Premium (excluding Service Tax and Education Cess) for Liability and OD coverages, quoted and agreed upon is : Rs.6712
17. NCB (No Claim Bonus) claimed by you and granted by us based on your declaration of no claim during your previous policy : -20 %.
18. About the last insurance company
(i) Insurance Provider : Bajaj Allianz General Insurance Co Ltd..
(ii) Previous Policy No : OG-14-2001-1801-00018326, Previous Policy Expiry Date :28-JUL-14
19. Whether your vehicle is Hypothecated and if so the details of Pledgee whose name is registered by us: No.
Name of Pledgee : NA.
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 toll
free number & register your objections/changes/disagreement to the contents of this transcript or you may also send us email or written
correspondence 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 : info@bajajallianz.co.in.
Website : www.bajajallianz.com.
Contact our policy servicing branch at: Vardhaman, 4th Floor, 7 Loves Chowk, Shankar Sheth Road, ,, Pune-411042 PH:66240100.
For Bajaj Allianz General Insurance Co Ltd
Authorized signatory

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of India [IRDA] vide Reg No.113)
Regd. Office: GE Plaza, Airport Road, Yerwada,Pune-411006(India)
Certificate of Insurance (Private Car Package Policy)
Policy Number: OG-15-2001-1801-00017036 Customer ID: 51657711
Particulars of Vehicle Insured:
Registration Number Place of Registration Engine Number Chassis Number Make & Model
MH12GF0562 CEV008967 TMBBHF5J2AG013883 SKODA - FABIA
Sub Type Year of Manufacturing NCB % CC Seating Capacity Final Premium
1.2 MPI AMBIENTE 2010 -20 1198 5 Rs.7540.
Name of Registration Authority :
Name and Address of Insured : SANJEEV BHISE
: BLOCK NO.14/A BHIMDEEP SOC, GOKHALE NAGAR, .,
PUNE, MAHARASHTRA-411016
Geographical Area : India
Business or Profession : NA
Effective date of commencement of Insurance for the purpose of act:
Policy Inception Date: From 00:00 O' Clock on 29-JUL-2014
Policy Expiry Date: Midnight on 28-JUL-2015
Persons or Class of Persons entitled to drive:
Any person including the insured:
a) Provided that a person driving holds an effective driving license at the time of the accident and is not disqualified from holding or obtaining
such a license.
b) Provided also that the person holding an effective learner's license may also drive the vehicle and that such a person satisfies the
requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.
Limitations as to Use:
The Policy covers use for any purpose other than
a) Hire or Reward, b) Carriage of goods (other than samples or personal luggage), c) Organized racing, d) Pace Making, e) Speed testing,
f) Reliability Trials, g) Any purpose in connection with Motor Trade
I/We hereby certify that the Policy to which this certificate relates as well as this Certificate of Insurance are issued in accordance with the
provisions of Chapter X and Chapter XI of M.V. Act, 1988.
Full address of Issuing Office :
Vardhaman, 4th Floor, 7 Loves Chowk, Shankar Sheth Road, ,, Pune-411042 PH:66240100
Date of issue :22-JUL-2014
For & On Behalf of
Bajaj Allianz General Insurance Company Ltd.
Authorized Signatory
For help and more information:
Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, 1800-22-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call)
Email us at customercare@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 22-Jul-2014 19:09:07 PM- maya gaikwad@general bajajallianz co inprint_flag=ORG (Web) (0)
Digitally signed by ASEEM GOEL
Date: 2014.07.22 19:09:07 IST
Reason: Policy Receipt
Location: BAJAJALLIANZ PUNE
HO
Signature Not Verified
BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED
(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of India [IRDA] vide Reg No.113)
Regd. Office: GE Plaza, Airport Road, Yerwada,Pune-411006(India)
PRIVATE CAR PACKAGE POLICY SCHEDULE
Policy Issuing Office
Vardhaman, 4th Floor, 7 Loves Chowk, Shankar Sheth Road, ,, Pune-411042 PH:66240100
INSURED DETAILS POLICY DETAILS
Insured Name SANJEEV BHISE
Insured Address
BLOCK NO.14/A BHIMDEEP SOC, GOKHALE
NAGAR, ., PUNE, MAHARASHTRA-411016
Geographical Area India
Customer ID 51657711
Policy Number OG-15-2001-1801-00017036
Policy Issued on 22-JUL-2014 19:08 PM
Period of Insurance
From : 29-JUL-2014 00:00 (Hrs)
To : 28-JUL-2015 Midnight
Cover Note Details /
Previous Policy No OG-14-2001-1801-00018326
Registration Number Place of Registration Engine Number Chassis Number Make & Model SubType
MH12GF0562 CEV008967 TMBBHF5J2AG013883 SKODA - FABIA 1.2 MPI AMBIENTE
NCB % CC Seating Capacity Year Of Manufacturing
Trailer Registration
Number
Hypothecation Details
-20 1198 5 2010 -,-
Vehicle IDV Value For Trailers Non electrical accessories
Electrical/Electronic
accessories
Value of CNG/LPG
kit
Total Value
280858 0 0 0 0 280858
Own Damage Premium(Rs.)
Own Damage Premium 4980
Special Discount 0
Total OD Premium - A 4980
Total Premium (Net Premium) (A+B) 6711
Service Tax 805
Education Cess 24
Final Premium Rs.
7540
Final Premium (in Words): Rupees seven thousand five hundred forty Only
Liability Premium(Rs.)
Basic Third Party Liability 1332
PA Cover for Owner-Driver 100
LL to person for Paid driver/Operation/Maintenance 50
PA Cover For 5 Passanger Of Rs. 100000 each 250
Total Act Premium - B 1732
**Note: The above Total OD Premium is inclusive of all applicable Loading /Discounts viz (Automobile association membership, Voluntary Excess, Anti Theft, Handicap Person,
Driver Tuition, Fiber Glass, CNG/LPG Unit, Geographical Extension, Imported Vehicle Etc. wherever Applicable)
Agency
Code&
Name
10032352/MAYA DAT-
TATRAYA GAIKWAD
Contact No. 9822351378/0
E-Mail ID. mayagaikwad1991@gmail.com
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 lug-
gage),Organised racing,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 license at the time of the accident and is not dis-
qualified from holding or obtaining such a license. Provided also that the person holding an effective Learner's license may also drive the
vehicle when not used for the transport of goods/passengers at the time of the accident and that such a person satisfies the requirements of
Rule 3 of the Central Motor Vehicle Rules, 1989.
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. Under section II-I(ii) of the policy -> Damage to Third Party Property : Rs. 750000
No Claim Bonus
The insured is entitled for a No Claim Bonus (NCB) on the Own Damage section of the policy, if no claim is made or pending during the
preceding year (s), as per the following: 1. The preceding year: 20% , 2. Preceding Two consecutive years: 25% , 3. Preceding Three con-
secutive years: 35%, 4. Preceding Four consecutive years: 45% , 5. Preceding Five consecutive years: 50% No Claim Bonus will only be
allowed provided the policy is renewed within 90 days of the expiry date of the previous policy.
Existing Damage Details
NA
Subject to Warranties/
IMT-Endorsements/Add on
Package
22, 28, 16,
Additional Details
Coinsurance Details: - NA. Transaction Id: - Nominee Details:
Premium Details
Receipt No. 2001-00954231, Date 22-JUL-14 ** If Premium paid through Cheque, the Policy is void ab-initio in case of dishonour of
Cheque.
Excess Details
Compulsory Excess: Rs.1000 ADDITIONAL EXCESS: Rs. 0 VOLUNTARY EXCESS: Rs.0

For help and more information:

Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, 1800-22-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call)
Email us at customercare@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 22-Jul-2014 19:09:07 PM- maya gaikwad@general bajajallianz co inprint_flag=ORG (Web) (0)

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 reason of 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 CERTAIN TERMS AND RIGHT OF RECOVERY.
For & On Behalf of
Bajaj Allianz General Insurance Company Ltd.
Authorized Signatory
This document is digitally signed, hence counter signature / stamp is not required.
Consolidated stamp Duty paid vide Receipt No: .16 dated 09-APR-14
Service Tax Reg. No. AABCB5730G-ST-001
For help and more information:
Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, 1800-22-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call)
Email us at customercare@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 22-Jul-2014 19:09:07 PM- maya gaikwad@general bajajallianz co inprint_flag=ORG (Web) (0)
.
Bajaj Allianz General Insurance Company Ltd.
Vardhaman, 4th Floor, 7 Loves Chowk, Shankar Sheth Road, ,, Pune-411042 Contact No: 66240100;
Fax No: 66240111
RECEIPT
Receipt Number 2001-00954231
Receipt Date 22/07/2014
Business Channel ML
Received with thanks from SANJEEV BHISE
(Customer ID : 51657711 ) a total sum of Rupees Seven Thousand Five Hundred Forty Only
by,
Instrument
Type
Inst./Ref No Instrument
Date
Bank Name Branch Name Amount
Cheque 987633 21/07/2014 ING VYSYA BANK
LTD
COMMERICAL
BUILDING
KALYANINAGAR
7,540
Total Amount Rs. 7,540.00
Note : Integrated Receipts: Cheque.
Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General
Insurance Company Limited. The insurance cover for the risk shall be as per the terms and
conditions 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
CIN:U66010PN2000PLC015329; E-mail: customercare@bajajallianz.co.in; Website:www.bajajallianz.com