Bajaj Allianz General Insurance Co. Ltd.

Servicing Office of Insurer: BLOCK NO 4, DLF TOWER, 15, SHIVAJI MARG, NEW DELHI 110015,
Delhi, Delhi (State Code:07) -110015, PH-- Website: www.bajajallianz.com
PAN: AABCB5730G . GSTIN: 07AABCB5730G1ZZ Insurer's IRDA Registration Number: 113
Tollfree Helpline 011-66278000 Email: CIN : U66010PN2000PLC015329

PRIVATE CAR PACKAGE POLICY-CERTIFICATE CUM POLICY SCHEDULE

(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. OG-22-9910-1801-00267388 Policy Issued On 29-MAR-2022 (13:40)

Insured Name MR. SUMANTA KUMAR PATEL
Own Damage Period 02-APR-2022(00:00) To 01-APR-2023(Midnight) Motor Liability Period 02-APR-2022(00:00) To 01-APR-2023(Midnight)

Proposal No. & Date PRODFORD3445428, 29-MAR-2022 CPA Cover Period 02-APR-2022(00:00) To 01-APR-2023(Midnight)
Insured Add. WZ-1390/12 C1, PANKHA ROAD NANGAL RAYA EXTENSION, , DELHI , DELHI (State Code:07) -110046
Previous Insurer ITG Previous Policy No. 66109703 02-APR-2021 To 01-APR-2022
Broker Details
IRDA Lic. No.: 375, CIN No.: U50300MH1997PLC149349 Broker Category: Composite Broker, Validity: 13-MAY-20 To 12-MAY-23
Name & Add.: TATA MOTORS INSURANCE BROKING AND ADVISORY SERVICES LTD, 1ST FLOOR, AFL HOUSE, LOK BHARTI COMPLEX, MAROL MAROSHI ROAD,
ANDHERI (EAST), MUMBAI - 400 059

Make Model Sub Model Cubic Capacity Manufacturing Year Seating capacity

FORD FORD FREESTYLE FORD FREESTYLE 1.2 1194 2019 5

PETROL TITANIUM MT
Body Type Registration No. RTO Invoice Date Engine No. Chassis No.

HATCHBACK DL 9C AR 6047 DELHI 02-APR-2019 KC62593 MAJGXXMTKGKC62593

Vehicle IDV CNG/LPG Kit Elec. Accessories Non-Elec. Accessories Total IDV

466,200 0 0 0 466,200

Schedule of Premium (Amount in Rs.)

Own Damage Premium (A)
Basic Premium Deductibles
Vehicle 6,123 Voluntary Deductibles (0) (IMT-22A) 0

Non-Elec. Accessories 0 Anti Theft Device (IMT-10) 0

Elec. Accessories (IMT-24) 0 AA Membership (IMT-8) 0

CNG/LPG Kit (IMT-25) 0 No Claim Bonus (25%) 1,531

Sub Total (Basic Premium) 6,123 Handicapped Discount (0%) 0

Geographical Area Extension (IMT-1) 0 Sub Total (Deductibles) 1,531

IMT 23 Premium 0

Add On Coverages (NILDEP4YEAR) 4196

Sub Total-Addition 10,319 Net Own Damage Premium (A) 8,788

Liability Premium (B)

Basic Third Party Liability 3221 PA Cover For 5 Persons of Rs. 100000 Each (IMT-16) 250
Third Party Liability For Bi-Fuel Kit 0 PA cover for Paid Driver of Rs 2,00,000 (IMT± 0
Third Party Liability For Geographical Area Extension 0 Legal Liability For Paid Driver (IMT-28) 50
PA Cover For Owner Driver Of Rs. 1500000 (IMT-
331 Legal Liability for Employees (for 0 persons) (IMT± 0
15)
Net Liability Premium (B) 3852

Note: 1.Warning that in case of dishonour of the premium cheque, this document stands
automatically cancelled 'ab-initio Total Premium (A+B) 12640
2.Consolidated stamp duty paid to state exchequer. CGST (9%) 1138
3.The policy is subject to compulsory deductible of Rs.1000 (IMT-22) SGST (9%) 1138

5.Add-on: NILDEP4YEAR(Nil Depreciation-1 Year:4196)

6.The insurance company will display terms & conditions on its website www.bajajallianz.com which can
be accessed by you online.
*Subject to IMT Endt. Nos.& Memorandum:22,16,28 Gross Premium Paid 14916

Nominee Details
Name of Nominee Age Relationship with Insured Name of Appointee Relationship with Nominee
ASMITA PATEL 31 SPOUSE --N.A-- --N.A--
Payment Details : Cheque No.: 111455852512, Cheque Date: 29-MAR-2022, Bank Name: PAYLINK, Bank City:
Hypothecation Details: ----NA----
MISP Name: MOBILITY MOTORS PVT LTD, MISP PAN No: AAKCM8671J, MISP Code: MISP/AAKCM8671J
SAC:997134, Description of Service :Motor Vehicle Insurance Services, Place of Supply :DELHI(State Code:07), Receipt No/Invoice No:FBA/PRODFORD3445
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 Motor
Vehicle Act, 1988
For & On Behalf of Bajaj Allianz General Insurance Co. Ltd.

Authorized Signatory
In case of any claim or assistance required please contact our help line at 1800-258-2545 and you may also reach us at fordinsurance@tmibasl.com
 Bajaj Allianz General Insurance Co. Ltd.
Servicing Office of Insurer: BLOCK NO 4, DLF TOWER, 15, SHIVAJI MARG, NEW DELHI 110015,
Delhi, Delhi (State Code:07) -110015, PH-- Website: www.bajajallianz.com
PAN: AABCB5730G . GSTIN: 07AABCB5730G1ZZ Insurer's IRDA Registration Number: 113
Tollfree Helpline 011-66278000 Email: CIN : U66010PN2000PLC015329

PRIVATE CAR PACKAGE POLICY-CERTIFICATE CUM POLICY SCHEDULE

(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. OG-22-9910-1801-00267388 Policy Issued On 29-MAR-2022 (13:40)

Insured Name MR. SUMANTA KUMAR PATEL
Own Damage Period 02-APR-2022(00:00) To 01-APR-2023(Midnight) Motor Liability Period 02-APR-2022(00:00) To 01-APR-2023(Midnight)

Limitations as to use: The policy covers use of the vehicle for any purpose other than (1) Hire or Reward (2) Carriage of
goods (other than samples or personal luggage) (3) Organized racing (4) Pace making (5) Speed testing (6) Reliability trials (7)
Any purpose in connection with motor trade.

Driver¶s Clause: Any person including the insured: Provided that the person driving holds an effective driving license at the
time of the accident and is not disqualified from holding or obtaining such license. Provided also that the person holding an
effective learners license may also drive the vehicle & that such a person satisfies the requirements of Rule 3 of the Central
Motor Vehicle Rules, 1989.

NCB Clause: 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)-20%, preceding two consecutive years-25%, preceding three consecutive
years-35%, preceding four consecutive years-45%, preceding five consecutive years-50% of NCB on OD Premium. NCB is
allowed provided the policy is renewed within 90 days of the expiry date of the previous policy.

Important Notice: The insured is not indemnified if the vehicle is used or driven otherwise than in accordance with the
schedule. Any payment made by the company by reasons 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 ³AVOIDANCE OF CERTAIN TERMS &
RIGHT OF RECOVERY´For legal interpretation English version will hold good.

Note: This Schedule, the attached Policy and Endorsements mentioned herein above shall read together and word or
expression to which a specific meaning has been attached in any part of this policy or of the Schedule shall bear the same
meaning wherever it may appear. Any amendments/modifications/alterations made on this system generated policy document
is not valid and Company shall not be liable for any liability whatsoever arising from such changes. Any changes required to
be made in the policy once issued would be valid and effective, only after written request is made to the Company and
Company accepts the requested amendments/modifications/alterations and records the same through separate endorsement to
be issued by the company.
In Witness whereoff this policy has been signed at DELHI on 29-MAR-2022 13:40
 Bajaj Allianz General Insurance Co. Ltd.
Servicing Office of Insurer: BLOCK NO 4, DLF TOWER, 15, SHIVAJI MARG, NEW DELHI 110015,
Delhi, Delhi (State Code:07) -110015, PH-- Website: www.bajajallianz.com
PAN: AABCB5730G . GSTIN: 07AABCB5730G1ZZ Insurer's IRDA Registration Number: 113
Tollfree Helpline 011-66278000 Email: CIN : U66010PN2000PLC015329

PRIVATE CAR PACKAGE POLICY-CERTIFICATE CUM POLICY SCHEDULE

(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. OG-22-9910-1801-00267388 Policy Issued On 29-MAR-2022 (13:40)

Insured Name MR. SUMANTA KUMAR PATEL
Own Damage Period 02-APR-2022(00:00) To 01-APR-2023(Midnight) Motor Liability Period 02-APR-2022(00:00) To 01-APR-2023(Midnight)

PRIVATE CAR PACKAGE POLICY: ADD ON COVERS

Endorsement Wordings

In consideration of payment of additional premium, it is hereby agreed and declared that this Policy extends to cover the
depreciation amount, partly or fully, on assessed damaged parts allowed for replacement during repairs in the event of a
Partial Loss to the Insured Vehicle. In the event You have opted for co-payment, Your contribution shall be to the extent
agreed by You as shown in the Schedule for the depreciation amount on the assessed parts for each and every Partial Loss
claim. The benefits under Depreciation Shield would be available only if the Insured Vehicle is repaired at Our authorized
workshops. In case You have opted to repair the Insured Vehicle at a non-authorized workshop, Our liability will be
restricted to 90% of the assessed total claim amount under this cover.

Conditions

1. Claims made by You against Us under Depreciation Shield are subject to the terms and conditions set forth under the
Motor Insurance Policy
2. In case of transfer of ownership of the Insured Vehicle, the cover under Depreciation Shield shall expire
3. The benefits under Depreciation Shield can be utilized for a maximum of two times during the Policy Period

Exclusions

In addition to the exclusions mentioned under Motor Insurance Policy, We will not be liable to indemnify You for the
following events:

1. Where the Own Damage Claim made by You against Us under the Motor Insurance Policy is not payable
2. Depreciation pertaining to any part/ sub part/ accessories not approved for replacement by Us under Motor Insurance
Policy
3. Loss or damage to tyres and/or battery of the Insured Vehicle
4. Consequential loss of any kind arising out of claims lodged under Depreciation Shield
5. Where a loss is covered under Motor Insurance Policy or any other type of insurance policy with any other insurer or
manufacturers warranty or recall campaign or under any other such packages at the same time

If You do not agree whether any of these exclusions apply to Your claim, You agree to accept the burden of proving that
they do not apply.

Definitions

The words and phrases listed have special meanings We have set below whenever they appear in bold type and initial
capitals. Please note that references to the singular or to the masculine also include references to the plural or to the female
the context permits and if appropriate.

1. You, Your, Yourself: The person or persons We insure as set out in the Schedule
2. We, Our, Us: Bajaj Allianz General Insurance Company Limited
3. Accident, Accidental: A sudden, unintended and fortuitous external and visible event
4. Policy/ Motor Insurance Policy: Private Car Package Policy issued by Us to which this cover is extended
5. Insured Vehicle: The vehicle insured by Us under the Motor Insurance Policy and as shown on the Schedule
6. Policy Period: The period between and including the commencement date and expiry date as shown in the Motor
Insurance Policy Schedule
7. Schedule: The Schedule and any Annexure or Endorsement to it which sets outYour personal details and the
insurance cover in force
8. Own Damage Claim: The claims raised by You against Us for loss or damage to the Insured Vehicle due to the perils
mentioned under Section 1 of Motor Insurance Policy
9. Total Loss/ Constructive Total Loss: A loss under the Motor Insurance Policy where the aggregate cost of retrieval
and/ or repair of the Insured Vehicle, subject to terms and conditions of the Policy, exceeds 75% of the IDV of the
Insured Vehicle
10. Partial Loss: Any loss falling into a category other than (a) the loss mentioned under Sr. No. 9 above and (b) theft of
the Insured Vehicle