Bajaj Allianz General Insurance Company Ltd.

Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune

Transcript of Proposal for Liability Only Policy for Two Wheeler

Dear AMAN DEV

We wish to inform you that the contract under policy number 'OG-24-9906-1806-00177731' 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 : AMAN DEV
2. Proposer Address : PLOT 87A KHNO-15/6 POLE NO 110, QUTUB VIHAR PHASE 1 CHHAWLA , ,,
DELHI - 110071
3. Proposer Mobile Number : NA
4. Proposer Residential Number : NA
5. Proposer e-mail id : Pagseth@gmail.com
6. Proposer Profession : NA
B.Vehicle Details

Registration Month / Vehicle Vehicle Vehicle Fuel Type Cubic Year of Seating Capa-
Number Year of Make Model Sub Type Capacity/ Manufacture city
Regn Kilowatt
DL3SDE090 MAY-2015 SUZUKI GIXXER ALLOY PETROL 150 2015 2
5 WHEEL
Engine Chassis Vehicle IDV Electrical Non-Electrical CNG/LPG Unit Total IDV (in Rs.)
Number Number (in Rs.) IDV (in Rs.) Accessories IDV (Extra fitted)
(in Rs.) IDV (in Rs.)
BGA1155559 MB8NG4BBE 0 0 0 0 0
F8103231
C. Coverage opted
1. Period of Insurance : From 21-Aug-2023 (Hrs) To
20-Aug-2024 Midnight
2. Is your vehicle fitted with external LPG/CNG kit : No.
3. Whether PA cover is opted for owner-driver : No.
4. Whether geographical area extension is opted : No.
Details of Countries to which geographical area extension cover is given : NA.
5. Is LL to person for Paid driver/Operation/Maintenance opted : No.
6. Whether PA cover is opted for paid driver other than owner driver : No.
Number Of Paid Driver(s) : : NA
Sum Insured Per Paid Driver : : Rs.NA.
7. Whether PA cover is opted for passengers : No.
Number Of Passengers : : NA
Sum Insured per Passenger : Rs.NA
8. Is TPPD restricted to statutory limit of Rs.6,000? : Yes.
9. Premium for Liability coverage, quoted and agreed upon is : Rs.664.00.
10. Do you have valid PUC certificate of the vehicle : NA
11. Do you have valid Fitness certificate of the vehicle : NA
12. About the last insurance company

Previous Insurer - NA Previous Policy No -NA

Expiry On - 11-MAY-23
 13. To support our Go Green initiative, send policy copy link on registered
mobile number / email id:
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:
I/We hereby unconditionally allow the Company to share all my / our information being collected in this proposal form or
through telephonic / email / web-inputs means or other means, as updated from time to time within group entities.

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

Email address : Bagichelp@bajajallianz.co.in
Website : www.bajajallianz.com
Contact our policy servicing branch at: Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune-411014
Phone No :1800-209-0144.
INSURANCE ACT, 1938 SECTION 41 - PROHIBITION OF REBATES
No person shall allow or offer to allow either directly or indirectly, as an inducement to any person to take out or renew or
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 a policy
accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.
ANY PERSON IN BREACH OF COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE
WITH FINE WHICH MAY EXTEND TO RUPEES TEN LAKH.Bajaj Allianz General Insurance Co Ltd
*360799860*

Bajaj Allianz General Insurance Company Ltd.

Bajaj Allianz House, Airport Road, Yerwada, Pune - 411006(India)
LIABILITY ONLY POLICY FOR TWO WHEELER CERTIFICATE CUM POLICY SCHEDULE
UIN : IRDAN113RP0041V01200102

Policy issuing office and Correspondence address for communication by policyholder for claim, service request, notice,
summons, etc; Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune-411014 Phone No :1800-209-0144
Policy Number OG-24-9906-1806-00177731 Product Liability Only Policy For Two Wheeler
Period Of Insurance From: 21-Aug-2023 Policy issued on 19-Aug-2023 -
To: 20-Aug-2024 Midnight Cover Note No /
Application No Scrutiny No 360799860
Insured Name AMAN DEV Zone B
Insured Address PLOT 87A KHNO-15/6 POLE NO 110, QUTUB
VIHAR PHASE 1 CHHAWLA , ,, DELHI 110071

Customer ID 400584354 Premium Payer ID 400584354

Transaction Id
Policy Status ISSUED
GSTIN / UIN NA Place of Supply/State 07 - Delhi
Code/Name
Invoice No. 389627167/1
Company GST No 27AABCB5730G1ZX
Company PAN No AABCB5730G
Registration Make SubType Model CC/KW Mfg Seat Cap Vehicle/ Engine
No. year Trailer Number
Chassis
No
DL3SDE0905 SUZUKI ALLOY 150 2015 2 MB8NG4B BGA1155559
WHEEL
GIXXER BEF81032
31
SCHEDULE OF PREMIUM
OWN DAMAGE LIABILITY

Total Own Damage Premium: Basic Third Party Liability 664.00

Total premium 664.00 Total Liability Premium: 664.00

Special Discount 0
Net Premium 664.00
Integrated GST (18%) 120.00
Final Premium Rs. 784.00 ***All Premium Figures are in Rupees

Geographical Area : No Claim Bonus : 0%

Nominee Details Name : Ramdev Relationship : Father
Previous Insurer - NA Previous Policy No -NA Expiry On - 11-MAY-23
As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th
September of the next financial year
I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more
than the aggregate turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of
the provisions of the said sub-rule.

Nominee Details Name : Ramdev Relationship : Father

LIMITS OF LIABILITY: Under Section II-1(i) of the policy -> Death of or bodily injury : Such amount as is necessary to meet there requirements of the Motor
Vehicles Act,1988. Under Section II-1(ii) of the policy -> Damage to Third Party Property : Rs.6,000.00/-
 LIMITATION AS TO USE: The Policy covers use
of the vehicle for any purpose other than : Hire
or reward, Carriage of goods(other than
Stamp samples or personal luggage), Organised racing,
DutyRs. Pace making, Speed testing, Reliability trials,
0.5 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
obtaining such 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 Central Motor Vehicles Rules, 1989.
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".
Subject To IMT Endorsement Nos : 20 & Policy wordings attached herewith
Warranted that insured named herein or owner of the vehicle insured holds a valid Pollution Under Control (PUC)
and / or Fitness Certificate on the date of commencement of the Policy. If the PUC and/or Fitness Certificate is not
found to be valid on the date of commencement of the Policy, the Company reserves its right to consider the policy
void ab initio.
Broker Code 43080002 Channel Name : WS
Broker Name : POLICYBAZAAR INSURANCE BROKERS PRIVATE LIMTED
Contact No : 18002585881/18002585970
Email - care@policybazaar.com
Damage Details as per Annexure I
Premium Collection Details :- [Receipt No/Collection No/Amount] 9906-08519041 / 360799860 / Rs. 784.00 , *** If
premium paid through cheque, the policy is void ab-initio in case of dishonour of cheque.
This certificate of insurance is issued in accordance with the provision of Chapter X and Chapter XI of M.V. Act, 1988.
Damage Details Annexure : - NA
Remarks PDAMODULE

In case of any claim, please contact our 24 Hour Call centre at 1800-102-5858 (Toll Free) / 91-020-30305858 (chargeable, add area
code before this number in case of mobile call) or email us at 'Bagichelp@bajajallianz.co.in'.
360799860/-/43080002/NA/-
This is a one page Policy Document [without enclosing the Terms and Conditions (T&C) of the Policy] issued by the Company, pu rsuant to the authorization of Insured to display the T&C of the Policy on its website (www.bajajallianz.com) that enables access b y
the Insured. The T&C of the Policy are available on the Company's website and can be accessed by the Insured.
Kindly contact our nearest / local office(s) for No Claim Bonus Confirmations.

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

Regd. Office : Bajaj Allianz House, Airport Road, Yerawada,Pune - 411006 (India),A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance
Regulatory and Development Authority of India [IRDA] vide Reg No.113, Corporate Identification Number U66010PN2000PLC015329.Principal Location : Bajaj Allianz House,
Airport Road, Yerwada, Pune - 411006 PH:66026666 | Services Accounting Code : 997134 - Motor vehicle insurance services. No reverse charge is payable on these services.
- Latest Schedule - 19-Aug-2023 16:29:51 PM (Web)
*360799860*

Authorized Signatory This document is digitally signed, hence counter signature / stamp is not required
Printed , Signed and Executed at Pune

Consolidated Stamp Duty of Rs.0.5/- paid towards Insurance Stamps vide Challan No. MH004724512202324M Defaced No. 0003192043202324 dated 03-AUG-23 timing
14:53:10 of General Stamp Office,Mumbai,India.
Generated by Silent_Printing
Regd. Office : Bajaj Allianz House, Airport Road, Yerawada,Pune - 411006 (India),A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance
Regulatory and Development Authority of India [IRDA] vide Reg No.113, Corporate Identification Number U66010PN2000PLC015329.Principal Location : Bajaj Allianz House,
Airport Road, Yerwada, Pune - 411006 PH:66026666 | Services Accounting Code : 997134 - Motor vehicle insurance services. No reverse charge is payable on these services.
- Latest Schedule - 19-Aug-2023 16:29:51 PM (Web)

Bajaj Allianz General Insurance Company Ltd.

Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune - 411014 Contact
No:Contact No: 1800-209-0144

RECEIPT

Receipt Number 9906-08519041

Receipt Date 19/08/2023
Business Channel WS

Received with thanks from AMAN DEV

(Customer ID : 400584354 ) a total sum of Rupees Seven Hundred Eighty Four Only by,

Instrument Instrument No. Instrument Bank Name Branch Name Amount

Type Date
Online PBPB7600359 19/08/2023 NA NA 784
Payment 5
Total Amount Rs. 784.00
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: Bajaj Allianz House,Airport Road, Yerwada, Pune - 411006