Policy Number : P0023400023/4113/103141

DEVELOPMENT HOUSE, 24 Park Street , Kolkata -700016

In case of any query, assistance or claims, please contact us at 1800 266 3202
UIN: IRDAN149P0002V02201213

Two Wheeler Policy- Bundled - 5 year Act only and 1 year Own Damage
Endorsed Certificate of Insurance cum Schedule /TAX INVOICE
Policy Servicing Office 4TH FLOOR, ANUJ CHAMBER, 24 PARK STREET ,KOLKATA -700016 ,WEST BENGAL , PH: (1800) 2663202
Policy No P0023400023/4113/103141 Period of Insurance(Own Damage) 17:55 Hrs of 03/07/2022 To 23:59 Hrs of 02/07/2023
Insured Mr SAMBHU MODAK Period of Insurance(Third Party Liability) 17:55 Hrs of 03/07/2022 To 23:59 Hrs of 02/07/2027
Address ASWINI PALLY BARASAT Period of CPA Cover 17:55 Hrs of 03/07/2022 To 23:59 Hrs of 03/07/2023
NORTH 24 PARGANAS PRANAB KUMAR DUTTA-POS0001114-AKIPD9858M-
Agent No.:
WEST BENGAL 700124 XXXXXXXX9572
Mobile:8017395488 Endt. No. EE01
Contact Number 8017395488 Endt. Effective Date 03/07/2023
Email ID:
GST Number Unregistered Hypothecation with TATA CAPITAL FINANCIAL SERVICES LTD
INSURED MOTOR VEHICLE DETAILS AND PREMIUM COMPUTATION
Registration Mark & No. & RTA
Year of Manufacture Engine No. Chassis No. Make/Model/Type of Body CUBIC CAPACITY SEATING CAPACITY
Location
NEW /
2022 CK3FN2204081 MD626BK33N2F04074 TVS NTORQ 125 XT BS VI/SCOOTER 125 2
BARASAT
IDV (INSURED'S DECLARED VALUE)
IDV of Vehicle Non Electrical Accessories Electrical/electronic Accessories Bi-Fuel kit(LPG/CNG) Other accessories Total Value
96885 0 0 0/0 0 96885
OWN DAMAGE(A) LIABILITY(B)

Basic OD 487.14 Basic TP 3,851.00

Sub Total 487.14 PA Owner Driver -SI Rs.1500000 Tenure 1 Year(s) 350.00
Total Own Damage Premium(A) 487.00 Sub Total 4,201.00
Less:
TPPD Discount 250.00
Sub-Total Deductions 250.00
Total Liability Premium(B) 3,951.00
Premium Computation
Total Package Premium(A+B) 4,438.00
CGST @ 0% 399.42
SGST @ 0% 399.42
TOTAL 5,237.00
Disclaimer:The Exclusions in this policy are as specified in the pre inspection report ID :
LIMITATIONS AS TO USE - The Policy covers use of the vehicle 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)Use in connection with Motor Trade
Driver 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.Provided also that the person holding an effective Learner's license
Clause : may also drive the vehicle and that such a person satisfies the requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.
LIMITS OF LIABILITY
Under Excess in respect of each and every claim under Sec I of motor Under In respect of any one Under Damage to Third Party Property Rs. 6000/- in Under PA Owner – Driver as per
Section I policy Section II-I accident -- As per Motor Section II-I respect of any one claim or series of claims Section III: premium computation table
Compulsory : Rs. 100/- Voluntary : Rs. 0/- Imposed : Rs. 0/- (i) Vehicle Act (ii) arising out of one event.
Total : Rs. 100/-
Subject to I.M.T Endorsement Nos. IMT 7,IMT 20,IMT 22

Date of Signature of proposal 03/07/2022

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.

Premium Amount in Word's ( ) :- Five Thousand Two Hundred Thirty-Seven Only

For Magma HDI General Insurance Co. Ltd.
In case of Claims, please contact us at 1800 266 3202

Date of Issue : 03/07/2023

Place : Kolkata

Consolidated Stamp Duty on the issue of General Insurance Policies Paid vide G.O No. 1879, dated 16/10/2023
GST Number of MHDI 19AAGCM1685C1ZG
GST Invoice Number - POL1907230000557
Accounting Code for Service - 997134, Motor vehicle insurance services

Previous GST Invoice No. -POL1907230000557

Authorised Signatory
Place of Supply:WEST BENGAL ( 19 )

Whether Tax is payable on Reverse Charge - No

UIN : IRDAN149P0002V02201213
This is a valid Tax invoice in terms of Sub-rule 2 of Rule 54 of CGST Rule 2017. Further, being an Insurer, issuing of e-invoice and QR Code are not
applicable on us in terms of Notification No 13 and 14 of 2020 dated 21st March 2020 issued from Central Board of Indirect Taxes and Customs.
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 legal interpretation English version will be good. Please note that any
misrepresentation, non disclosure or withholding of material facts will lead to cancellation of policy ab initio with forfeiture of premium and non consideration of claim, if any.

As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 31st October of the next financial year.
For Complete details of coverage , terms, conditions & exclusion please refer the standard policy wording attached with this schedule

IMPORTANT - 1) The Validity of this Certificate of Insurance cum Schedule is subject to realisation of the premium cheque.
2) No Claim Bonus will only be allowed provided the Policy is renewed within 90 days of the expiry date of the previous policy.
3) This document is digitally signed, hence counter signature / stamp is not required.
4) For detailed terms & conditions please refer our website www.magmahdi.com
 Policy Number : P0023400023/4113/103141
We at MAGMA HDI prefer receiving premium amount through cheque
No. TW./{lblProposalNo}

Call Us : 1800 266 3202

(Information for fields marked with asterisk [*] is mandatory)

Proposal Form for {lblHeadingMotor1}
Customer ID
*Proposal For: New Policy Roll- Over Renewal Endorsement
*Type of Vehicle : Two Wheeler Private Car Three Wheeler *Vehicle Insured is: New Used

*Coverage Comprehensive Package Cover Third Party Liability only Cover Third Party, fire & theft only Cover
Required: Third Party and Fire only Cover Third Party and Theft only Cover {lblLongTerm}

Intermediary Code: Intermediary Name:

{lblPOSPDetails}
{lblProposalFormPeriod}
(Note: Cover shall not commence earlier than the date and time of acceptance of risk and/or issuance of cover note and subsequent to payment of premium)

1. *Proposer Details:
1. Name (Registered Owner of the Vehicle): Mr

PAN No: *DOB: *Gender: M F *Occupation: *Marital Status:

Bank Name Branch Name A/c Type- Saving Current
Account No. MICR IFSC
2. *Address where Vehicle Registered and Based
ASWINI PALLY BARASAT, NORTH 24 PARGANAS, WEST BENGAL 700124, 8017395488 ,Mobile:8017395488 {lblWhatsappDetails}
{lblGSTNumber}
3. *Communication Address (For policy dispatch)
ASWINI PALLY BARASAT, NORTH 24 PARGANAS, WEST BENGAL 700124
{lblGSTNumber}
4. City where the vehicle will primarily be used: NORTH 24 PARGANAS
5. Have you been previously insured in respect of this vehicle? Yes No Policy No.

If so, are you entitled to No Claim Bonus from your previous Insurer? Yes No
If Yes, Kindly indicate the percentage: 20% 25% 35% 45% 50% 55% {lblPlan500} 65%

I/We hereby declare that the rate of NCB claimed by me/us is correct and that NO CLAIM has arisen in the expiring policy period (Copy of Policy enclosed). I/We further undertake that if this declaration is found incorrect, all
benefits under the Policy in respectof Section1 of the Policy will stand forfeited.

Signature of Proposer
6. About the Motor Vehicle to be Insured
*Make *Chassis No Speedometer reading as on date
*Model RTO where vehicle will be registered *Vehicle IDV
*Year of Manufacture - Date of Registration /Purchase Trailer(s) Identification No. 1_________
*CC/GVW Licensed Carrying Capacity 2_________
(No of Passengers Including driver)
*Registration No. 3_________
Type of Body Colour of the vehicle 4_________
*Engine No. Vehicle Make (Indigenous or Imported)
Note: Either Registration no or Engine and Chassis Number is mandatory

*Vehicle Rate Under: Zone -A Zone -B

*Fuel Used: Petrol Diesel Bi Fuel LPG/CNG Electric Hybrid Others (please specify)
*Type of Permit: Express Way National/State Highways City/Town Road District Roads Private Road
* Average Monthly usage : Less Than 50 Kms Between 50 and 100 Kms Between 101 and 250 Above 251 Kms
Whether any modification or conversion has been done in the vehicle from the maker’s standard specification? Yes No
If Yes, please give details of such modifications/conversions...................................
Is the vehicle in good state of repair? Yes No If No, please furnish details ................
Where will the vehicle be generally parked?

Roadside Public Parking Road Outside Parking lot open or covered Within compound of residence open

Within compound of residence covered

7. Financier Details: Hypothecation Hire Purchase Lease Financier Name :

8. Nominee Details : Nominee Name: DOB Relationship

Appointee Name & age *If Nominee is minor (below 18 yrs) Appointee Name is mandatory.
9. Insured Declared value of the Vehicle:
The IDV of the vehicle will be deemed to be the Sum-Insured for the purpose of the Policy and will be fixed on the basis of the manufacturer’s listed selling price of the brand and model as the vehicle proposed for insurance at the
time of commencement of insurance / renewal and adjusted for depreciation as per the schedule specified below.
Age of the Vehicle % of Depreciation Insured Decleared Value 1st Year ( ) 2nd Year ( ) 3rd Year ( )
Not exceeding 6 months 5% *Vehicle Chassis Value {lblIDVofBody2} {lblIDVofBody3}
Exceeding 6 months but not exceeding 1 year 15% Vehicle Body Value {lblVehChasV2} {lblVehChasV3}
Exceeding 1 year but not exceeding 2 years 20% Non- Electrical Accessories (Other than factory fitted): Details {lblNonElecAcc2} {lblNonElecAcc3}
Exceeding 2 years but not exceeding 3 years 30% Electrical Accessories (Other than factory fitted) Details {lblElecAcc2} {lblElecAcc3}
{lblIDVofLpg2} {lblIDVofLpg3}
Exceeding 3 years but not exceeding 4 years 40% Bi- Fuel/ CNG/LPG Kit
{lblIDVofCng2} {lblIDVofCng3}
Exceeding 4 years but not exceeding 5 years 50% Trailer(s)/ Side Car Value (only for 2 wheelers): {lblVehBodyV2} {lblVehBodyV3}
Total IDV: {lblTotalVal12} {lblTotalVal12Two} {lblTotalVal12Three}
Note - For vehicles more than 5 years old, please contact the Company for fixing the IDV
 Policy Number : P0023400023/4113/103141

We at MAGMA HDI prefer receiving premium amount through cheque

10. Extended Covers/ Extra Benefits at Additional Premium:
Extension of Geographical Area: Vehicle is fitted with Fibre Glass Fuel Tank Yes No

Bangladesh Bhutan Nepal Vehicle will be used for Driving Tuitions Yes No

Maldives Pakistan Sri Lanka Imported vehicle without payment of customs duty Yes No

Compulsory Personal Accident for {lblCPASi} /- Per Yes No {lblNA} Is the vehicle Company Yes No
Annum (If owner has a valid driving license) Maintained?

{lblPAOwnerDetails} Will the vehicle be let out on occasional Hire? Yes No

Whether the vehicle is certified as Vintage Car by Yes No

Vintage and Classic Car Club of India ?
Vehicle used for commercial purposes: Yes No

Yes No {lblNA} Do you wish to include Personal Accident cover for unnamed occupants of the vehicle in excess of the compulsory
Do you want to opt for wider legal liability to Paid Driver Personal Accident cover for the Owner/Driver?

Yes No
Other employees Yes No
(If Yes, No. of persons tobe covered.........) Sum Insured per person to be Rs
Nominee Details : Name _________________
Do you want to cover loss of accessories
due to burglary, Age _______________ Relationship _______________
Yes No If yes, please indicate the Sum-Insured per person (In multiples of Rs.10000/- for a maximum of Rs.1 lakh per
housebreaking or theft?
person for Two Wheelers and Rs. 2 lakhs per person for Private Cars. The number of persons to be covered for the
(Applicable only for Two-Wheelers) purpose of this Add-on will be equivalent to the registered carrying capacity of the vehicle)

Do you wish to have an enhanced Personal Do you wish to cover Hospital Cash for hospitalisation arising out of accident for Yourself/Your Driver/Unnamed
accident cover for Yourself/ occupants of the vehicle?
Your Driver/Unnamed occupants of the
Yes No {lblNA} Yes No
vehicle?

If Yes, please provide the Sum Insured per

person............

Do you wish to include Personal Accident cover for named persons? {lblPlan1005} Yes {lblPlan1006} No {lblNA}

If YES, give name and Capital Sum Insured (CSI) opted for :

{lblCSIDetails}
(Note : The maximum CSI available per person is Rs. 2 lakhs in case of Private Cars and Rs.1 Lakh in the case of motorized Two wheeler)

11. Add On Coverage at additional :

{lblAddonPlan}

{lblExAddonPlan}
{lblPreAddon}
12. Restrictions of Cover/ Discounts:
Is the vehicle designed for use of Blind / Handicapped/Mentally challenged persons and duly endorsed as such by
RTA ?
Vehicle fitted with Anti-theft device approved by ARAI: Yes No {lblNA}
Yes No
Vehicle will be used within own premises : Yes No {lblNA}
Are you a member of Automobile Association of India? {lblPlan1003} Yes {lblPlan1004} No
Third Party Property Damage cover restricted to 6000 Yes No {lblNA}
If yes, please state
(Third Party Property Damage cover of Rs 1 lakh for 2 wheelers and Rs 7.5 lakhs for Private cars)
a. Name of Association {lblNameofAsso}
b. Membership No. {lblMembershipNo} c. Date of expiry {lblXpiryDate}
*Voluntary Deductible :
Two Wheeler : None 500/- 750/- 1,000/- 1,500/- 3,000/-

{lblPlan206} I hold a valid and effective PUC and/or fitness certificate, as applicable, for the vehicle mentioned herein above and undertake to renew the same during the policy period.

Signature of Proposer
13. Previous Insurance Details:
Previous Insurer Name: Type of cover:
Policy/ Cover note number: Period of Insurance: From To
Has any Insurance Company ever: Claims reported in last 5 years
1) Declined the proposal Year 1 2 3 4 5
2) Cancelled & Refused to renew
3) Required an increase in Premium Type of Claims
4) Imposed special conditions or excess (OD/TP)
No. of Claims
Amount
14. Driver Details:
a. Age & Date of Birth of the Owner : Age:_______ Yrs DOB:_____/_____/_____
b. Age & Date of Birth of the Driver : Age:_______ Yrs DOB:_____/_____/_____
c. Does the driver suffer from defective
vision or hearing or any physical infirmity? {lblPlan183} Yes {lblPlan184} No
lf YES, please give details of such infirmity :
d. Has the driver ever been involved/convicted
for causing any-accident of loss? {lblPlan185} Yes {lblPlan186} No

lf YES, give details as under including the pending prosecutions:

-Driver's Name :
-Date of Accident:
-Loss / Cost ( Rs.)
-Circumstances of Accident / Loss
15. Premium Details

Total Premium (Including GST): Payment Mode : Cash Cheque DD

Cheque/DD, Cheque No Bank/Branch Date.
16. Electronic Insurance Details
• Do you wish to have this Policy credited to an eIA? (Please select any one)
• {lblPlan250} No, I do not have an eIA and do not wish to open one {lblPlan251} Yes, Credit this Policy to my e-Insurance account
• If yes, Please share existing e-Insurance Account No : {lblEIANumber}
• Please select Insurance Repository Name (you have opened your account with)
• {lblPlan252} M/s NSDL Database Management Limited {lblPlan253} M/s Karvy Insurance Repository Limited
• {lblPlan254} M/s Central Insurance Repository Limited {lblPlan255} M/s CAMS Repository Services Limited (Please select any one) Or
• {lblPlan256} I do not have existing e-Insurance account and I am interested in creating a new e-Insurance account (Please submit electronic insurance account opening form (eIA form) along with relevant documents)
• My CKYC No. (Central Know Your Customer registry number) is (if available): {lblCKYCNumber}
• Representative Details (only if eIA is to be opened for any other person other than Proposer and primary Insured)
{lblRepresentativeDetails}

Declaration: I/We hereby declare that the statements made by me/us in this Proposal Form are true to the best of my / our knowledge and belief and I/We hereby agree that this declaration shall form thebasis of the contract
between me/us and the Magma HDI General Insurance Co. Ltd.
I/We also declare that any additions or alterations carried out after the submission of this Proposal Form would be conveyed to Magma HDI General Insurance Co. Ltd immediately.
I/We hereby agree to receive a One Page Motor Insurance Policy in Physical Form, to be read along with the detailed Terms and Conditions available on the website www.magmahdi.com
Yes No
I/We further confirm that the existing damages as per the pre inspection report, if any, have duly been shared with me & my consent has been obtained for the same.
I/We hereby declare and undertake that the amount paid by me/us as premium for the aforementioned vehicle is out of my/our lawful and declared source of Income.

{lblAgreedLine}
I wish to get all policy related communications on My Whatsapp Number:{lblWhatsappNo} and allow to make welcome calls, Services calls or any other communication(electronic or otherwise),subject to the provision of
applicable law. The salient features of the policy,terms and conditions of this proposal have been explained to me/us in___________________ language, and I/we agree to the same.
 Policy Number : P0023400023/4113/103141
__________________________________
Place: Kolkata Date: Signature of Proposer
SECTION 41 INSURANCE LAWS (AMENDMENT) ACT, 2015 - PROHIBITION OF REBATES
1.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 or 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 policy accept any rebate except such rebate as may be allowed in accordance
with the prospectus or tables of the Insurer.
2.If any person fails to comply with sub-regulation (1) above, he shall be liable to payment of a fine which may extend to Ten Lakh Rupees.

{lblDeclaration} {lblTermsAndCondi} {lblIPDetails}

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