Trejhara

Mr. RAVINDRA .
R/O KASAR BHOSGA
JEWARGI
JEWARGI
KARNATAKA India - 585310
7845******

Welcome on board.
Your Reliance Commercial Vehicles (Passengers
Carrying 3W<6) Package Policy - Schedule
Number 131622423390000501 is now live to
access your policy anytime, anywhere
download our Reliance Selfi App and enjoy a
host of special features.

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off Western
Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0012V02100001. Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/PCV/PS/Ver. 1.3/310118
Page 1 of 10
 Digitally signed by Reliance
General Insurance
Company Limited
Date: 2024.07.22 19:55:10
Trejhara IST

Reliance Commercial Vehicles (Passengers Carrying 3W<6) Package Policy - Schedule

Policy Number : 131622423390000501 Proposal/Covernote No: R220724109134
Insured Name : Mr. RAVINDRA . Period of Insurance : From 19:52 Hrs on 22-Jul-2024 to Midnight of
21-Jul-2025
Communication Address & Place of Supply : R/O KASAR BHOSGA JEWARGI Policy Issuing Branch : F-17, UG Floor, Unit 1/2, Preet Vihar, , NEW DELHI,
JEWARGI, GULBARGA, KARNATAKA, India, 585310. DELHI, 110092.

Mobile No : 7845****** Tax Invoice No. & Date: R220724109134 & 22 Jul 2024 07:55
Email-ID : B*******@SMDIPOINT.COM GSTIN/UIN & Place of Supply : KARNATAKA

Insured Vehicle Details

Registration No. NEW Mfg. Month & Year JUL-2024
Make / Model & Variant BAJAJ RE COMPACT PETROL 4S CC / HP / Watt 236
Engine No. / Chassis No. AZXWRD36679 / MD2B51BX6RWD15886 LCC Including Driver 4
Type of Body NA Total Premium ` 8216
RTO Location KARNATAKA - Gulbarga Total IDV ` 215,000.00
Manufacturer fully build in Yes Hypothecation/Lease Bajaj Auto Credit Ltd
Vehicle Category Vehicle Usage Type
Vehicle Usage Sub Type

Insured Declared Value (IDV)

Chassis IDV ` 0.00 Non Electrical Accessories ` 0.00
Body IDV ` 0.00 CNG / LPG Kit ` 0.00
Vehicle IDV ` 215,000.00 Trailer / Side Car ` 0.00
Electrical / Electronic Accessories ` 0.00 Total IDV ` 215,000.00
Premium Summary
Own Damage - Section I Amount (`) Liability - Section II Amount (`)
Basic OD 704.34 Basic Liability (TPPD 1) 5,773.00
Covers for Lamps Tyres/Tubes Mudguards/Bonet/Side Total Basic Liability Premium 5,773.00
parts etc (IMT-23) 105.65 PA Benefits - Section III
Total Basic Own Damage Premium 809.99 Compulsory PA cover to Owner Driver 330.00
Total PA Premium 330.00
Legal Liability to paid driver and/or Conductor and/or
cleaner 50.00
null (S.I.null) TOTAL LIABILITY PREMIUM 6,153.00
TOTAL OWN DAMAGE PREMIUM 809.99 TOTAL PACKAGE PREMIUM (Sec I + II + III) 6,963.00
IGST (@18.00%) 1253.00
TOTAL PREMIUM PAYABLE (`) 8,216.00
Subject to I.M.T.Endt.Nos. & Memorandum printed/herein/attached hereto. IMT 40,23,22,7
GSTIN :07AABCR6747B1ZI
HSN : 997134, Description of services : Motor vehicle Insurance Service
"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." As per th

PA-Nominee Details Name Age Relation

1 MOHAMMED IBRAHIM 58 Father
Consolidated Stamp duty Paid vide Letter of Authorisation“NO LOA/ENF-1/CSD/22/2024-25/(Validity Period Dt.12/06/2024 to Dt.01/12/2025)/2575 Date 07-06- 2024” at
General Stamp Office, Mumbai.** Not Applicable for the State of Jammu & Kashmir.
22BRG690 / ZOPPER INSURANCE
8929876286 aakash@bimaboss.in
BROKERS PRIVATE LIMITED
Intermediary Code/Name Intermediary Contact No. Intermediary E-mail ID POS UID Aadhaar No. / PAN No.
Limits of liability : PA cover for owner driver under section III CSI ₹ 1500000 (a) Under Section II (1)(i) of the Policy-Death of or bodily
injury to any person so far as it is necessary to meet the requirements of the Motor Vehicle Act, 1988. (b) Under Section II
(1)(ii) of the Policy-Damage to property other than property belonging to the insured or held in trust or in the custody of
control of the insured up to the limits specified- (TPPD 1 Sum Insured - ₹ 7,50,000/-, TPPD 2 Sum Insured- ₹ 6,000/-).
Limitations as to use : The policy covers the use only under a permit within the meaning of Motor Vehicle Act, 1988 or such a carriage falling
under sub-section (3) of Sec 66 of the Motor Vehicle Act, 1988. The Policy covers use for any purpose other than: (a)
Organized racing (b) Pace making (c) Speed testing (d) Reliability trials.(e) Use whilst drawing a trailer except the
towing (other than for reward) of any one disabled mechanically propelled vehicle.

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0012V02100001. Trade logo displayed above belongs to Anil Dhirubhai Ambani
Ventures Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/PCV/PS/Ver. 1.3/310118
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 Trejhara

Persons/Classes of persons : Any person including insured:

entitled to drive: Provided that a person driving holds a valid driving license at the time of the accident and is not disqualified from holding
or obtaining such a license. Provided that the person holding a valid learner’s license may drive the vehicle when not used
for the transport of goods at the time of the accident and that such a person satisfies the requirements of Rule 3 of the

Deductible under Section-I : : (i) Compulsory deductible ` 500/- (ii) Additional compulsory deductible ` 00/- (iii) Voluntary deductible ` 0/-
The NCB provided is on Basic OD Premium excluding Add-on wherever applicable. The policy wording with detailed terms, conditions and exclusions are available on
our website www.reliancegeneral.co.in
Statutory Provisions :
"As per Section 146 of the Motor Vehicle Act, 1988 it is Mandatory to have your vehicle insured against third party risk."
As per Section 196 of the Motor Vehicle Act, 1988 driving an uninsured vehicle is punishable with fine or Rs. 2000 and/or imprisonment up to 3 months for the first
offence and fine of Rs. 4000 and/or imprisonment up to 3 months for the second offence."
I/We hereby certify that the Policy to which the certificate relates as well as this certificate of insurance are issued in accordance with the provision of Chapter X and
Chapter XI of M.V. Act, 1988.
Note :In the event of dishonor of cheque, this policy document automatically stands cancelled from inception irrespective of whether a separate communication is sent
or not.

Safeguard your transaction by paying your premium via crossed cheque/DD in favour of Reliance General Insurance Co. Ltd.
The policy has been issued based on the information provided by you and the policy is not valid if any of the information provided is incorrect. Subject otherwise to the
terms, conditions and exclusions of the Reliance Miscellaneous and Special Types of Vehicles Package Policy Certificate Cum Policy Schedule. In witness whereof this
Policy has been signed at Mumbai on policy tax invoice date in lieu of Proposal/Covernote No. as mentioned in the policy.
This document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services Tax Rules 2017.
Updating Registration Number of vehicles within 15 days of policy inception is MANDATORY as per IRDA. Kindly provide the same to your Agent/Our Call
centre/Policy issuing Branch (Applicable for policies booked without Registration No of vehicles).

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 hold good.
In case of a renewal, the benefits provided under the policy and/or terms and conditions of the policy including premium rate may be subject to change.
As per National Highways Authority of India, kindly ensure to affixed FASTag on your vehicle.
Grievance Clause : For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 02248903009 or may
write an email at rgicl.services@relianceada.com. In case the insured is not satisfied with the response of the office, insured may contact the
Nodal Grievance Officer of the Company at rgicl.grievances@relianceada.com. In the event of unsatisfactory response from the Nodal
Grievance Officer, insured may email to Head Grievance Officer at rgicl.headgrievances@relianceada.com. In the event of unsatisfactory
response from the Head Grievance Officer, he/she may, subject to vested jurisdiction, approach the Insurance Ombudsman for the redressal of
grievance. Details of the offices of the Insurance Ombudsman are available at IRDAI website www.irda.gov.in or on company website
www.reliancegeneral.co.in or on www.gbic.co.in. The insured may also contact the following office of the Insurance Ombudsman within whose
territorial jurisdiction the branch or office of the Company is located.
Smt. Sandhya Baliga Office of the Insurance Ombudsman,2/2 A,Universal Insurance Building,Asaf Ali Road,New Delhi – 110 002. Tel.: 011 -
23239633 / 23237532 Fax: 011 - 23230858 Email: bimalokpal.delhi@cioins.co.in
Note: Kindly acknowledge the receipt of this policy. In case you find any variations against your proposal or any discrepancy in the policy, kindly contact us immediately.

Fast Tag ID -

The policy does not cover liability for death, bodily injury or damage as excluded under Section 150 (2) (ii) and (iii): b and C of the Motor Vehicles Act 1988 (Inserted
Vide GSR no 164 (f) dated 25.02.2022 w. e. f 01.4.2022)
In the unfortunate event of a claim, please call quoting your Policy No. on 022 48903009(Paid) and register your claim immediately within 7days from the date of loss.
In the absence of any communication from you within a period of 15 days of receipt of this letter, we will consider that the issued policy is in order and as per your
proposal.
Special Conditions : NA
Policy has been issued with reference to vehicle inspection report, reference lead no. & special conditions.The inspection report remarks can be
viewed on company's website by the lead no.

For Reliance General Insurance Co. Ltd.

Authorised Signatory

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0012V02100001. Trade logo displayed above belongs to Anil Dhirubhai Ambani
Ventures Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/PCV/PS/Ver. 1.3/310118
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0 0 0 Risk Assumption Letter

Dear Mr. RAVINDRA .
Thank you for choosing Reliance General Insurance.
Please find enclosed policy no.: 131622423390000501 which has been issued based on the details declared by the applicant.

Insured Vehicle Details

Registration No. NEW Mfg. Month & Year JUL-2024
Make / Model & Variant BAJAJ RE COMPACT PETROL 4S CC / HP / Watt 236
Engine No. / Chassis No. AZXWRD36679 / MD2B51BX6RWD15886 LCC Including Driver 4
Type of Body NA Total Premium ` 8216
RTO Location KARNATAKA - Gulbarga IDV ` 215000
Manufacturer fully build in Yes Hypothecation/Lease Bajaj Auto Credit Ltd

Insured's Declared Value (IDV)

Chassis IDV ` 0.00 Non Electrical Accessories ` 0.00
Body IDV ` 0.00 CNG / LPG Kit ` 0.00
Vehicle IDV ` 215000 Trailer / Side Car ` 0.00
Electrical / Electronic Accessories ` 0.00 Total IDV ` 215,000.00

Previous Policy Details

Previous Year Policy No. Period of Insurance Previous Policy-Claim Status
From: To: Yes No
YOU HAVE OPTED FOR THE FOLLOWING COVERS
Standard Vehicle Own Damage + Third Party Coverage
Cover Electrical/electronic accessories
Non-electrical accessories
Bi-fuel kits comprising LPG/CNG systems
Add-on Covers
Nil Depreciation Cover No deduction for depreciation on vehicle parts other than tyres and tubes with respect of approved partial loss claims.

Additional towing Charges Provides cover for towing charges over and above the standard policy guideline as per the cover opted by customer (Sum
Insured - ` 0/-)
Additional Limit of TPPD Indemnify the Insured for an additional TPPD amount opted for damage to property other than the property belonging to the
Insured or held in trust or in custody of Insured.
Emergency Hotel Provide allowance towards the Hotel accommodation insured vehicle met with accident/ stolen 200 kms away from the location
Accommodation provided in policy copy.
Please take a moment to carefully check your policy details mentioned above and in the policy schedule. Kindly confirm that the same are in order. In case of
discrepancies, please let us know immediately. You can write to us at rgicl.services@relianceada.com or call us 022 48903009(Paid) for necessary
changes/rectification. In the absence of any communication from you within a period of 15 days of receipt of this letter, we will consider that the issued policy is in order
and as per your proposal. Non disclosure and/or misrepresentation of claims in the previous policy period can lead to cancellation of your policy or rejection of your
claims.
(Note- Warranted that the insured named herein/owner of the vehicle holds a valid Pollution Under Control (PUC) Certificate and/or valid fitness certificate, as applicable,
on the date of commencement of the Policy and undertakes to renew and maintain a valid and effective PUC and/or fitness Certificate, as applicable, during the
subsistence of the Policy. Further, the Company reserves the right to take appropriate action in case of any discrepancy in the PUC or fitness certificate.)

For Reliance General Insurance Co. Ltd.

Authorised Signatory

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0012V02100001. Trade logo displayed above belongs to Anil Dhirubhai Ambani
Ventures Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/PCV/PS/Ver. 1.3/310118
Page 4 of 10
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Know your policy

Remember to carefully go through the Risk Assumption Letter and confirm your personal as well as your vehicle details.
In case of any discrepancy in the policy details, kindly revert within 15 days from the policy start date on 022 48903009 (Paid) or visit any of our branches.
Kindly refer to the Key Feature Document and Policy Wording at www.reliancegeneral.co.in to understand your policy better and learn more about the policy coverages,
add-on covers and Policy Exclusion. This document is a statement of the specific provisions that form the Terms and Conditions of this Policy.

What documents do you require for making any change to your policy
1. Changes in vehicle make & model/cubic capacity/seating capacity/engine & chassis no./year of manufacture/registration no./ location/address
Documents required : Letter for change, policy copy and registration certificate copy along with additional premium cheque, if applicable.
2. Changes in electrical and non electrical accessories/CNG/LPG kit
Documents required : Letter for addition, policy copy, invoice copy of accessories, endorsed registration certificate copy (for CNG/LPG kit) and cheque for additional
premium.
3. Changes in financier details (Hypothecation/Lease/Hire purchase)
Documents required : Letter for change, policy copy, endorsed registration certificate copy and no objection certificate from financier (not mandatory for deletion, if
registration certificate copy is endorsed).

How to register a Claim - Cashless

How to register a Claim - Reimbursement

What documents do you require to register a Claim

1. Claim form duly filled and signed (company stamp in case of company registered vehicles)
2. Registration copy
3. Driving License of the driver at the time of loss
4. Policy copy
5. Vehicle fitness certificate
6. Vehicle route permit
7. Vehicle carriage permit
8. Road tax copy
9. Load Challan (if applicable)
Note: 1. As soon as a claim occurs, please intimate immediately to our call centre 022 48903009 (Paid). Delay in intimation would result in the violation of policy
condition.
2. Any additional document, if required, will be informed.

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0012V02100001. Trade logo displayed above belongs to Anil Dhirubhai Ambani
Ventures Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/PCV/PS/Ver. 1.3/310118
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Proposal Form for POS Reliance Commercial Vehicles Package Policy

(Other than Motor Trade Internal Risks Policy)
(The queries made/details stated below are the minimum requirement to be furnished by a proposer.
The Insurer may seek any other information as desired for under for underwriting purpose.)
*(Applicable to all classes of vehicles with suitable amendments in 'Limitations as to Use')
PCV GCV MISC D Trailer

For Office Use Only

Policy Number 131622423390000501 Date
Savvion Reference No. Inspection Lead No.

Intermediary Details (To be filled in BLOCK LETTERS)

Intermediary Name ZOPPER INSURANCE BROKERS PRIVATE LIMITED Code 22BRG690
Branch Name Vikas Marg Code 1316
Sales Manager Name Dhiraj Sinha Code 70900283
*POS PAN No. *POS UID Aadhaar No.

Details (To be filled in BLOCK LETTERS)

1. This Proposal is for A new Policy Renewal of Policy Endorsement Others (Please specify)
2a. Proposer's Full Name Mr. Mrs. RAVINDRA .
2b. Address Address for Communication Address where vehicle is normally kept and Used

Flat/Building/Door/Block No.
R/O KASAR BHOSGA JEWARGI
Road /Street/Sector

Nearest Landmark
Area
City JEWARGI
Pin Code 585310
State KARNATAKA
Country India
Phone Mobile 7845******
Emergency Contact No. Blood Group
Email B*******@SMDIPOINT.COM Fax
3. Period of Insurance From 22/07/2024 To 21/07/2025
4. Source of Funds Business Profession Salary Agricultural Income Savings
5. Monthly Income Upto `20,000 `20,001 to `50,000 `50,001 to `1,00,000 `1,00,001and above
6. UID Aadhaar No. 7. PAN No.
8. Fast Tag ID

Details of the Vehicle

9. Registration Number NEW 10. Date of Registration 22/07/2024
11. Registering Authority & Location KARNATAKA - Gulbarga
12. Year & Month of Manufacture JUL-2024 13. Cubic Capacity 236
14. Engine Number AZXWRD36679
15. Chassis Number MD2B51BX6RWD15886
16. Make of Vehicle BAJAJ
17. Type of Body/Model NA/RE
18. Gross Vehicle Weight (GVW)/Cubic Capacity (C.C.)
19. Goods type (Applicable only if GVW+7500kgs) Hazardous Goods Non-Hazardous Goods
20. Is the Vehicle made in India? Yes No
21. Max. Licensed carrying capacity (No. of Passengers) in case of Passenger carrying vehicles 3
22. Vehicle Category Bus Taxi
Vehicle usage type (Applicable if bus) : Contract Carriage Stage Carriage Private Usage
Vehicle usage sub type (Applicable if Contract Carriage): School Bus Employee pickup Bus Others
23. Seating capacity (Including Driver) 4

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0012V02100001. Trade logo displayed above belongs to Anil Dhirubhai Ambani
Ventures Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/PCV/PS/Ver. 1.3/310118
Page 6 of 10
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Details of the Vehicle Type and Use

24. a. Whether the Vehicle is driven by Non-conventional source of power? Yes No If yes Bi Fuel CNG LPG

Insured's Declared Value Non - electrical Electronic accessories Value of CNG/ LPG Kit Bi Total Value (₹)
(IDV) of vehicle Chasis accessories fitted to the fitted to the vehicle (₹) Fuel (₹)
Body vehicle (₹)
215,000.00 0.00 0.00 0.00 215,000.00

b. Do you have a valid PUC? Yes No

(Note- Warranted that the insured named herein/owner of the vehicle holds a valid Pollution Under Control (PUC) Certificate and/or valid fitness certificate, as
applicable, on the date of commencement of the Policy and undertakes to renew and maintain a valid and effective PUC and/or fitness Certificate, as applicable, during
the subsistence of the Policy. Further, the Company reserves the right to take appropriate action in case of any discrepancy in the PUC or fitness certificate.)

25. Details of Driver : (a) Age of Owner Driver Others

(b) Does the driver suffer from defective vision or hearing or any physical infirmity. Yes No
If "Yes" please give
details_______________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

(c) Has the driver ever been involved for causing any accident or loss? Yes No
If "Yes" please give details as under including the pending prosecution, if any:-

(d) D.O.B.
26. Add On Covers (Subject to availability and eligibility)

(a) Easy Monthly Instalment (EMI) Protection Cover: (RGI-MO-A00-00-17-V01-14-15)

If Yes, please choose any one option;
Plan I - 1 EMI, EMI Amount : ₹
Plan II - 2 EMIs, EMI Amount : ₹
Plan III - 3 EMIs, EMI Amount : ₹
(b) Additional Towing Charges No
(c) Nil Depreciation Cover: No
(d) Total Cover No
(e) Voluntary Deductible
Voluntary Deductible amount opted: ₹ ______________________
(f) Emergency Hotel Accommodation No
Benefit Amount: ₹
(g) Additional limit of TPPD No
Additional amount opted: ₹
(h) Personal Belongings Cover No
Benefit Amount: ₹
(i) Daily Allowance Benefit No
Per day allowance amount opted : ₹
Coverage Days opted:
(j) Daily Allowance Benefit Plus No
Per day allowance amount opted: ₹
Coverage Days opted:
(k) Tools and Equipment Cover
(l) Any other Details
___________________________________

27. Is the vehicle fitted with any Anti-theft device approved by the ARAI ? Yes No
If Yes,please attach certificate of Installation in the vehicle,issued by Automobile Association of India.

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0012V02100001. Trade logo displayed above belongs to Anil Dhirubhai Ambani
Ventures Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/PCV/PS/Ver. 1.3/310118
Page 7 of 10
 Trejhara

28. Are you a member of Automobile Association of India ? If Yes,please submit membership copy. Yes No
29. Whether the Vehicle is used for Driving Tuitions? Yes No
30. Whether use of Vehicle is limited to Own Premises? Yes No
31. Whether the commercial vehicle is also used for Private purposes (excluding use for hire or reward)? Yes No

33. Whether the Vehicle is fitted with Fibre Glass Tank? Yes No
34. Whether the Vehicle belongs to the Embassy/Consulate of a Foreign Country? Yes No
If so, is the duty element included in the IDV?
35. Whether the Vehicle is design for use of Blind/Handicapped/Mentally Challenged Person? Yes No
36. Date of purchase of the Vehicle by the Proposer 22/Jul/2024
37. Whether the Vehicle at the time of purchase was New Second Hand

Risk Inclusions
38. Do you wish to restrict the above limits to the statutory TPPD Liability limit of ₹ 6000/- only? Yes No
Do you wish to cover legal liability to?
(a) Driver/Conductor /Cleaner (No. of persons) Yes No
(b) Other employees (No. of Persons) Yes No
(c) Non-fare paying passenger (No. of persons) Yes No

38. Do you wish to include personal Accident (P.A.) Cover for paid drivers, cleaners and conductors? Yes No
If Yes, give name and Capital Sum Insured (CSI) opted for. The maximum CSI available per person is ₹ 1 Lakh in the case of Motorised two wheelers and ₹ 2
lakhs for other classes of vehicles.

39. Personal Accident Cover for Owner Driver. Please give details of nomination
Name of the Appointee (if
Name Name of the Nominee Age of Nominee Relationship Address
Nominee is Minor)
MOHAMMED IBRAHIM 58 Father

(Note: 1. Personal Accident cover for owner driver is compulsory for Sum Insured of ₹ 15,00,000/- for Two Wheeler, Private Car, GCV, PCV and Misc-D
2. Compulsory PA cover for owner driver cannot be granted where a vehicle is owned by a company, a partnership firm or a similar body corporate or
where the owner-driver does not hold an effective driving license)

40. Do you wish to include Personal Accident cover Named Persons? Yes No
Name of the Appointee
Name CSI Opted Name of Nominee Age of Nominee Relationship Address
(If Nominee is Minor)

41. Extension of Geographical Area

Whether extension of Geographical Area to the following Countries required ?

1. Bangladesh
2. Bhutan

3. Maldives

4. Nepal

5. Pakistan

6. Sri Lanka

Details of Hire Purchase / Hypothecation / Lease

42. Please state if the vehicle is under Hire Purchase Lease Agreement Hypothecation Agreement
If so, give name and address of concerned parties.
43. Full Name M/s Bajaj Auto Credit Ltd
44. Address
Note
The Insured's Declared Value (IDV) of the vehicle will be deemed to be the 'SUM INSURED' for the purpose of this tariff and it will be fixed at the commencement of
each policy period for each insured vehicle.
The IDV of the vehicle is to be fixed on the basis of manufacturers' listed selling price of the brand & model as the vehicle proposed for insurance at the commencement
of insurance / renewal, and adjusted for depreciation as per policy wordings.

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0012V02100001. Trade logo displayed above belongs to Anil Dhirubhai Ambani
Ventures Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/PCV/PS/Ver. 1.3/310118
Page 8 of 10
 Trejhara

Details of Previous Insurance

45. Full Name of previous insurer
46. Address -
47. Policy Number Previous Policy Expiry
48. Type of Cover Package Policy Liability only others (to be describe)
49. NO CLAIM BONUS allowed under previous policy (%)
50. Claims taken in previous policy Yes No
If yes, No. of Claims Claims Amount `
51. Are you entitled to No Claim Bonus Yes No
If yes, please submit/attached proof thereof
Payment Details
Cheque/ DD ________________________ Cheque/ DD No.
Cheque/ DD Date _________________________ Cash Credit Card Others
Proposer's Bank Details
52. Name of the Bank Account Holder
53. Bank Account No.: 54. Account: Saving Current
55. Name of the Bank
56. Branch
57. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank)
58. IFSC Code (11 character code appearing on your cheque leaf)
I understand that any refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank Account .*
* As per IRDAI, its mandetory that all payments made to the insured are only through electronic mode.

Declaration by Proposer
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 the basis of the contract between me/us and RELIANCE General Insurance Company Limited. I/We also declare that, if any additions or
alterations are carried out after the submission of this proposal form, then the same would be conveyed to the insurers immediately. I/We hereby declare that the
contents of the form and documents have been fully explained to me/us and that I/We have fully understood the significance of the proposed contract. I/We agree to accept
a policy subject to the condition prescribed by the company. • I have read and understood the brochure, prospectus, sales literature & Policy wordings and confirm to
abide by the same. • I/We declare that the rate of NCB stated above by me/us is correct and that no claim has arisen in the expiring policy (copy of the policy enclosed). •
I/We further undertake that, if this declaration is found to be incorrect, all benefits under the policy in respect of section I of the policy will stand forfeited. • I/We further
understand and agree that RELIANCE General Insurance will seek confirmation of above stated details from my/our previous insurers. Pending receipt of necessary
confirmation, I/We agree that, though coverage under the policy will be available to me/us, RELIANCE General Insurance will be liable to release the payment towards
any claims under section I of the policy only after a confirmation in this regard is received. In the event this declaration is found to be incorrect, any and all coverage
available under section I of the policy from the date of commencement of the policy shall stand automatically forfeited. Further, any survey arranged/allowed by
RELIANCE General Insurance of the motor vehicle, pending confirmation of the declaration from my/our previous insurers, shall be without prejudice to any of the rights
and remedies available to RELIANCE General Insurance as contained herein and under the relevant laws and regulations. • I/We acknowledge and agree that, Pending
receipt of confirmation of the declaration from my/our previous insurers, the "cash-less repair facility" provided by RELIANCE General Insurance shall stand suspended.
• I/We also shall endeavour to procure the renewal notice and pass on the same to RELIANCE General Insurance immediately upon the receipt of such renewal notice.
Mode of Payment: Secure your payment by cheque/DD favouring Reliance General Insurance CO.Ltd. This policy shall be voidable at the option of the Company in the
event of mis-representation, mis-description of nondisclosure of any material particulars by the Proposer. Any person who, knowingly and with intent to defraud the
Insurance Company or other persons, files a proposal fo insurance containing any false information, or conceals for the purpose of misleading, information, information
concerning any fact material thereto, commits a fraudulent act which will render the policy voidable at the company's sole discretion and result in a denial of insurance
benefits.• I/We here by state that the above mentioned address shall be taken as address on record for the purpose of GST. • I/We hereby confirm that the contents of the
proposal form and connected documents have been fully explained to me/us and I/We have fully understood the significance of the proposed contract.

This proposal form was completed by

You can support our Go Green Initiative by saying “No” to Policy kit, Renewal Notice and Other Communications hard copy. We will be sending you a
digitally signed soft copy on your registered Email ID & Mobile number.
Hard copy required Yes No
Name ____________________________ Place : ____________________________
Date : 22 Jul 2024 07:55 Date : 22 Jul 2024 07:55

Signature Signature of Proposer & Company Seal

Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment ) Act, 2015
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 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 or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published
prospectuses or tables of the insurer.

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0012V02100001. Trade logo displayed above belongs to Anil Dhirubhai Ambani
Ventures Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/PCV/PS/Ver. 1.3/310118
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2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.

Supporting Confirmation of Agent/Broker/SM/CSO

I confirm the above signature tobe of the registered owner of the vehicle proposed for insurance
Name of IRDAI Agent/ Broker Mr. Mrs.
Place
Date
(In case of Direct Business, Name & Signature of CSO /SM to be taken) Signature of IRDAI Agent/ Broker

* Mandatory details to be filled

The policy does not cover liability for death, bodily injury or damage as excluded under Section 150 (2) (ii) and (iii): b and C of the Motor Vehicles Act 1988 (Inserted
Vide GSR no 164 (f) dated 25.02.2022 w. e. f 01.4.2022)

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0012V02100001. Trade logo displayed above belongs to Anil Dhirubhai Ambani
Ventures Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/PCV/PS/Ver. 1.3/310118
Page 10 of 10