Subject to I.M.T.Endt.Nos. & Memorandum printed/herein/attached hereto.

IMT 28, IMT 22 Service Tax Registration No: AABCR6747BST001

Category-General nsurance Business Service 00440005
Total Net Basic Own Damage Premium(Including addon
covers as applicable.)
9828
TOTAL OWN DAMAGE PREMIUM 9828
A. Own Damage
Basic OD Including Add On Where Applicable 9828
Add: Service Tax @ 12% 1690.44
PACKAGE PREMIUM (Total ODP + Total Liability Premium) 14087
TOTAL LIABILITY PREMIUM 4259
FINAL PREMIUM 15828
Add: Higher Educational Cess @ 1% 16.9
Add: Educational Cess @ 2% 33.81
Legal Liability to paid driver,cleaner & conductor (IMT-28) No. of
people :1
50
Total 4109
Basic premium including premium for TPPD Vehicle 4109
B. Liability
Legal Liability
Compulsory PA covers for owner-driver (IMT-15) 100
PA Benefits
This policy provides you with a host of roadside assistance services at no extra cost*. Services include assistance for Towing, Battery Jumpstart, Minor Repairs, Tyre Punctures, Emergency Fuel, Delivering Back
up key , Organizing a taxi, Organizing Hotel Accommodation and Sending Outgoing Messages.
* Terms & Conditions Apply
* No Claim Bonus is subject to no claim on the previous policy Benefits under the policy stands forfeited if claim is/was made in previous policy.
Subject to Reliance GI Endorsement Numbers printed herein/attached hereto. 0
Insured's Declared Value
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. No Claim Bonus will only be allowed, provided the policy
is renewed within 90 days of the expiry of the previous policy.
400000 0 0 0 0 0 400000
For the Vehicle For Trailers Electrical / Electronic
Accessories
Non Electrical
Accessories
CNG / LPG Kit Total Cover SI(Rs.) Total Value
Schedule of Premium
Branch Issuance Office : SCO- 145 -146, 2nd Floor, Sector - 9 C, Madhya Marg , CHANDIGARH U.T.
Reliance General nsurance Co. Ltd.
Registered office reliance Center19, Walchand Hirachangd Marg, Bailard Estate, Mumbai - 400001
Policy ssuing Office : 570/Naigaum Cross Road, Next to Royal ndustrial Estate Wadala (W)., Mumbai - 400 031
An ISO 9001:2008 Certified Company
Intermediary Code/Name :
13BRG050 / PROBUS INSURANCE BROKER LTD
Intermediary Contach No.:
9029013043
IMPORTANT NOTICE : The insured is not indemnified if the vehicle is used or driven otherwise than in accordance with
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 Private Car Policy. In witness whereof this Policy has been signed at Mumbai on 07-Oct-2014 in lieu of Cover Note No/Proposal No. W10071403813 Dated 07-Oct-2014
this Schedule. Any payment made by the Company by reason of wider terms appealing in the Certificate in order to comply with For Reliance General Insurance Co. Ltd.
In the unfortunate event of a claim, Please call along with your Policy No.on 1800 103 1999 (toll free) or 022
41112600 (Standard STD Rates Apply) and register your claim immediately within 7 days from the date of loss. For
Customer service, Please call along with your Policy No. on 1800 3009(toll free)| www.reliancegeneral.co.in
Duly Constituted Attorney(s)
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. NOTE: Kindly acknowledge receipt of this policy. In
case you find any variations against your proposal or any discrepancy in the policy, kindly contact us immediately
It is hereby declared and agreed that all pre-existing damages to the vehicle having occurred prior to the commencement of cover are excluded from the scope of the policy. Consolidated Stamp duty Paid vide
GRAS GRN No. MH001673304201415E dated 08 July 2014** ** Not Applicable for the State of Jammu & Kashmir
Contact details : 9991566564 Zone : Geographical Area : India
S/O SH SAHAB SINGH , VILL KANHRI KHURD TEH JAGADHARI JAGADHRI TOWN , JAGADHRI -
135003 , HARYANA
Hypothecated with : Mahindra And Mahindra
Financial Services
Limited
Location :
Email :
HR-45--9997 &
KARNAL
(COMMERCIAL
VEHICLES ONLY)
TOYOTA / INNOVA 2.0
V
8580506 / 9624172 1998 OCT-2006 8
14087 400000
Registration No. &
Place
Make / Model Variant Engine No. / Chassis No. Type of Body Cubic
Capacity
Mfg. Year Seating Capacity Net Premium Rs. IDV (Insured's Declared
Value) Rs.
Particulars of vehicle Insured :
Policy / Certificate No. : 2004542311019780
Reliance Private Car Vehicle Certificate cum Policy Schedule
Proposal /Covernote No : W10071403813
Address : Business/Occupation: Others
Name of Insured : MR. RANBIR KUMAR Period of Insurance : From 13:46 Hrs on 07-Oct-2014 to midnight of 06-Oct-2015
PA Cover for owner-driver under Section-III CSI - Rs. 2,00,000/-
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 Rs. 750000/-
Deductible under Section-1: (i) Compulsory deductible Rs. 2000/- (ii) Additional compulsory deductible Rs. 0/-, (iii) Voluntary deductible Rs. /-
Special Conditions: __________________________________________________________________________________________________________
e. Speed testing, f. Reliability trials, g. Any purpose in connection with Motor Trade.
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,
Persons/Classes of Persons entitled to drive : Any person including the Insured provided that a person driving holds an effective driving license at the time of the accident and is not disqualified
Limits of Liability : 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
from holding or obtaining such a license. 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
Signed by:Mukul
Kishore
Date:2014.10.07
Policy Number - Previous Insurer Name -
Policy End date Branch Name & Address -
Premium Amount 15828 Payment Date 07/10/2014
(lX) Previous Year Policy Details
Declaration
I agree that the insurance benefit available to me shall become voidable in the event of any untrue or incorrect statement, misrepresentation,non-description or non-disclosure in any particulars in the application
form / personal statement, declaration and connected documents or any material information has been withheld by me or anyone acting on my behalf to obtain insurance benefit. I hereby declare that I am not
aware of any neglect and omission or error or existence of any circumstances likely to give rise to a claim thereof. I hereby declare, incase of false declaration the Insurance Company shall have the right to
cancel the policy. The insurance company shall have the right to change the premium and conditions agreed to subject to such terms and conditions as has been communicated to me. I hereby agree that my
enrollment for insurance would be at the sole discretion of the insurance company. I declare and warrant that the information I have given in this online form will be considered as the proposal form in relation to
myself (or other person or categories of persons to be insured) and any documentation of information accompanying it or arising out of the answers I have given is complete and accurate in all respects. I
understand and agree that this online form and other information and documentation I have given or will give,relating to myself or any other person to be insured, will be the basis of any insurance that you may
issue, and I also understand the consequences of any default. I further understand that the coverage offered is subject to realization of premium payment.
Claim (Yes or No) YES Current NCB % -
NCB% for this Policy NO
Against this discount you have accepted an additional voluntary deductible of Rs 0 against each claim
Restrict TPPD Liability To 6000 NO
Anti Theft Device Discount NO Automobile Association Disc NO
Voluntary Deductible Discount NO Automobile Association Membership
number/Name
-
(VlIl) Payment Details
Payment Mode Cash Bank Name -
(VIl) PA to Owner Driver - Nominee Details
For detailed terms & condition (Policy Wordings) governing this policy, kindly refer our website.
In case of any query you may contact our customer care service numbers given on the face of the policy. We look forward to having a long term & fruitful relationship
Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to five hundred rupees.
We hope the information shown above is found by you as correct
Authorized Signatory
For Reliance General Insurance Co ltd
Yours truly
Insured Name : RANBIR KUMAR Date : 07/10/2014
The information that you give to Reliance General Insurance on this online form will be treated as the proposal form and details in any supplemental information form or documentation supplied by you or on your
behalf will influence our decision to offer insurance and the terms upon which to offer it. Further, any policy we issue will be based on what you have told us. It is therefore important that your answers are
complete and accurate in all respect.
Online Transaction Facility - Terms and Conditions:
have read and understood the terms and conditions governing the Online Transaction Facility of Reliance General nsurance Company Ltd. have also
read and understood the salient, features, terms and conditions of the policy as stated in the brochure.
Statutory Warning - PROHIBITION OF REBATES (Under Section 41 of Insurance Act 1938)
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.
The questions in this online form are indicative rather than exhaustive. You must provide us with all information relevant to the risk to be insured,even if it is not the subject of a question in this online form. If you
are in any doubt as to what information should be given, please email us at services.rgicl@rcap.co.in. Any failure to provide us with full and accurate material information may mean that your policy can be
declared as void.
No insurance cover will be in force until we have approved it and the premium has been paid.
(VI) Discounts Claimed
Total Insured Declared Value (IDV) 400000 Total Premium amount 15828
Policy Start date 07/10/2014 Policy End date 06/10/2015
Email Mobile number 9991566564
(II) Policy Details
(III) Vehicle Details
Make TOYOTA Manufacturing Month/Year OCT-2006
Hypothecation Type Mahindra And Mahindra Financial Services Limited Name of Financial Institution Mahindra And Mahindra Financial Services Limited
Address of Financial Institution Renewal/Rollover/New
We are pleased to enclose Private Car Package Policy as Proposed by you
This Policy has been issued on the basis of the information provided by you during the transaction. The information has been captured by the system as
ONLNE PROPOSAL FORM for future reference. Given here below is an extract of the same for your records and reference
Dear RANBIR KUMAR
We thank you for placing your trust with Reliance General Insurance Company Limited
Address S/O SH SAHAB SINGH VILL KANHRI KHURD TEH
JAGADHARI JAGADHRI TOWN
City JAGADHRI
Landline number -
(I) Details of Registered Owner/Insured
Name of the Insured RANBIR KUMAR State HARYANA
Is Vehicle used for Driving Tuitions NO Legal Liability to Employees NO
Fiber Glass Fuel Tank NO If Yes Extension in Geographical Area NO
Non Electrical Accessories NO Personal Accident Cover for unnamed
Passengers
NO
CNG/LPG Kit Attached NO Extension in Geographical Area NO
(V) Add on Cover/s Opted
Nil Depreciation Cover NO Total Covers NO
Personal Accident Cover for Named
Passengers
NO Legal liability to Cleaner & conductor NO
Legal liability to Non-Fare Passenger No Loading charged NO
Engine Number 8580506 Registration number HR-45--9997
Chassis Number 9624172 Seating Capacity Including Driver 8
Model INNOVA Date of Purchase/Registration 07/10/2006
Variant 2.0 V RTO Location HARYANA-KARNAL (COMMERCIAL VEHICLES
ONLY)
(IV) Additonal Cover/s Opted
Electrical Accessories NO Legal Liability to Paid Driver YES
Vehicle IDV 400000 Value of Electrical Accessories 0
Value of CNG/LPG KIT 0 Value of Non Electrical Accessories 0