HDFC ERGO General Insurance Company

Limited
Certificate of Insurance cum Policy Schedule
Policy No. 2311 1002 2333 4600
000

Motor Insurance - Private Car Comprehensive Policy

Insured Name Mr J S BIBRA RTO JABALPUR PAN No.

Corr.Address/ B 307 JASMINE COURT
Place of KATTUPAKKAM CHENNAI, TAMIL
Supply NADU, 600056

Mobile 8964044400 Phone - E Mail jsbibra@gmail.com Registration No. MP-20-CF-0366

Period of Insurance From Date & Time 20/08/2017 00:01hrs To Date & Time 19/08/2018 Midnight Policy Issuance Date 09/08/2017

Make Model - Variant Engine No Chassis No Mfg Yr Seats Body Type CC

HYUNDAI CRETA 1.6 SX (O) - D4FBFM388013 MALC381ULFM020556H 2015 5 SUV
1582

Insured's Declared The Vehicle (`) For Trailer (`) Non Electrical Acc. (`) Electrical Acc. (`) CNG/LPG Kit (`) Total IDV (`)
Value (IDV) 1,094,000 0 0 0 0
1,094,000

Named Persons & Nominee (IMT-15)

Nominee for Owner driver Appointee
Hypothecated(IMT-7) with: STATE BANK OF INDIA.
Premium Details (`)
Own Damage Premium (a) Liability Premium (b)
Basic Own Damage: 18292 Basic Third Party Liability:
7890
PA Cover for Owner Driver of ` 200000
Total Basic Premium 100
18292

Less: No Claim Bonus (25%) 4573

Total - Less
Add on Coverages Net Liability Premium (b)
7990
Zero Depreciation 7658
Total Package Premium (a+b)
29717
Emergency Assistance 350 Integrated Tax 18%
5349
Total - Add on 8008
Net Own Damage Premium (a) 21727 Total Premium
35066

Geographical Area India , Compulsory Deductible (IMT-22) ` 2000.00 Voluntary Deductible (IMT-
22A) ` 0.00
Fund Transfer No.
Payment Dated : 09/08/2017 Drawn on : BizDirect Invoice No.: 100223334600000 HSN
Details: MT1708051688
Code: 9971
Previous Policy No. 3001/W47285533/00/000 Valid from 20/08/2016 to 19/08/2017 of ICICI LOMBARD GENERAL INSURANCE
CO. LTD. No Claim Bonus 20% If declaration found incorrect, benefits under the present policy in respect of own damage section will
stand forfeited.

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) Any purpose in connection with Motor Trade. Persons or Class 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
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. Limits of Liability 1. Under Section II-1 (i) of the policy - Death of or bodily injury - Such amount as
is necessary to meet the requirements of the Motor Vehicles Act, 1988. 2. Under Section II - 1(ii) of the policy -Damage to Third Party Property- ` 750000 3. P. A. Cover
under Section III for Owner - Driver(CSI): ` 200000Terms, Conditions & Exclusions: As per the Indian Motor Tariff. A personal copy of the same is available free of
cost on request and the same is also available at our website.

I / We hereby certify that the policy to which the certificate relates as well as the certificate of insurance are issued in accordance with the provision of chapter X, XI of M. V.Act
1988. "The stamp duty of
` 0.50 paid by Demand Draft,vide Receipt/Challan no. 1709262201718 dated 03/07/2017 as prescribed in Government Notification Revenue and Forest Department No.
Mudrank 2004/4125/CR 690/M-1, dated 31/12/2004". Goods and Service Tax Registration No: 27AABCH0738E1ZX . 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". Disclaimer: The Policy shall be void from inception if the premium cheque is not realized. In the event of misrepresentation, fraud or non-

Registered & Corporate Office: 1st Floor, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai - 400020. Customer Service Address: 6th Floor, Leela
Business Park, Andheri Kurla Road, Andheri (E), Mumbai - 400 059. Toll Free : 1800-2-700-700 (Accessible from India only) | Fax : 91 22 6638 3699 |
care@hdfcergo.com | www.hdfcergo.com. CIN : U66010MH2002PLC134869. IRDAI Reg No. 125.
 HDFC ERGO General Insurance Company
Limited

disclosure of material fact, the Company reserves the right to cancel the Policy. Please note that the insured vehicle was pre-inspected and a report was prepared
accordingly. The existing damages to the vehicle as mentioned in the report shall not be paid by the Company. The policy is issued basis the information provided by you,
which is available with the company. In case of discrepancy or non recording of relevant information in the policy, the insured is requested to bring the same to the
notice of the company within 15 days. Goods and Service Tax for this invoice is not payable under reverse charge basis..

Policy Issuing Office : LEELA BUSINESS PARK, 6TH FLR, ANDHERI - KURLA RD, MUMBAI, 400059. Phone No. : +91-22-66383600

Registered & Corporate Office: 1st Floor, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai - 400020. Customer Service Address: 6th Floor, Leela
Business Park, Andheri Kurla Road, Andheri (E), Mumbai - 400 059. Toll Free : 1800-2-700-700 (Accessible from India only) | Fax : 91 22 6638 3699 |
care@hdfcergo.com | www.hdfcergo.com. CIN : U66010MH2002PLC134869. IRDAI Reg No. 125.
 HDFC ERGO General Insurance Company
Limited
Certificate of Insurance cum Policy Schedule
Policy No. 2311 1002 2333 4600
000

For HDFC ERGO General Insurance Company Ltd.

Agent Name : MANGOTREE INSURANCE WEB AGGREGATORS

PVT LTD
Agent Code : 200631705465 Duly Constituted Attorney

Registered & Corporate Office: 1st Floor, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai - 400020. Customer Service Address: 6th Floor, Leela
Business Park, Andheri Kurla Road, Andheri (E), Mumbai - 400 059. Toll Free : 1800-2-700-700 (Accessible from India only) | Fax : 91 22 6638 3699 |
care@hdfcergo.com | www.hdfcergo.com. CIN : U66010MH2002PLC134869. IRDAI Reg No. 125.
HDFC ERGO General Insurance Company
Limited

Motor Insurance - Proposal Form For Private Car

Package
Proposal No. 2311100223334600000

Insured Name Mr J S BIBRA RTO JABALPUR PAN No.

Correspondence B 307 JASMINE COURT
Address KATTUPAKKAM CHENNAI, TAMIL
NADU, 600056
Mobile 8964044400 Phone E Mail jsbibra@gmail.com Registration No. MP-20-CF-0366

Period of Insurance From Date & Time 20/08/2017 00:01hrs To Date & Time 19/08/2018 Midnight Proposal Issuance Date 09/08/2017
Make Model - Variant Engine No Chassis No Mfg Yr Seats Body Type CC
HYUNDAI CRETA 1.6 SX (O) - D4FBFM388013 MALC381ULFM020556H 2015 5 SUV
1582

Insured's Declared The Vehicle (`) For Trailer (`) Non Electrical Acc. (`) Electrical Acc. (`) CNG/LPG Kit (`) Total IDV (`)
Value (IDV) 1,094,000 0 0 0 0
1,094,000

Fuel Type Cover Type Date of Registration TPPD restriction Higher deductible
DIESEL PACKAGE 19/08/2015 NA NA

Named Persons & Nominee (IMT-15)

Nominee for Owner driver Appointee
Hypothecated(IMT-7) with: STATE BANK OF INDIA.
Premium Details (`)
Own Damage Premium (a) Liability Premium (b)
Basic Own Damage: 18292 Basic Third Party Liability:
7890
PA Cover for Owner Driver of ` 200000
Total Basic Premium 100
18292

Less: No Claim Bonus (25%) 4573

Total - Less 4573
Add on Coverages Net Liability Premium (b)
7990
Zero Depreciation 7658
Total Package Premium (a+b)
29717

Total - Add on Integrated Tax 18%

8008 5349

Net Own Damage Premium (a) 21727 Total Premium

35066

Geographical Area India , Compulsory Deductible (IMT-22) ` 2000.00 Voluntary Deductible

(IMT-22A) ` 0.00
Payment Details: Fund Transfer No. MT1708051688 Dated : 09/08/2017 Drawn on BizDirect
Previous Policy No. 3001/W47285533/00/000 Valid from 20/08/2016 to 19/08/2017 of ICICI LOMBARD GENERAL INSURANCE
CO. LTD. No Claim Bonus 20% If declaration found incorrect, benefits under the present policy in respect of own damage section will
stand forfeited.

Agent Name : MANGOTREE INSURANCE WEB AGGREGATORS PVT

LTD
Agent Code : 200631705465
HDFC ERGO General Insurance Company
Limited

Motor Insurance - Proposal Form For Private Car

Package
Disclaimer : Proposal Form and Policy Schedule have been generated basis details entered by proposer / insured on Online Platform (either on HDFCERGO.com or its
affiliated Online Channels (IRDAI Licensed Intermediaries). For any modification, kindly visit URL https://www.hdfcergo.com/customer-care/customer-
support.html and register your service request or write to us at care@hdfcergo.com

Customer Name: J S BIBRA PAN

No. :
Registered & Corporate Office: 1st Floor, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai - 400020. Customer Service Address: 6th Floor, Leela
Business Park, Andheri Kurla Road, Andheri (E), Mumbai - 400 059. Toll Free : 1800-2-700-700 (Accessible from India only) | Fax : 91 22 6638 3699 |
care@hdfcergo.com | www.hdfcergo.com. CIN : U66010MH2002PLC134869. IRDAI Reg No. 125.
HDFC ERGO General Insurance Company
Limited

Motor Insurance - Proposal Form For Private Car

Package
Proposer
declaration

DECLARATION ON BEHALF OF ALL PERSONS TO BE INSURED : I/We hereby understand, declare, consent and authorize the Company to use personal
health details and financial information, as provided to the Company for underwritingthe risk. I/We hereby also understand, declare, consent and authorize the
Company that the Company shall have right to retain the aforementioned information anddisseminate the same to its service provider(s) for providing services related to
insurance.

Anti rebate clause

Prohibition of Rebates (Section 41 of Insurance Act, 1938 as amended) : 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: provided that acceptance by an insurance agent of commission in
connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be acceptance of a rebate of premium within the meaning of this sub-
section if at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed by the insurer.

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..

Disclaimer : Proposal Form and Policy Schedule have been generated basis details entered by proposer / insured on Online Platform (either on HDFCERGO.com or its
affiliated Online Channels (IRDAI Licensed Intermediaries). For any modification, kindly visit URL https://www.hdfcergo.com/customer-care/customer-
support.html and register your service request or write to us at care@hdfcergo.com

Customer Name: J S BIBRA PAN

No. :
HDFC ERGO General Insurance Company
Limited

Motor Insurance - Proposal Form For Private Car

Registered & Corporate Office: 1st Floor, 165-166 Package
Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai - 400020. Customer Service Address: 6th Floor, Leela
Business Park, Andheri Kurla Road, Andheri (E), Mumbai - 400 059. Toll Free : 1800-2-700-700 (Accessible from India only) | Fax : 91 22 6638 3699 |
care@hdfcergo.com | www.hdfcergo.com. CIN : U66010MH2002PLC134869. IRDAI Reg No. 125.