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Digitally signed by
Raman Arora
Date: 2019.04.21
SID042119010470

http://rgiclser Reliance Two Wheeler Package Policy - Schedule

Record
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Policy Number : 110421923120104899 Proposal/Covernote No: R21041906817 2312

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Insured's Name : Period of Insurance :
FINA
MRS.MANSI M PARSEKAR From 11:55 Hrs on 21-Apr-2019 to 23:59 Hrs of 20-Apr-2020

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Communication Address : Policy Servicing Branch :
0 A SUNRISE APT VAHATUK NAGAR,KEVANI PADA JOGESHWARI WEST, TIARA BUILDING, 4TH FLOOR, MAHARASHTRA NAGAL LANE, OFF.

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MUMBAI, MAHARASHTRA, CHANDAVARKAR LANE, OFF. L T ROAD, BORIVALI WEST, MUMBAI -
INDIA,400102 400092

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Mobile No : 7045506331 Tax Invoice No. & Date : R21041906817 & 21/04/2019
Email-ID : NA GSTIN/UIN &Place of supply:

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Insured's Blood Group : CGST
Insured Two Wheeler Details

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Registration No. MH02EG5167 Mfg. Month & Year APR-2016
Make / Model HONDA / ACTIVA / 3G
CC / HP 110

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Engine No. / Chassis No. JF50EU3035788 / ME4JF505CGU035644 Seating Capacity Including Driver 2
Type of Body NA Total Premium ` 1313.00
RTO Location MAHARASHTRA - Mumbai Western Suburbs-Andheri
e IDV ` 35434.00
West
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Hypothecation/Lease NA

Insured Declared Value (IDV)

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Vehicle IDV ` 35434.00 Non Electrical Accessories ` 0.00

Electrical / Electronic Accessories ` 0.00 Total IDV ` 35434.00
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Premium Summary
Own Damage - Section I (`)
AmountMAHARASHTRA
Liability - -Section Amount (`)
MumbaiIIWestern Suburbs-
110421923120104899
Basic OD 0 605.21 Basic Liability (TPPD 1) 0 720.00
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Total Basic Own Damage Premium 1 605.21 Total Basic Liability Premium 1 720.00
Less 1 PA Benefits - Section III 1
Deduct 35 % for NCB 0 -211.82 TOTAL LIABILITY PREMIUM 1 720.00
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Sub Total of Deductions 1 -211.82 TOTAL PACKAGE PREMIUM (Sec I + II + III) 1 1113.00
TOTAL OWN DAMAGE PREMIUM 1 393.39 CGST (@9.00 %) 0 100.00
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SGST (@9.00 %) 0 100.00

TOTAL PREMIUM PAYABLE (`) 1313.00
GSTIN : 27AABCR6747B1ZG , HSN : 9971 Subject to I.M.T.Endt.Nos. IMT 22
Description of services : Motor vehicle insurance services 0.0
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Add-on for Total Cover : Provides cover for registration charges, road tax and insurance premium (Total Cover Sum Insured - `0.0 )
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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
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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 - ` 1,00,000 /- ,TPPD 2 Sum Insured - ` 6,000 /-) (iii) PA cover for owner driver under section III CSI `
0.0/-
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Consolidated Stamp duty Paid vide Letter of Authorisation No. CSD/310/2019/383/19 dated 25th Jan 2019**Not Applicable for the State of J&K

11A14736/Dinesh S Jaiswal 9320828777 insurance@dolphingroup.co.in

Intermediary Code/Name Intermediary Contact No. Intermediary E-mail ID

Limitations as to use : The Policy covers use for any purpose other than: (a) Hire or Reward other than for the purpose of driving tuition, (b)
Carriage of goods (other than samples or personal luggage), (c) Organized racing, (d) Pace making, (e) Speed testing, (f)
0.00 Reliability trials, (g) Any Purpose in connection with Motor Trade

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Persons/Classes of persons : Any person including the Insured Provided that a person driving holds a valid driving license at the time of the accident and
entitled to drive is not disqualified from holding of such a license. Provided that the person holding a valid Learner's License may drive the
vehicle and that such a person satisfies the requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.
Deductible under Section-I : (i) Compulsory deductible ` 100.0/- (ii) Additional compulsory deductible `0/- (iii) Voluntary deductible ` 0.0/-

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Compulsory PA cover for owner driver : 0.00
Insured is not eligible for compulsory PA cover for owner driver in the policy as the same has not been opted for the reasons allowed as per motor tariff and/or

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basis insured's declaration given below:
"I/ we hereby declare that I/ we hold an effective personal accident insurance policy covering death and permanent disability (total & partial) and/ or compulsory
personal accident (CPA) for owner driver in other vehicles; whereby the Sum Insured limit is of Rs 1,500,000 or more in all such above mentioned conditions."

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In case you have missed it, please opt for compulsory PA cover by payment of additional premium as applicable .Liability of insurance company shall commence
from the date of receipt of such additional premium .
*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.

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"It is hereby declared and agreed that any damages pre-existing, any losses occurred & any Liability having been incurred, prior to the commencement of cover
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under this policy are excluded from the scope of this policy."
The policy wording with detailed terms, conditions and exclusions are available on our website www.reliancegeneral.co.in.

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Statutory Provisions:
"As per Section 146 of the Motor Vehicle Act, 1988 it is Mandatory to have your vehicle insured against third party risk.
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.

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*No Claim Bonus will be allowed, provided the policy is renewed within 90 days of the expiry of the previous policy.
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.
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

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the terms,conditions and exclusions of the Reliance Two Wheeler Package 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.
Safeguard your transaction by paying your premium via crossed cheque/DD in favour of Reliance General Insurance Co. Ltd.
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)
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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
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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.
Grievance Clause :- For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 1800 3009 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
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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
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Ombudsman within whose territorial jurisdiction the branch or office of the Company is located.Office of the Insurance Ombudsman,3rd
Floor,Jeevan Seva Annexe,S. V. Road,Santacruz (W), Mumbai - 400 054. Tel.: 022 - 26106552 / 26106960 Fax: 022 - 26106052 Email:
bimalokpal.mumbai@gbic.co.in | Shri. A. K. Sahoo Office of the Insurance Ombudsman,Jeevan Darshan Bldg.,3rd Floor,C.T.S. No.s. 195
to 198,N.C. Kelkar Road,Narayan Peth, Pune – 411 030. Tel.: 020-41312555 Email: bimalokpal.pune@gbic.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
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immediately.
This document shall be trated as a Tax Invoice as per Rule 9(2) of the Goods and Services Tax Invoice Rules
In the unfortunate event of a claim, please call quoting your Policy No. 18003009 (toll free) or (022) 48903009 on and register your claim immediately
within 7days from the date of loss.
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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 : .
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CGST
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.
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Authorised Signatory
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Reliance General Insurance Company Limited. IRDAI Registration No. 103. An ISO 9001:2015 Certified Company
Registered Office: H Block, 1st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai 400710.
Corporate Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway , Santacruz (East), Mumbai - 400 055.
Corporate Identity No.U66603MH2000PLC128300. RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.

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Proposal Form For Reliance Two Wheeler Package Policy

Is the Vehicle Made in India Yes No SID Type of Vehicle : Two wheeler Four wheeler Three Wheeler

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For Office Use Only

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Policy Number 110421923120104899 Date
Savvion Reference No. Inspection Lead No.

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Intermediary Details (To be filled in BLOCK LETTERS)
Intermediary Name DINESH S JAISWAL Code 11A14736

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Branch Name Borivali Code 1104
Sales Manager Name Panchamrut Penkar Code 70287893

Details (To be filled in BLOCK LETTERS)

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1. This Proposal is for A new Policy Renewal of Policy Rollover Policy Used Policy SI
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2a. Proposer's Full Name Mr. Mrs. Ms. MANSI M PARSEKAR

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2b. Address Address for Communication Address where vehicle is normally kept and Used
Flat/Building/Door/Block No. A Sunrise Apt Vahatuk Nagar , Kevani
Pada Jogeshwari West

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Road /Street/Sector
Nearest Landmark
Area
City MUMBAI,
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Pin Code 400102
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State MAHARASHTRA,
Country India
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Phone Mobile 7045506331

Emergency Contact No. Blood Group
Email NA Fax
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3. Period of Insurance From 21/04/2019 To 20/04/2020

4. Source of Funds Business Profession Salary Agricultural Income Savings Others
5. Monthly Income ` 20,001 to ` 50,000 ` 1,00,001 and above
Upto ` 20,000 ` 50,001 to ` 1,00,000
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6. UID Aadhaar No. 7. PAN No.

8. Do you have GST Registration Number Yes No
If Yes, Please Specify
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9. Related Party Yes No

Details of the Vehicle

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10. Registration Number MH02EG5167 11. Date of Registration 22-Apr-2016

12. Registering Authority & Location MAHARASHTRA - Mumbai Western Suburbs-
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13. Year & Month of Manufacture APR-2016 14. Cubic Capacity 110
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15. Engine Number JF50EU3035788

16. Chassis Number ME4JF505CGU035644
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17. Make of Vehicle HONDA

18. Type of Body/Model NA / ACTIVA 19. Seating Capacity including Driver 2
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An ISO 9001:2015 Certified Company

IRDAI Registration No. 103.Reliance General Insurance Company Limited.Registered Office: H Block,1st Floor,Dhirubhai Ambani Knowledge City,Navi
Mumbai -400710. Corporate Office: Reliance Centre,South Wing,4th Floor,Off. Western Express Hightway,Santacruz(East),Mumbai-400 055. Corporate
Identity Number U66603MH2000PLC128300.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/MOT-02/PVT-CAR-TWO-WHELLER-PF/Ver. 1.3/300117.

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Details of the Vehicle Type and Use

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

Insured declared value Non-electrical electrical & electronics Side Car(Two_wheeler) Value of Total Value

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(IDV) of the Vehicle Accessories fited to the Accessories fited to the Trailer(Pvt.Cars) CNG/ LPG Kit
Vehicle Vehicle

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35434.00 0.00 0.00 0.00 0.00 35434.00

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21. Age of Owner Driver 22. D.O.B.
23. Add On Covers (Subject to availability and eligibility) Pe

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a. Nil Depreciation Cover
b. NCB Retention Cover
c. Easy Monthly Installment(EMI) Protection Cover :(RGI-MO-A00-0017-V01-14-15) Yes No
If Yes, please chooose any one option ;

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Plan I -1 EMI,EMI Amount : Plan II -2 EMI,EMI Amount :
Plan III -3 EMI,EMI Amount :

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d. Total Cover
e. Daily allowance benefits(RGI--MO-A00-an-19-V02-14-15)
Per Day Allowance Coverage Days

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24. 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.
25. Are you a member of Automobile Association of India ? If Yes,please submit membership copy. Yes No
26. Will the Vehicle be used exclusively for
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a. Private,social,domestic,pleasure and professional purposed ? Yes No
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b. Carriage of goods other than samples or personal luggage? 0 Yes No
27. Whether the Vehicle is used for Driving Tuitions ? Yes No
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28. Whether use of Vehicle is limited to Own Premises ? Yes No

29. Whether the Vehicle is fitted with Fibre Glass Tank ? Yes No
30. Whether the Vehicle belongs to the Embassy/Consulate of a Foreign Country ? Yes No
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If so,is the duty element included in the IDV ? Yes No

31. Whether the Vehicle is design for the use of Blind/Handicapped/Mentally Challenged Person ? Yes No
32. Date of purchase of the Vehicle by the Proposer 22-Apr-2016
33. Whether the vehicle at the time of the Purchase was New Second Hand
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Risk Inclusions

34. Please Select the higher deductible if you wish to opt for over nd above the compulsory deductible (` 1000 - for Vehicles not execeeding 1500 cc,
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` 2000 for vehicles exceeding 1500 cc)

Two Wheeler : 0.00
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35. Liability to third parties : The policy provides Third Party Property Damage(TPPD) of ` 1 lakh (Two wheelers)

Do you wish to restrict the above limits to the statutory TPPD Liability limit of ` 6000/- only ? Yes No

Legal Liability No. of Persons

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Driver 100
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36. Personal Accident Cover for Owner Driver. Please give details of nomination
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Name Age of Name of the Appointee Relationship Address

Name of Nominee Nominee (If Nominee is Minor)
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(Note : 1. Personal Accident cover for Owner driver is compulsory for sum insured of ` 0.0 /-
2. Compulsary 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 licence)

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37. Extension of Geographical Area

INDIA
Whether the extention of Geographical Area to the following Countries required ?
1. Bangladesh 2. Bhutan 3. Maldives 4. Nepal 5. Pakistan 6. Sri Lanka

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Details of Hire Purchase / Hypothecation / Lease

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38. Please state if the vehicle is under Hire Purchase Lease Agreement Hypothecation Agreement FINA
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If so give name and address of concerned parties

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39. Full Name M/S
40. Address

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Details of Previous Insurance

41. Full Name of Previous Insurer TATA AIG General Insurance Company Ltd.
42. Address MUMBAI

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43. Policy Number 017030919900 Previous policy expiry 14-Apr-2019
44. Type of Cover Package Policy Liability only others (to be describe)
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45. NO CLAIM BONUS allowed under previous policy (%) 25.00
46. Claims taken in previous policy Yes No
If yes No. of Claims Claims Amount `

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47. Are you entitled to no claim bonus Yes No
If yes, please submit/ attached proof thereof

Payment Details e
Cheque/ DD Cheque/ DD No.
SID0421190104
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Cheque/ DD Date Cash Credit Card Others

Proposer's Bank Details

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48. Name of the Bank Account Holder

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49. Bank Account Number 50. Account: Saving Current
51. Name of the Bank
52. Branch
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53. MICR Code (9 digit MICR code number of bank and branch appearing on cheque issued by the bank)
54. IFSC Code (11 digit characted code appearing on cheque leaf)

I understand that any refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank Account .*
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* As per IRDAI, its mandetory that all payments made to the insured are only through electronic mode.

AML Guidelines
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I/We herby confirm that all premiums have been/ will be paid from bonafide sources and no premium have been/ will be paid out of the proceeds of crime
related to any of the offence listed in Prevention of Money Laundering Act 2002. I undersand that the company has the right to call for the documents to
establsh source of funds. The insurance company has the right to cancel the insurance contract in case I am/ have been found guilty by any competent court
of law under any of the status, directly/ indirectly governing the prevention of Money Laundering in India.
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Nationality Indian Non-Indian , If Non Indian Please specify the country SID0421190104
Type of organization : Corporation Goverment Non Goverment Organization Society Trust
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Partenership International Organization Corporatives Section 25 Companies

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Declaration by Proposer

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I/We hereby declare that te 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

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declartion 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/We declare that the rate of NCB stated above by me/us is correct and that no claim has arisen in

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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

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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

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RELIANCE General Insurance immediately upon the receipt of such renewal notice. Mode of Payment: Secure your payment by cheque/DD favouring Reliance
General Inurance CO. Ltd. This policy shall be voidable at the option of the company in the event of mis-representation, mis-descriptionof non-disclosure of any
material particulars by the Poposer. Any person who knowingly and with intent to defraud the Insurance Companyor other persons, files a proposalto insurance
containing any false information, or conceals for the purpose of misleading, information, information concerning any fact material thereto, commits a fraudulent act

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which will render the policy voidable at the company's sole discretion and result in a denial of insurance benefits.

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This proposal form was completed by
Name SID0421190104 Place
Date Date

Signature
e Signature of Proposer & Company seal
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Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment ) Act, 2015
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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 livesor properly in India, any rebate of the whole or part of the commission payableor any rebate of the premium shown on the
policy, nor shall any person taking out or renewing or continuing a policyaccept any rebate as may be allowed in accordance with the published
prospectuses or tables of the insurer
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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 repees.
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Supporting Confirmation of Agent/Broker/SM/CSO

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I confirm the above signature tobe of the registered owner of the vehicle proposed for insurance SID0421190104
Name of IRDAI Agent/ Broker Mr. Mrs. DINESH S JAISWAL
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Place
Date
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(In case of Direct Business, Name & Signature of CSO /SM to be taken) Signature of IRDAI Agent/ Broker
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