Date: 02 May 2019

Policy Number: FTW/SA437558/U1/04/003628

YADAV RAMASHANKAR
BHIMPURA NO 2 NAGRA
MOB 8765015010
..
BALLIA 221711
UP
INDIA 221711
Phone Number: 8765015010
EmailID: omhondaagency@gmail.com

Dear YADAV RAMASHANKAR

Sub:Risk Assumption Letter
We thank you for choosing Bharti AXA Two Wheeler - Comprehensive Insurance Policy.
Please find enclosed Policy No. FTW/SA437558/U1/04/003628 which has been issued on the below mentioned details.

Insured Vehicles Details

Name of the Insured YADAV RAMASHANKAR
Period of Insurance April 29, 2019 0.00 to Midnight of April 28, 2020
Vehicle Make/Model HONDA MOTORS-ACTIVA
RTO City BALLIA
Vehicle Registration No. NEW
Vehicle Registration Date 23/02/2019
Engine No. JF50EU9115660
Chassis No. ME4JF50CBJU115586
Current Year NCB(%) 20.00
The information provided above is based on the information received from you and accordingly, the policy has been processed. Coverage of risk
and subject to realization of the full premium, post which, insurance coverage under the policy would commence. In case the premium is not
received by us due to cheque dishonour or any other reason, the insurance cover shall be voidab-initio.
If you require any changes in the Certificate of Insurance you are requested to inform us by writing to
customer.service@bhartiaxa.com or calling our 24 hour toll free helpline or 1800-103-2292
Absence of any communication within a period of 15 days of the date mentioned on this letter would mean that the issued policy is in order and as
per your proposal.

To ensure a smooth claims process for our customers, we have a network of 2000+ cashless garages across India. We are available 24X7 claim
intimation at the above mentioned number.

Bharti AXA General Insurance has a variety of products like Health, Travel Home & Personal Accident Insurance to suit your varied needs. This is
one of the reasons why AXA has been ranked the No. 1global insurance brand by interbrand. To know more about our products, you can visit on
www.bharti-axagi.co.in. `

We welcome you to the Bharti AXA family andensure you of our best services always.
Warm Regards
BHARTI AXA GENERAL INSURANCE COMPANY LTD.

Authorised Signatory

Registered office address: Bharti AXA General Insurance Co. Ltd.,HOSTO CENTRE No.43, Millers Road,Vasanth Nagar. Bangalore -
560046. INDIA. IRDA Reg. No. 139.For more details on risk factors and terms & conditions, please read the sales brochure carefully
before concluding a sale. Insurance is the subject matter of solicitation. RAL/Motor/TrueTongue/05-17.
 Annexure I
List of Insurance Ombudsmen

Office of the Ombudsman Contact Details Areas of Jurisdiction

AHMEDABAD Insurance Ombudsman, State of Gujarat and Union Territories of Dadra & Nagar
Office of the Insurance Ombudsman, 2nd Floor, Ambica House, Nr. C.U. Shah College, Ashram Road, Haveli and Daman and Diu
AHMEDABAD-380 014. Tel.:- 079-27545441, Fax :079- 27546142, Email bimalokpal.ahmedabad@gbic.co.in

BENGALURU Insurance Ombudsman, State of Karnataka

Office of the Insurance Ombudsman ,19/19,Jeevan Soudha Building , Ground Floor, 24th Main, JP Nagar
First Phase, Bengaluru–560025 .Tel.: 080-26652049/26652048, Email:bimalokpal.bengaluru@gbic.co.in

BHOPAL Insurance Ombudsman, States of Madhya Pradesh and Chhattisgarh

Office of the Insurance Ombudsman, Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar, Opp. Airtel, Near
New Market, BHOPAL(M.P.)-462 023. Tel.:- 0755-2769201/9202, Fax : 0755-2769203, Email:
bimalokpal.bhopal@gbic.co.in

BHUBNESHWAR Insurance Ombudsman, State of Odisha

Office of the Insurance Ombudsman, 62, Forest Park, BHUBANESHWAR-751 009. Tel.:- 0674-2596455,
Fax :0674-2596003, Email bimalokpal.bhubaneswar@gbic.co.in

CHANDIGARH Insurance Ombudsman, States of Punjab, Haryana, Himachal Pradesh, Jammu &
Office of the Insurance Ombudsman, S.C.O. No.101-103, 2nd Floor, Batra Building. Sector 17-D, Kashmir and Union territory of Chandigarh
CHANDIGARH - 160017. Tel.:- 0172 - 2706468/2772101, Fax : 0172 - 2708274, Email
bimalokpal.chandigarh@gbic.coin

CHENNAI Insurance Ombudsman, States of Punjab, Haryana, Himachal Pradesh, Jammu &
Office of the Insurance Ombudsman, Fathl ma Akhtar Court, 4th Floor, 453 (old 312), Anna Salai, Teynampet, Kashmir and Union territory of Chandigarh
CHENNAI-600 018. Tel.:- 044-24333668 /5284, Fax :044-24333664, Email bimalokpal.chennai@gbic.co.in

NEW DELHI Insurance Ombudsman, State of Delhi

Office of the Insurance Ombudsman, 2/2 A, Universal Insurance Bldg., Asaf All Road, NEW DELHI-110 002.
Tel.:- 011-23234057/23232037, Fax : 011-23230858, Email bimalokpal.delhi@gbic.co.in

GUWAHATI Insurance Ombudsman, States of Assam, Meghalaya, Manipur, Mizoram,

Office of the Insurance Ombudsman, 2/2 A, Universal Insurance Bldg., Asaf All Road, NEW DELHI-110 002. Arunachal Pradesh, Nagaland and Tripura
Tel.:- 011-23234057/23232037, Fax : 011-23230858, Email bimalokpal.delhi@gbic.co.in

HYDERABAD Insurance Ombudsman, States of Andhra Pradesh, Telangana and Union

Office of the Insurance Ombudsman, 6-2-46, Ist Floor, Moin Court, A.C. Guards, Lakdi-Ka-Pool, Territory of Yanam which is a part of Union Territory of
HYDERABAD-500 004. Tel : 040-65504123/23312122, Fax: 040-23376599, Pondicherry
Email bimalokpal.hyderabad@gbic.co.in

JAIPUR Office of the Insurance Ombudsman, Jeevan Nidhi - II Bldg., Gr. Floor, Bhawani Singh Marg,Jaipur -302 005. Tel.: 0141 State of Rajasthan
- 2740363, Fax: 0141 - Email: bimalokpal.jaipur@gbic.co.in

KOCHI Office of the Insurance Ombudsman, Jeevan Nidhi - II Bldg., Gr. Floor, Bhawani Singh Marg,Jaipur -302 005. Tel.: 0141 State of Kerala and Union Territory of
- 2740363, Fax: 0141 - Email: bimalokpal.jaipur@gbic.co.in (a) Lakshadweep
(b) Mahe - a part of Union Territory of Pondicherry

KOLKATA Insurance Ombudsman, States of West Bengal, Sikkim and Union Territories of
Office of the Insurance Ombudsman, 4th Floor, Hindusthan Bldg. Annexe, 4, C.R.Avenue, Kolkatta - 700 072. Andaman & Nicobar Islands
Tel: 033-22124339/22124346, Fax: 22124341, Email: bimalokpal.kolkata@gbic.co.in

LUCKNOW Insurance Ombudsman, Districts of Uttar Pradesh:

Office of the Insurance Ombudsman, Jeevan Bhawan, Phase-2, 6th Floor, Nawal Kishore Road, Lalltpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot,
Hazaratganj, LUCKNOW-226 001. Tel :0522 -2231331/2231330, Fax :0522-2231310, Allahabad, Mirzapu, Sonbhabdra, Fatehpur, Pratapgarh,
Email bimalokpal.lucknow@gbic.co.in Jaunpur,Veranasi, Jalaun, Kanpur, Lucknow,
Unnao, Si tapur, Lakhimpur, Bahraich, Barabanki,Raebareli,
Sravasti, Gonda, Falzabad, Amethl, Kaushambi, Balrampur,
Basil, Arnbedkamagar, Sultanpur, Maharajganj,
Santkabimagar, Azamgarh, Kushinagar, Gorkhpur, Deoria,
Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar

MUMBAI Insurance Ombudsman, States of Goa. And Mumbal Metropolitan Region

Office of the Insurance Ombudsman, 3rd Floor, Jeevan Seva Annexe, S.V. Road, Santacruz(W), excluding Areas of Navi Mumbal & Thane
MUMBAI-400 054. Tel : 022-26106960/26106552, Email bimalokpal.mumbai@gbic.co.in

NOIDA Insurance Ombudsman, State of Uttaranchal and the following Districts of State of
Office of the Insurance ombudsman, bhagwan sahai palace, 4th floor, Main Road, Naya Bans, Sec 15 G.B. Uttar Pradesh:- Agra, Aligarh, Bagpat, Bareilly, Bijnor,
Nagar, Noida - 201301. Tel : 0120 - 2514250/2514252-53 Email : bimalokpal.noida@gbic.co.in Budaun, Bulandshehar, Etah, Kanooj, Mainpuri, Mathura,
Meerut, Moradabad, Muzaffamagar, Auraiya, Pilibhit, Etawah,
Farrukhabad, Firozabad, Gautam BuddhaNagar, Ghaziabad,
Kasganj, Hardoi, Shahjahanpur, Hapur, Shamll, Rampur,
Sambhal, Amroha, Hathras, Kanshiram Nagar, Saharanpur

Insurance Ombudsman, States of Bihar and Jharkhand

PATNA Office of the Insurance ombudsman, Kalpana Arcade Building, 1st Floor, Bazar Samiti Road, Bahadurpur,
Patna 800 006. Tel No-0612-2680952 Email : bimalokpal.patna@gbic.co.in.

Insurance Ombudsman, State of Maharashtra, Areas of Navi Mumbai and Thane

PUNE Office of the Insurance Ombudsman, Jeevan Darshan Bldg., 2nd Floor, C.T.S. No.s. 195 to 198, N.C. but excluding Mumbal Metropolitan Region
Kelkar Road, Narayan Peth, Pune - 411 030. Tel.: 020 - 32341320, Email - bimalokpal.pune@gbic.co.in

OFFICE OF THE GOVERNING BODY OF INSURANCE COUNCIL

Smt. Ramma.Bhasin, Secretary General Shri. Y. R. Raigar, The Secretary
3rd Floor, Jeevan Seva Annexe, 3' Floor, Jeevan Seva Annexe,
S.V. Road, Santacruz(W), S.V. Road, Santacruz (W),
MUMBAI - 400 021 MUMBAI - 400 021.
Tel:022-26106889/6671 Tel :022-26106980
Fax : 022-26106949 Fax : 022-26106949
Email- inscoun@gbic.co.in
Web: http://www.gbic.co.in/
 Bharti Axa General Insurance Company Limited
1800-103-2292
customer.service@bhartiaxa.com
SMS<SERVICE>to 5667700
www.bharti-axagi.co.in
Smart Drive Two Wheeler Package Policy
Insured Name MR YADAV RAMASHANKAR Agent Name & No MS DEVI KIRAN (U1002019)
Agent contact No
Address BHIMPURA NO 2 NAGRA
MOB 8765015010 Policy No FTW/SA437558/U1/04/003628
..
BALLIA 221711 Policy Period April 29, 2019 0.00 to Midnight of April 28, 2020
UP
INDIA 221711 Policy Period (PA) 0.00 to Midnight of
Telephone No Mobile No 8765015010
Email Address omhondaagency@gmail.com Policy Issued On April 30, 2019
Nominee Name RADHIKA DEVI Appointee Name - Covernote No
Appointee Relation - RTO Location BALLIA
Relationship WIFE Age 56 Hypothecated To Owned - -
Registration No. Make/Model Type of Body CC Mfg Yr Seating Capacity Chassis No. Engine No
HONDA MOTORS-ACTIVA
NEW 110 2018 0002 ME4JF50CBJU115586 JF50EU9115660

Additional Trailer Non Electrical Electrical/ Electronic CNG/ LPG Unit Total IDV
Vehicle IDV Side car
Accessories (`) Accessories (`) Accessories (`) (`) (`)
41,781.00 0.00 0.00 0.00 41,781.00

Premium Details
OWN DAMAGE (A) (`) LIABILITY (B) (`)
Premium on Vehicle and non Electrical Accessory 700.25 Basic Third Party Liability 720.0
Elec Accessory 0 Comp PA 285.00
CNG/LPG 0 CNG/LPG 0
AntiTheft 0 Restricted TPPD 0
Handicap 0 LL Others 0
NCB (20.00) 140.05 Legal Liability to Paid Driver 0
Load/Discount 0 Unnamed PA Cover for 2 Persons each 0.00
Own premises 0 PA to paid driver 0
Voluntary Excess 0 LL to employee 0
Fibre Glass Tank 0 Geographical Area 0
IMT 23 0 Total Liability Premium (B) 1005.0
Geographical Area 0 Total Package Premium (A+B) 1,565.00

GST (18%) 281.70

Total Premium Payable in Rs. 1,846.70
Total Own Damage Premium (A) 560.00
Geographical Area INDIA Applicable IMT Clauses I022 I015 I007
Compulsory Deductible INR 100.00 Voluntary Deductible 0.00
Receipt No. 48389897 Premium Amount 1,846.70

LIMITS OF LIABILITY: a) Under Section II-I(i) of the policy: Death of or bodily injury – Such amount as is necessary to meet the requirements of the Motor Vehicles Act 1988. (b) Under Section II-I(ii) of the policy:
Damage to Third Party Property Rs.100,000.00; PA Cover for Owner-Driver under Section III: CSI Rs. 1,500,000.00 p.a. Limitations as to Use: The Policy covers use of the vehicle for any purpose other than: Hire or
Reward, Carriage of goods (other than samples of personal luggage), Organized racing, Pace Making, Reliability trails or Speed testing, any purpose in Connection with Motor Trade. Driver’s Clause: Any person
including the insured: Provided also that a person driving holds an effective driving licence at the time of the accident and is not disqualified from holding or obtaining such a licence. Provided also that the person
holding an effective learner’s licence may also drive the vehicle and that such a person satisfies the requirement of rule 3 of the Central Motor Vehicles Rules, 1989. 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 RIGHTS OF RECOVERY”. For legal interpretation, English version will hold good.
No Claim Bonus: The insured is entitled for a No Claim Bonus (NCB) on the own damage section of the policy, if no claim is made of pending during the preceding year(s) as follows: The preceding year - 20%,
preceding two consecutive years - 25%, preceding three consecutive years - 35%, preceding four consecutive years - 45%, preceding five consecutive years - 50% of NCB on OD Premium. NCB will only be allowed
provided the policy is renewed within 90 days of the expiry date of the previous policy.
Disclaimer: Please visit www.bharti-axagi.co.in for the detailed policy wordings, inclusions, exclusions,for complete details on terms and conditions governing the coverage and NCB. This document is to be read with
the policy wordings. The policy is valid subject to realisation of cheque. We accept premium only via legally recognised modes. In case of dishonour of premium cheque, the company shall not be liable under the policy
and the policy shall be void ab-initio. In case of any discrepancy with respect to the policy, please revert within 15 days from the policy start date. This policy is underwritten on the basis of the information provided by you
and as detailed in the Risk Assumption Letter shared with you along with the policy.
Grievance Redressal: For redressal of your grievance, if any, you may approach any one of the offices – 1. Policy issuing office 2. Corporate office. 3. Contact us: 1800-103-2292 (Toll free), 4.Register Grievances at :
www.bharti-axagi.co.in. In case, you are not satisfied with our own grievance redressal mechanism; you may also approach Insurance Ombudsman. Details of Insurance Ombudsman offices are available at IRDA
website: www.irda.gov.in, or on the website of the General Insurance Council: www.gicouncil.in or on the company website www.bharti-axagi.co.in
ISSUED BY – INB5766 on April 30, 2019

I/We hereby certify that the policy to which this Certificate relates as well as this certificate of insurance are BHARTI AXA GENERAL INSURANCE COMPANY LTD.
issued in accordance with the Provisions of Chapter X and XI of Motor Vehicle Act, 1988. In witness of this
policy has been signed at __________________ on April 30, 2019
Authorised Signatory
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 Vehicles Act is recoverable from the insured. See the clause headed “AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY”
The Schedule, the attached Policy and Endorsements mentioned herein above shall read together and word or expression to which a specific meaning has been attached in any part of this Policy or of the Schedule shall
bear the same meaning wherever it may appear. Any amendments / modifications / alterations made on this system generated policy document is not valid and Company shall not be liable for any liability whatsoever
arising from such changes. Any changes required to be made in the policy, once issued, would be valid and effective, only after written request is made to the company and Company accepts the requested
amendments/modifications/ alterations and records the same through separate endorsement to be issued by the Company
This document is
Stamp duty paid to the account of The District Registrar of Stamps (ACC Head 0030-02-103-0-10), Bangalore Karnataka. digitally signed
“Warranted that the Assured named herein/owner of the vehicle insured holds a valid Pollution Under Control (PUC) Certificate on the date of commencement of the Policy and renews and maintains valid and effective
PUC Certificate during the duration of the Policy period. If the PUC is not found valid on the date of loss, the company shall repudiate the OD claim made under the Policy”.
 TAX INVOICE U/S 28 OF GST ACT, 2016

Supplier's Name : BHARTI AXA GENERAL INSURANCE COMPANY LTD

Supplier's address : RATAN SQUARE,
OFFICE NO 507,
20 VIDHAN SABHA MARG,
LUCKNOW-226001
Tel:0522-4087900 Fax:
Email: customer.service@bhartiaxa.com GSTIN of Supplier : 09AADCB2008D1ZA

Sold To Invoice No. : 2000245745

Buyer Name : YADAV RAMASHANKAR Date : 30/04/2019
Buyer Address : BHIMPURA NO 2 NAGRA
MOB 8765015010
..
BALLIA 221711
UP
INDIA 221711
Contact Number : 8765015010
Email Id : omhondaagency@gmail.com

Location of Recipient (State) : 09 -Uttar Pradesh Location of Supply (State) : 09 -Uttar Pradesh

GSTIN of the buyer/ Unique ID : UNREGISTERED

IGST CGST SGST

Gross
Sr. No. Description SAC Total Value
Value
Rate Amount Rate Amount Rate Amount

0001 SA437558/00002/FTW/0001/TDP 997134 1,005.00 0.00 0.00 9.00 90.45 9.00 90.45 1,185.90
0002 SA437558/00002/FTW/0001/OWT 997134 560.00 0.00 0.00 9.00 50.40 9.00 50.40 660.80

1,846.70

Total Invoice Value (In figures) 1,846.70

Total Invoice Value (In words) Rupees- One Thousand Eight Hundred Forty Six and Seventy Paisa Only

Remarks, if any

For Bharti Axa General Insurance Co. Ltd.

Authorised Signatory