Bajaj Allianz General Insurance Co. Ltd.

Servicing Office of Insurer: 164/1 MANICKTALA MAINROAD,MANI SQUARE 6TH FLOOR,CANAL

CIRCLE ROAD,PREMISES NO-41, KOLKATA±Kolkata, West Bengal (State Code:19) -700054,
PH-- Website: www.bajajallianz.com
PAN: AABCB5730G . GSTIN: 19AABCB5730G1ZU Insurer's IRDA Registration Number: 113
Tollfree Helpline 033 - 30212900 Email: CIN : U66010PN2000PLC015329

STANDALONE OWN DAMAGE COVER FOR PRIVATE CAR CUM RECEIPT (UIN-
IRDAN113RP0001V01201920)
OD Policy No. OG-20-2401-1870-00001686 Policy Issued On 27-FEB-2020 (12:30)
Insured Name MRS. SOMALI CHAKRABORTY
Own Damage Period 27-FEB-2020(12:30) To 26-FEB-2021(Midnight) Motor Liability Period 18-DEC-2018(12:30) To 17-DEC-2021(Midnight)
Motor Liability Policy No OG-19-2401-1825-00002235 (BAG)

Proposal No. & Date PRODFORD2365592, 27-FEB-2020

Insured Add. 103 SALT LAKE , BLOCK -EC SALT LAKE (N) , KOLKATA , WEST BENGAL (State Code:19) -700064
Previous Insurer BAG Previous Policy No. OG-19-2401-1825-00002235 18-DEC-2018 To 17-DEC-2019
Broker Details
IRDA Lic. No.: 375, CIN No.: U50300MH1997PLC149349 Broker Category: Composite Broker, Validity: 13-MAY-17 To 12-MAY-20
Name & Add.: TATA MOTORS INSURANCE BROKING & ADVISORY SERVICES
LTD, 1ST FLOOR, AFL HOUSE, LOK BHARATI COMPLEX, MAROL MAROSHI ROAD, ANDHERI (EAST), MUMBAI 400 059, INDIA

Make Model Sub Model Cubic Capacity Manufacturing Year Seating capacity

FORD ECOSPORT 1.5 ECOSPORT PTL TIT MT 1499 2018 5

Body Type Registration No. RTO Invoice Date Engine No. Chassis No.

UAV WB 08 F 6521 KOLKATA 18-DEC-2018 JM48730 MAJAXXMRKAJM48730

Vehicle IDV CNG/LPG Kit Elec. Accessories Non-Elec. Accessories Total IDV

832,368 0 0 0 832,368

Schedule of Premium (Amount in Rs.)

Own Damage Premium (A)
Basic Premium Deductibles
Vehicle 10,931 Voluntary Deductibles (0) (IMT-22A) 0

Non-Elec. Accessories 0 Anti Theft Device (IMT-10) 0

Elec. Accessories (IMT-24) 0 AA Membership (IMT-8) 0

CNG/LPG Kit (IMT-25) 0 No Claim Bonus (20%) 2,187

Sub Total (Basic Premium) 10,931 Handicapped Discount (0%) 0

Geographical Area Extension (IMT-1) 0 Sub Total (Deductibles) 2,187

IMT 23 Premium 0

Add On Coverages (NILDEP2YEAR) 4579

Sub Total-Addition 15,510 Net Own Damage Premium (A) 13,323

Note: 1.Warning that in case of dishonour of the premium cheque, this document stands
automatically cancelled 'ab-initio Total Premium (A) 13323
2.Consolidated stamp duty paid to state exchequer CGST (9%) 1200
3.The policy is subject to compulsory deductible of Rs.1000 (IMT-22) SGST (9%) 1200

5.Add-on: NILDEP2YEAR(Nil Depreciation-1 Year:4579)

6.The insurance company will display terms & conditions on its website www.bajajallianz.com which can
be accessed by you online.
*Subject to IMT Endt. Nos.& Memorandum:7,22 Gross Premium Paid 15723
0
Payment Details : Cheque No.: 109782877696, Cheque Date: 27-FEB-2020, Bank Name: NON-CUG HDFC CCAVENUE, Bank City:
Hypothecation Details: FORD CREDIT INDIA PVT LTD - KOLKATA - kolkata
MISP Name: KNR AUTOMOBILES PVT LTD, MISP PAN No: AAECK2111K, MISP Code: MISP/AAECK2111K
SAC:997134, Description of Service :Motor Vehicle Insurance Services, Place of Supply :WEST BENGAL(State Code:19), Receipt No/Invoice No:149866693/1
For & On Behalf of Bajaj Allianz General Insurance Co. Ltd.

Authorized Signatory
In case of any claim or assistance required please contact our help line at 1800-258-2545 and you may also reach us at fordinsurance@tmibasl.com
 Bajaj Allianz General Insurance Co. Ltd.
Servicing Office of Insurer: 164/1 MANICKTALA MAINROAD,MANI SQUARE 6TH FLOOR,CANAL
CIRCLE ROAD,PREMISES NO-41, KOLKATA±Kolkata, West Bengal (State Code:19) -700054,
PH-- Website: www.bajajallianz.com
PAN: AABCB5730G . GSTIN: 19AABCB5730G1ZU Insurer's IRDA Registration Number: 113
Tollfree Helpline 033 - 30212900 Email: CIN : U66010PN2000PLC015329

STANDALONE OWN DAMAGE COVER FOR PRIVATE CAR CUM RECEIPT (UIN-
IRDAN113RP0001V01201920)
OD Policy No. OG-20-2401-1870-00001686 Policy Issued On 27-FEB-2020 (12:30)
Insured Name MRS. SOMALI CHAKRABORTY
Own Damage Period 27-FEB-2020(12:30) To 26-FEB-2021(Midnight) Motor Liability Period 18-DEC-2018(12:30) To 17-DEC-2021(Midnight)
Motor Liability Policy No OG-19-2401-1825-00002235 (BAG)

Limitations as to use: The policy covers use of the vehicle for any purpose other than (1) Hire or Reward (2) Carriage of
goods (other than samples or personal luggage) (3) Organized racing (4) Pace making (5) Speed testing (6) Reliability trials (7)
Any purpose in connection with motor trade.

Driver¶s Clause: Any person including the insured: Provided that the person driving holds an effective driving license at the
time of the accident and is not disqualified from holding or obtaining such license. Provided also that the person holding an
effective learners license may also drive the vehicle & that such a person satisfies the requirements of Rule 3 of the Central
Motor Vehicle Rules, 1989.

Own Damage Cover is subject to a valid Third Party Policy.

This policy covers damages to vehicle only and not the Third Party losses. Third Party cover is taken by the customer in
previous policy, details of which are as per the customer declaration only. Customer needs to ensure that there is a valid TP
cover at all times.
 Bajaj Allianz General Insurance Co. Ltd.
Servicing Office of Insurer: 164/1 MANICKTALA MAINROAD,MANI SQUARE 6TH FLOOR,CANAL
CIRCLE ROAD,PREMISES NO-41, KOLKATA±Kolkata, West Bengal (State Code:19) -700054,
PH-- Website: www.bajajallianz.com
PAN: AABCB5730G . GSTIN: 19AABCB5730G1ZU Insurer's IRDA Registration Number: 113
Tollfree Helpline 033 - 30212900 Email: CIN : U66010PN2000PLC015329

STANDALONE OWN DAMAGE COVER FOR PRIVATE CAR CUM RECEIPT (UIN-
IRDAN113RP0001V01201920)
OD Policy No. OG-20-2401-1870-00001686 Policy Issued On 27-FEB-2020 (12:30)
Insured Name MRS. SOMALI CHAKRABORTY
Own Damage Period 27-FEB-2020(12:30) To 26-FEB-2021(Midnight) Motor Liability Period 18-DEC-2018(12:30) To 17-DEC-2021(Midnight)
Motor Liability Policy No OG-19-2401-1825-00002235 (BAG)

PRIVATE CAR PACKAGE POLICY: ADD ON COVERS

Endorsement Wordings

In consideration of payment of additional premium, it is hereby agreed and declared that this Policy extends to cover the
depreciation amount, partly or fully, on assessed damaged parts allowed for replacement during repairs in the event of a
Partial Loss to the Insured Vehicle. In the event You have opted for co-payment, Your contribution shall be to the extent
agreed by You as shown in the Schedule for the depreciation amount on the assessed parts for each and every Partial Loss
claim. The benefits under Depreciation Shield would be available only if the Insured Vehicle is repaired at Our authorized
workshops. In case You have opted to repair the Insured Vehicle at a non-authorized workshop, Our liability will be
restricted to 90% of the assessed total claim amount under this cover.

Conditions

1. Claims made by You against Us under Depreciation Shield are subject to the terms and conditions set forth under the
Motor Insurance Policy
2. In case of transfer of ownership of the Insured Vehicle, the cover under Depreciation Shield shall expire
3. The benefits under Depreciation Shield can be utilized for a maximum of two times during the Policy Period

Exclusions

In addition to the exclusions mentioned under Motor Insurance Policy, We will not be liable to indemnify You for the
following events:

1. Where the Own Damage Claim made by You against Us under the Motor Insurance Policy is not payable
2. Depreciation pertaining to any part/ sub part/ accessories not approved for replacement by Us under Motor Insurance
Policy
3. Loss or damage to tyres and/or battery of the Insured Vehicle
4. Consequential loss of any kind arising out of claims lodged under Depreciation Shield
5. Where a loss is covered under Motor Insurance Policy or any other type of insurance policy with any other insurer or
manufacturers warranty or recall campaign or under any other such packages at the same time

If You do not agree whether any of these exclusions apply to Your claim, You agree to accept the burden of proving that
they do not apply.

Definitions

The words and phrases listed have special meanings We have set below whenever they appear in bold type and initial
capitals. Please note that references to the singular or to the masculine also include references to the plural or to the female
the context permits and if appropriate.

1. You, Your, Yourself: The person or persons We insure as set out in the Schedule
2. We, Our, Us: Bajaj Allianz General Insurance Company Limited
3. Accident, Accidental: A sudden, unintended and fortuitous external and visible event
4. Policy/ Motor Insurance Policy: Private Car Package Policy issued by Us to which this cover is extended
5. Insured Vehicle: The vehicle insured by Us under the Motor Insurance Policy and as shown on the Schedule
6. Policy Period: The period between and including the commencement date and expiry date as shown in the Motor
Insurance Policy Schedule
7. Schedule: The Schedule and any Annexure or Endorsement to it which sets outYour personal details and the
insurance cover in force
8. Own Damage Claim: The claims raised by You against Us for loss or damage to the Insured Vehicle due to the perils
mentioned under Section 1 of Motor Insurance Policy
9. Total Loss/ Constructive Total Loss: A loss under the Motor Insurance Policy where the aggregate cost of retrieval
and/ or repair of the Insured Vehicle, subject to terms and conditions of the Policy, exceeds 75% of the IDV of the
Insured Vehicle
10. Partial Loss: Any loss falling into a category other than (a) the loss mentioned under Sr. No. 9 above and (b) theft of
the Insured Vehicle