The New India Assurance Co. Ltd.

Servicing Office of Insurer: TIEDAuto Tie-Up DO 710500, I FLOOR, East Coast Chambers,92, G.N.
Chetty Road, , Chennai, Tamil Nadu (State Code:33) -600017, PH-- Website: www.newindia.co.in
PAN: AAACN4165C . GSTIN: 33AAACN4165C4ZV Insurer's IRDA Registration Number: 190
Tollfree Helpline 4428152566 Email: nia.710500@newindia.co.in CIN : U99999MH1919GOI000526

BUNDLED MOTOR POLICY FOR PRIVATE CARS -CERTIFICATE CUM POLICY

SCHEDULE (UIN-IRDAN190RP0023V01201819)
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. 71050031210960038730 Policy Issued On 14-OCT-2021 (15:45)

Insured Name MR. VIKRANT SINGH
Own Damage Period 14-OCT-2021(15:45) To 13-OCT-2022(Midnight) Motor Liability Period 14-OCT-2021(15:45) To 13-OCT-2024(Midnight)

Proposal No. & Date PRODFORD3217422, 14-OCT-2021 CPA Cover Period 14-OCT-2021(15:45) To 13-OCT-2024(Midnight)
Insured Add. S/O MR. BHEEM SEN,MELAGHAT ROAD,RAJEEV NAGAR BHOOD MAHOLIYA,KHATIMA, , UDHAM SINGH NAGAR , UTTARAKHAND (State
Code:05) -262308
Previous Insurer NA Previous Policy No. NA
Broker Details
IRDA Lic. No.: 375, CIN No.: U50300MH1997PLC149349 Broker Category: Composite Broker, Validity: 13-MAY-20 To 12-MAY-23
Name & Add.: TATA MOTORS INSURANCE BROKING AND ADVISORY SERVICES LTD, 1ST FLOOR, AFL HOUSE, LOK BHARTI COMPLEX, MAROL MAROSHI ROAD,
ANDHERI (EAST), MUMBAI - 400 059

Make Model Sub Model Cubic Capacity Manufacturing Year Seating capacity

FORD ECOSPORT 1.5 PETROL TITANIUM+ AT 1497 2021 5

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

UAV UDHAM SINGH NAGAR 14-OCT-2021 MA40833 MAJAXXMRKAMA40833

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

1,082,050 0 0 4,790 1,086,840

Schedule of Premium (Amount in Rs.)

Own Damage Premium (A)
Basic Premium Deductibles
Vehicle 13,812 Voluntary Deductibles (0) (IMT-22A) 0

Non-Elec. Accessories 153 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 (0%) 0

Sub Total (Basic Premium) 13,965 Handicapped Discount (0%) 0

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

IMT 23 Premium 0

Add On Coverages (NIL DEPRECIATION) 4891

Sub Total-Addition 18,856 Net Own Damage Premium (A) 18,856

Liability Premium (B)

Basic Third Party Liability 9534 PA Cover For 5 Persons of Rs. 100000 Each (IMT-16) 750
Third Party Liability For Bi-Fuel Kit 0 PA cover for Paid Driver of Rs 2,00,000 (IMT± 0
Third Party Liability For Geographical Area Extension 0 Legal Liability For Paid Driver (IMT-28) 150
PA Cover For Owner Driver Of Rs. 1500000 (IMT-15)
780 Legal Liability for Employees (for 0 persons) (IMT± 0

Net Liability Premium (B) 11214

Note: 1.Warning that in case of dishonour of the premium cheque, this document stands
automatically cancelled 'ab-initio Total Premium (A+B) 30070
2.Consolidated stamp duty paid to state exchequer.
3.The policy is subject to compulsory deductible of Rs.1000 (IMT-22) IGST (18%) 5413

5.Add-on: NIL DEPRECIATION(Nil Depreciation-1 Year:4891)

6.The insurance company will display terms & conditions on its website www.newindia.co.in which can
be accessed by you online.
*Subject to IMT Endt. Nos.& Memorandum:7,24,22,16,28 Gross Premium Paid 35483

Nominee Details
Name of Nominee Age Relationship with Insured Name of Appointee Relationship with Nominee
RUCHI SINGH 44 SPOUSE --N.A-- --N.A--
Payment Details : Cheque No.: 110307840589, Cheque Date: 14-OCT-2021, Bank Name: NON-CUG HDFC CCAVENUE, Bank City:
Hypothecation Details: INDIAN BANK - NAUGAWAN THAGGU - UDHAM SINGH NAGAR
MISP Name: PAL PRATEEK MOTORS PVT LTD, MISP PAN No: AAFCP0212R, MISP Code: MISP/AAFCP0212R
SAC:997134, Description of Service :Motor Vehicle Insurance Services, Place of Supply :UTTARAKHAND(State Code:05), Receipt No/Invoice No:31210038730
I/we hereby certify that the policy to which this certificate relates as well as this certificate of insurance are issued in accordance with the provisions of Chapter X and Chapter XI of Motor
Vehicle Act, 1988
For & On Behalf of The New India Assurance 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
 The New India Assurance Co. Ltd.
Servicing Office of Insurer: TIEDAuto Tie-Up DO 710500, I FLOOR, East Coast Chambers,92, G.N.
Chetty Road, , Chennai, Tamil Nadu (State Code:33) -600017, PH-- Website: www.newindia.co.in
PAN: AAACN4165C . GSTIN: 33AAACN4165C4ZV Insurer's IRDA Registration Number: 190
Tollfree Helpline 4428152566 Email: nia.710500@newindia.co.in CIN : U99999MH1919GOI000526

BUNDLED MOTOR POLICY FOR PRIVATE CARS -CERTIFICATE CUM POLICY

SCHEDULE (UIN-IRDAN190RP0023V01201819)
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. 71050031210960038730 Policy Issued On 14-OCT-2021 (15:45)

Insured Name MR. VIKRANT SINGH
Own Damage Period 14-OCT-2021(15:45) To 13-OCT-2022(Midnight) Motor Liability Period 14-OCT-2021(15:45) To 13-OCT-2024(Midnight)

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.

NCB Clause: The insured is entitled for a No Claim Bonus (NCB) on the own damage section of the policy, if no claim is
made or pending during the preceding year(s)-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 is
allowed provided the policy is renewed within 90 days of the expiry date of the previous policy.

Important Notice: The insured is not indemnified if the vehicle is used or driven otherwise than in accordance with the
schedule. Any payment made by the company by reasons 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 ³AVOIDANCE OF CERTAIN TERMS &
RIGHT OF RECOVERY´For legal interpretation English version will hold good.

Note: This 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.
In Witness whereoff this policy has been signed at HALDWANI on 14-OCT-2021 15:45
 The New India Assurance Co. Ltd.
Servicing Office of Insurer: TIEDAuto Tie-Up DO 710500, I FLOOR, East Coast Chambers,92, G.N.
Chetty Road, , Chennai, Tamil Nadu (State Code:33) -600017, PH-- Website: www.newindia.co.in
PAN: AAACN4165C . GSTIN: 33AAACN4165C4ZV Insurer's IRDA Registration Number: 190
Tollfree Helpline 4428152566 Email: nia.710500@newindia.co.in CIN : U99999MH1919GOI000526

BUNDLED MOTOR POLICY FOR PRIVATE CARS -CERTIFICATE CUM POLICY

SCHEDULE (UIN-IRDAN190RP0023V01201819)
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. 71050031210960038730 Policy Issued On 14-OCT-2021 (15:45)

Insured Name MR. VIKRANT SINGH
Own Damage Period 14-OCT-2021(15:45) To 13-OCT-2022(Midnight) Motor Liability Period 14-OCT-2021(15:45) To 13-OCT-2024(Midnight)

PRIVATE CAR PACKAGE POLICY: ADD ON COVERS

Endorsement Wordings for Add on cover - Nil Depreciation

Notwithstanding anything contained to the contrary in the within mentioned policy it is hereby declared and agreed that
subject to the insured having paid the additional premium as applicable the cover under Section I of the within-mentioned
policy is hereby extended to the effect that in the event of any partial loss claim admissible under this policy no depreciation
shall be deducted, except on tyres and tubes which are damaged in the accident and are replaced.

Further this endorsement is not applicable:

1. For any extra fittings and/ or any internal improvements in the vehicle other than provided by the manufacturer in the
vehicle originally.
2. In relation to any accident occurring in any geographical area outside India.
3. All other terms and conditions of the within mentioned policy shall remain unaltered