3/24/23, 12:03 PM about:blank

SBI General Insurance Co. Ltd.

Natraj,301 Junction of Western Express Highway Andheri Kurla Road, Andheri (East) Mumbai MUMBAI -
400069,MAHARASHTRA
IRDA Registration Number: 144

Broker Details
TATA MOTORS INSURANCE BROKING AND ADVISORY SERVICES LTD,     1ST FLOOR, AFL HOUSE, LOK
CIN Number: U50300MH1997PLC149349
BHARTI COMPLEX, MAROL MAROSHI ROAD, ANDHERI (EAST), MUMBAI - 400 059, 022–62379515
License Validity: 13-MAY-20 To 12-MAY-
Category: Composite Broker IRDAI Lic. No: 375
23
   Proposal Details
Own Damage Period   31- Motor Liability Period 31-
Proposal No.   Proposal Date.   Cover Type.   1 YEAR Motor Liability Policy No
Mar-2023  To 30-Mar- Mar-2021 To 30-Mar-
PPVBU13985518 24-Mar-2023 STANDALONE OD TABL103382 ( RSA )
2024 2024
   Proposer Details
Address of the Proposer
Proposer Type Proposer Name Vehicle Usage
SONALI APARTMENT 242 G P ROAD STORE BAZAR ICHAPUR
Individual Mr. SOURAJIT DUTTA Private
NAWABGANJ 24 PARGANA NORTH WEST BENGAL 743144
   Vehicle Details
Invoice Date Chassis No. Engine No. Make Model & Variant CC
31-Mar-2021 MAT627145MLC18580 1.5CR05CYXW05179 NEXON  NEXON (D) XZA+ DT (O) NEW 1497
Place of Registration Registration No. Invoice Value Year of Manufacture Seating Capacity
BARRACKPORE WB 24 WB-24-BA-5411 1543000 2021 5
   Other Details
Branch/Office of HP/Lease/Hire
HP/Lease/Hire Pur. Agreement with Agreement Type Loan Account/Contract No
Purchaser
-- -- -
--
   Insured Declared Value (IDV)
Vehicle Electrical Accessories Non-Electrical Accessories CNG/LPG Total IDV
1080100 0 0 0 1080100
Premium Calculation
A.Own Damage Premium
Basic Premium Amount (Rs.)   Deductibles Amount (Rs.)
Vehicle 13787   Voluntary Discounts Rs. (0) 0
Non Electrical Accessories 0   Anti Theft Device 0
Electrical Accessories 0   AA Membership 0
Bi Fuel Kit 0   NCB (0%) 0
Sub Total (Basic Premium) 13787   Handicapped Discount (0%) 0
Geographical Area Extension 0   Sub Total (Discounts) 0
IMT 23 Premium 0  
Sub Total 13787  
Add-Ons 13123   Net Own Damage Premium(A) 26910
     
      Total Premium 26910
  CGST Premium (9%) 2422
  SGST Premium (9%) 2422
  Total GST Premium (18%) 4844
      Gross Premium 31754
Add-on: Road Side Assistance, Nil Depreciation, Consumables, Engine Protect
Payment Details ( MULTIPLE PAYMENT MODE )
MISP Details
MISP Name: MISP Code: MISP Pan No:
DHULICHAND MOTORS PVT LTD TMIBASL/MISP/AAACJ8280G AAACJ8280G

 Declaration I/ we hereby declare and state that the above statements made by me/ us are true and complete. No part
of it is false. I/ we desire to effect an insurance as describe herein with SBI General Insurance Co. Ltd. and I/ we agree
that this proposal and declarations shall be the basis of contract between me/ us and the SBI General Insurance Co. Ltd.
and I/ we agree to accept the policy subject to the condition specified by the Insurance Company.
I/ we agree to receive the policy document (without enclosing the terms and conditions of policy) from the company and
authorise the company to display Terms and Conditions of the policy on its website that enables access by me.
I hereby confirm that I have mandated to place my insurance cover and have read and agreed on the terms and
conditions and also give my unconditional consent for receiving a call from TATA MOTORS INSURANCE BROKING AND
ADVISORY SERVICES LTD or its affiliated entities on my number even if the number is enrolled under NDNC/DND
registry

 Date: 24-Mar-2023
Proposer Signature/ Thumb Impression 
INSURANCE ACT 1938, SECTION 41- PROHIBITION OF REBATES
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

about:blank 1/2
3/24/23, 12:03 PM about:blank
published prospectuses or tables of 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.

about:blank 2/2