Bajaj Allianz General Insurance Company Ltd.

Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune

Transcript of Proposal for Commercial Vehicle Package Policy

Dear GUMMADI NARASIMHARAO

We wish to inform you that the contract under policy number 'OG-23-1805-1803-00000248' has been finalized based on the in-
formation and declaration given by you, the transcript whereof is mentioned below. You are requested to reconfirm the same.
In case of any disagreement or objection or any changes with respect to information mentioned below, we request you to
please revert back within a period of 15 days from date of your receipt of this, failing which it will be deemed that you are sat-
isfied with the correctness of the details mentioned below. Kindly note that as the contents and declarations contained in this
transcript is the basis on which we have issued the policy to you, we advise you to please ensure that you have provided/dis-
closed and or not withheld any material facts/information and declarations, as Policy becomes Void ab initio if material facts
are not provided/disclosed and or withheld and in such case no claim, if any, will be considered by us apart from forfeiture of
the premium.
Details provided by you:

A. Proposer details

1. Proposer Name : GUMMADI NARASIMHARAO

2. Proposer Address : S/O SANJEEVARAO,, H NO;1-11,GOLLAGUDEM,KANNAIGUDEM,NELLIPAKA,,
,BHADRACHALAM, KHAMMAM - 507001
3. Proposer Mobile Number : 0-9515794797
4. Proposer Residential Number : NA
5. Proposer e-mail id : NAVEENA.SLIC@GMAIL.COM
6. Proposer Profession : NA

B.Vehicle Details

Registration Vehicle Vehicle Vehicle CC/KW Year Of Vehicle Vehicle/Trail- Vehicle Engine
Number Make SubType Model Manufac- Seating Ca- er Chassis Number
turing pacity Number
AP05TV495 TATA XMS ZEST 1248 2016 4 MAT624030G 100A20000661
0 QUADRA- PP46998 987
JET 75 PS
DIESEL
(4+1)

Fuel Type Vehicle IDV Electrical Non- Trailer Trailer Re- CNG/LPG Total Sum In-
(in Rs.) Accessor- Electrical Ac- gistration Unit (Extra sured
ies IDV (in cessories IDV Number fitted) IDV (in
Rs.) (in Rs.) Rs.)
DIESEL 4,02,500 0 0 0 4,02,500
 C. Coverage opted

1. Period of Insurance : From 20-Jul-2022 12:51(Hrs) To

19-Jul-2023 Midnight
2. Is your vehicle fitted with external LPG/CNG kit : No.
3. Electrical Accessories cover Opted (If Applicable) : No.
4. Non - Electrical Accessories cover Opted (If Applicable): : No.
5. Is Voluntary Excess opted : No.
Amount of voluntary excess opted : Rs.NA.
6. Whether PA cover is opted for owner-driver : Yes.
7. Is any additional compulsory deductible imposed and agreed upon : No.
Amount of additional compulsory deductible imposed : NA.
8. Whether geographical area extension is opted : No.
Details of Countries to which geographical area extension cover is given : NA.
9. Is LL to person for Paid driver/Operation/Maintenance opted : Yes.
10. Whether PA cover is opted for paid driver other than owner driver : No.
Number Of Paid Driver(s) : : NA
Sum Insured Per Paid Driver : : Rs.NA.
11. Whether PA cover is opted for passengers : No.
Number Of Passengers : : NA
Sum Insured per Passenger : Rs.NA
12. Is TPPD restricted to statutory limit of Rs.6,000? : No.
13. Pre Existing damages in the vehicle : NA.
14. Premium for Liability coverage, quoted and agreed upon is : Rs.12,233.00.
15. Premium for OD coverage, quoted and agreed upon is : Rs.5,646.00.
16. Do you have valid PUC certificate of the vehicle : NA
17. Do you have valid Fitness certificate of the vehicle : NA
18. Total Premium (excluding Goods and Service Tax (GST)) for Liability and
OD coverages, quoted and agreed upon is :Rs.17,879.00
19. NCB (No Claim Bonus) claimed by you and granted by us based on your
declaration of no claim during your previous policy :NA.
20. About the last insurance company

Previous Insurer - NA Previous Policy No -3370/00347619/000/00

Expiry On -
21. Whether your vehicle is Hypothecated and if so the details of Pledgee whose name is registered by us:
HYPOTHECATED WITH : SHRIRAM CITY UNION FINANCE LTD
22. Add on Cover(s) opted : No.Plan name:NA
23. To support our Go Green initiative, send policy copy link on registered mobile number / email id: YES
Please note Cover Note No. / issued to you basing on the above information.
In case of Disagreement or objection or any changes with respect to information and contents mentioned hereinabove, please
contact our toll free number & register your objections/changes/disagreement to the contents of this transcript or you may also
send us email or written correspondence at the following details within a period of 15 days from date of your receipt of this
transcript along with Policy:
I/We hereby unconditionally allow the Company to share all my / our information being collected in this proposal form or
through telephonic / email / web-inputs means or other means, as updated from time to time within group entities.
Toll free Number : 1800-102-5858,1800-209-5858
Email address : Bagichelp@bajajallianz.co.in
Website : www.bajajallianz.com
Contact our policy servicing branch at: BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED,, D No
:1-7-690/20,Subedari Main Road,, Loyola Arcade, 1st Floor,, Hanamkonda, WARANGAL-506001 Phone No :0870-2438080.
INSURANCE ACT, 1938 SECTION 41 - PROHIBITION OF REBATES
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 a policy
accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.
ANY PERSON IN BREACH OF COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE
WITH FINE WHICH MAY EXTEND TO RUPEES TEN LAKH.Bajaj Allianz General Insurance Co Ltd
  
Bajaj Allianz General Insurance Company Ltd.
Bajaj Allianz House, Airport Road, Yerwada, Pune - 411006(India)
COMMERCIAL VEHICLE PACKAGE POLICY CERTIFICATE CUM POLICY SCHEDULE
UIN : IRDAN113RP0027V01200102

Policy issuing office and Correspondence address for communication by policyholder for claim, service request, notice, summons,
etc; BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED,, D No :1-7-690/20,Subedari Main Road,, Loyola Arcade, 1st Floor,,
Hanamkonda, WARANGAL-506001 Phone No :0870-2438080
Policy Number OG-23-1805-1803-00000248 Product Commercial Vehicle Package Policy
Vehicle Type Passenger Carrying - 4 Wheel & Carrying Capacity <= 6
Period Of Insurance From: 20-Jul-2022 12:51 Policy issued on 20-Jul-2022 -
To: 19-Jul-2023 Midnight Cover Note No /
Application No 316457500Scrutiny No
Insured Name GUMMADI NARASIMHARAO B Zone
Insured Address S/O SANJEEVARAO,, H
NO;1-11,GOLLAGUDEM,KANNAIGUDEM,NEL
LIPAKA,, ,BHADRACHALAM, KHAMMAM -
507001
Customer ID 277565533 Premium Payer ID 277565533
Transaction Id
HYPOTHECATED WITH : SHRIRAM CITY UNION FINANCE LTD Policy Status ISSUED
GSTIN / UIN NA Place of Supply/State 36 - Telangana
Code/Name
Invoice No. 355930378/1
Company GST No 36AABCB5730G1ZY
Company PAN No AABCB5730G
Registration Make SubType Model CC/KW Mfg year Seat Cap Vehicle/ Engine Number
No. Trailer
Chassis
No
AP05TV4950 TATA XMS QUAD- ZEST 1248 2016 4 MAT62403 100A20000661987
RAJET 75 PS 0GPP4699
DIESEL (4+1) 8

Fuel Type Vehicle IDV Elec Acc Non Elec Acc Trailer Trailer Reg No CNG/LPG Unit Total Sum Insured

DIESEL 4,02,500 0 0 0 4,02,500

SCHEDULE OF PREMIUM
OWN DAMAGE LIABILITY
Total Own Damage Premium: 5,646.00 Basic Third Party Liability 11,852.00
PA Cover For Owner-Driver - SI - Rs. 331.00
15,00,000.00 Period: From 20-JUL-22 To
19-JUL-2023
LL For Operation/Maintenance For 1 Person 50.00
Total Liability Premium: 12,233.00
Total premium 17,879.00
Special Discount
Net Premium 17,879.00
State GST (9%) 1609
Central GST (9%) 1609
Final Premium Rs. 21,097.00 ***All Premium Figures are in Rupees
Geographical Area : No Claim Bonus : 0% Voluntary Excess : Nil
Nominee Details Name : Narasimharao Relationship : Owner
Compulsory Deductible : Rs.500 Additional Compulsory Deductible : Rs.0
Previous Insurer - NA Previous Policy No -3370/00347619/000/00 Expiry On -
The above Total OD Premium is inclusive of all applicable Loading/Discounts viz (Automoble Association Membership,Voluntary Excess,Anti-Theft,Handicap Per-
son,Driver Tution,Fibre Glass,Cng/Lpg Unit,Geographical Extn,Imported Vehicle etc wherever applicable)
As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th
September of the next financial year

LIMITS OF LIABILITY: Under Section II-1(i) of the policy -> Death of or bodily injury : Such amount as is necessary to meet there requirements of the Motor
Vehicles Act,1988. Under Section II-1(ii) of the policy -> Damage to Third Party Property : Rs.7,50,000.00/-
LIMITATION AS TO USE: The Policy covers use only under a permit within the meaning of the Motor Vehicle Act, 1988 or such a carriage falling under Sub-
section 3 of Section 66 of the Motor Vehicle's Act 1988. The Policy does not cover use for : Organised racing, Pace Making, Reliability Trials, Speed Test-
ing,Use whilst drawing a trailer except the towing (other than for reward) of any one disabled Mechanically propelled vehicle.
DRIVER : : Any person including the insured : Provided that a person driving holds an effective driving licence at the time of the accident and is not disquali-
fied from holding or obtaining such a licence. Provided also that the person holding an effective Learner's licence may also drive the vehicle when not used for
the transport of passengers at the time of the accident and that such a person satisfies the requirements 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 RIGHT OF RECOVERY".
Subject To IMT Endorsement Nos : 7, 22, 23, 35, 28, & Policy wordings attached herewith
Warranted that insured named herein or owner of the vehicle insured holds a valid Pollution Under Control (PUC) and
/ or Fitness Certificate on the date of commencement of the Policy. If the PUC and/or Fitness Certificate is not found to
be valid on the date of commencement of the Policy, the Company reserves its right to consider the policy void ab ini-
tio.
Broker Code 80312005 Channel Name : MD
Broker Name : Bharat Re- Insurance Brokers Pvt. Ltd.
Contact No : 9502048252/9502048252

Regd. Office : Bajaj Allianz House, Airport Road, Yerawada,Pune - 411006 (India),A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance
Regulatory and Development Authority of India [IRDA] vide Reg No.113, Corporate Identification Number U66010PN2000PLC015329.Principal Location : Bajaj Allianz
General Insurance Co Ltd, 4th Floor, North East Plaza, Erramanzil X Roads, Beside BMW Showroom, HYDERABAD - 500082 PH:04033122800 | Services Accounting
Code : 997134 - Motor vehicle insurance services. No reverse charge is payable on these services. - Latest Schedule - 20-Jul-2022 13:06:07 PM (Web)
  
Email - insurance_shriramcity@shriramcity.com
Damage Details as per Annexure I
Premium Collection Details :- [Receipt No/Collection No/Amount] 1805-00309343 / 316457500 / Rs. 21,097.00 ,
*** If premium paid through cheque, the policy is void ab-initio in case of dishonour of cheque.
This certificate of insurance is issued in accordance with the provision of Chapter X and Chapter XI of M.V. Act, 1988.
It is hereby understood and agreed that for the purpose of application of Endorsement IMT-21 attached to and forming part of the above policy, the towing vehicle and trailer(s) while attached
thereto shall be treated as a single unit.
Damage Details Annexure : - Cost of Repair / Replacement towards the damaged parts noticed during the inspection of your vehicle
prior to enrolment under this policy as per Inspection report reference number 2022-08141344 duly signed by you or your
representative as well as the photographs shall be excluded in the event of any future claims.
Remarks -

In case of any claim, please contact our 24 Hour Call centre at 1800-102-5858 (Toll Free) / 91-020-30305858 (chargeable, add area
code before this number in case of mobile call) or email us at 'Bagichelp@bajajallianz.co.in'.
316457500/-/80312005/NA/-
This is a one page Policy Document [without enclosing the Terms and Conditions (T&C) of the Policy] issued by the Company, pursuant to the authorization of Insured to display the T&C of the Policy on its website (www.bajajallianz.com) that enables access by the In-
sured. The T&C of the Policy are available on the Company's website and can be accessed by the Insured.
Kindly contact our nearest / local office(s) for No Claim Bonus Confirmations.

This is the 'Digital Print' and original Policy would follow and the Original policy, duly countersigned, to be relied on for all legal purposes.

For & On Behalf of Bajaj Allianz General Insurance Company Ltd.

Stamp
Duty
Rs.0.5

Authorized Signatory This document is digitally signed, hence counter signature / stamp is not required
null

Regd Office : Bajaj Allianz House,Airport Road, Yerwada Pune-411006 (India), A Company incorporated under Indian Companies Act, 1956 and licensed by In-
surance Regulatory and Development Authority of India [IRDA] vide Reg No.113, Corporate Identification Number U66010PN2000PLC015329.
Consolidated Stamp Duty of Rs.0.5/- paid towards Insurance Stamps vide Challan No. MH002405964202122M Defaced No. 0001482221202122 dated 05-JUL-21
timing 12:58:03 of General Stamp Office,Mumbai,India.
Generated by 80312005@md bajajallianz co in

Regd. Office : Bajaj Allianz House, Airport Road, Yerawada,Pune - 411006 (India),A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance
Regulatory and Development Authority of India [IRDA] vide Reg No.113, Corporate Identification Number U66010PN2000PLC015329.Principal Location : Bajaj Allianz
General Insurance Co Ltd, 4th Floor, North East Plaza, Erramanzil X Roads, Beside BMW Showroom, HYDERABAD - 500082 PH:04033122800 | Services Accounting
Code : 997134 - Motor vehicle insurance services. No reverse charge is payable on these services. - Latest Schedule - 20-Jul-2022 13:06:07 PM (Web)
 Bajaj Allianz General Insurance Company Ltd.
BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED, D No :1-7-690/20, Subedari Main
Road, Loyola Arcade, 1st Floor, Hanamkonda, WARANGAL - 506001
Contact No:Contact No: 0870-2438080,0870-2438080; Fax No: 0870-2510006

RECEIPT

Receipt Number 1805-00309343

Receipt Date 20/07/2022
Business Channel MD

Received with thanks from GUMMADI NARASIMHARAO

(Customer ID : 277565533 ) a total sum of Rupees Twenty One Thousand Ninety Seven Only
by,

Instrument Instrument No. Instrument Bank Name Branch Name Amount

Type Date
Online Pay- 94189530 20/07/2022 NA NA 21,097
ment

Total Amount Rs. 21,097.00

Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General In-
surance Company Limited. The insurance cover for the risk shall be as per the terms and con-
ditions of the Insurance Policy if and when issued.
* Cheque/DD/PO receipt is valid subject to realisation of the instrument.

For & on behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory

Regd.Office: Bajaj Allianz House,Airport Road, Yerwada, Pune - 411006