Ref No.: GEN/WEL/SG/0008.

3/2367756200

Date: 25/06/2022

To,
SANJAY SINGH
J - 213
SECTOR J ASHIYANA BANGLA BAZAR LDA COLONY
Lucknow - 226001
District: LUCKNOW
UTTAR PRADESH, India
Contact Details 8447631105

Policy number: 2367756200

Subject: Risk assumption for Kotak Car Secure - OD Only

Dear SANJAY SINGH,

We welcome you to Kotak Mahindra General Insurance Company Limited and thank you for choosing us as your preferred service
provider.

This is with reference to your above mentioned Policy issued under Kotak Car Secure - OD Only.

Enclosed please find the Policy Schedule outlining the details of your policy. Kindly note that the proposal is underwritten and policy is
issued based on the information submitted to us by you, as well as acceptance of the terms and conditions. Policy schedule must be read
in conjunction with the product brochure and policy wordings. Please visit https://www.kotakgeneralinsurance.com/customer-
support/downloads or scan above QR code for detailed policy wording.

We request you to carefully go through the same once again and in case of any disagreement, discrepancy or clarifications, please call us
on our toll free number 1800 266 4545 or write to us at care@kotak.com within 15 days from the date of this letter. Alternatively, you can
also write to us at 8th Floor, Zone IV, Kotak Infiniti, Bldg.No. 21, Infinity IT Park, Off WEH, Gen. AK Vaidya Marg, Dindoshi, Malad(E),
Mumbai – 400 097, India.

Please note that the information provided by you will be verified at the time of claim and the captioned Policy shall be treated as void if we
discover any untrue or incorrect statement, misrepresentation, non-description or non-disclosure in any form whatsoever made by you or
by your agent, on your behalf, at any stage.

In case where premium is not received by us due to cheque dishonour or any other reason, the insurance cover shall be void ab-initio.

As a valued customer, we would like to provide regular updates on your policy through email and SMS. We therefore request you to keep
us updated of any change in your contact details.

Assuring you of our best services at all times.

Thanking you,

Yours sincerely,

For Kotak Mahindra General Insurance Company Limited

Authorised Signatory

Kotak Mahindra General Insurance Company Limited

CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneral.com IRDAI Reg. No. 152
 Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneral.com IRDAI Reg. No. 152
 Kotak Car Secure - OD Only
Certificate cum Policy Schedule
Policy / Certificate No: 2367756200
For any assistance please call 1800 266 4545 or visit www.kotakgeneralinsurance.com

INSURED DETAILS POLICY DETAILS

Name: SANJAY SINGH Policy Issuing Office: H - 78, 7Th Floor, 23 Himalaya House Kg Marg Delhi
Delhi 110001.
Address: J - 213 SECTOR J ASHIYANA BANGLA BAZAR LDA
COLONY Lucknow - 226001 District: LUCKNOW UTTAR Period of Insurance:
PRADESH(09), India
From: 25/06/2022 02:13 to: 24/06/2023 Midnight
Place of Supply: UTTAR PRADESH
Type Of Vehicle : Private Car
Supply State Code: 09
Phone: NA Policy issued on: 25/06/2022 Cover Note No: NA

Mobile: 8447631105 Hypothecated to: CENTRAL BANK OF INDIA

Email: SANJAYSIGH2888@GMAIL.COM
GSTIN:

VEHICLE DETAILS

Registration Manufacturer Model Variant Year of RTO Location Engine Vehicle Chassis/ Cubic Seating
Number Manufacture Number Trailer Chassis No. Capacity Capacity

UP32MD9520 KIA SONET HTX 1.0 IMT G 2021 LUCKNOW G3LCMM287996 MZBFF811LMN091692 998 5

Insured Declared Value Non - Electrical Electrical & Electronic Trailer CNG / LPG Kit Total Value of the Vehicle
(IDV) of the Vehicle Accessories fitted to the Accessories fitted to the (in ₹) (in ₹) (in ₹)
(in ₹) Vehicle (in ₹) Vehicle (in ₹)

892000 0 0 0 0 8,92,000

PREMIUM COMPUTATION TABLE (IN ₹)

Section I Section II
Own Damage Personal Accident
Basic Own Damage 8,131.47 Not Applicable
Add:
Add on Covers Total Premium # 6,344.43
Less:
No Claim Bonus Percent 20% 1,626.29
Total Own Damage Premium 12,849.61
Taxable value of Services (A) 12,849.61
IGST @ 18% 2,312.93
Total Premium (in ₹ ) 15,163.00

Add on Covers Opted For: Consumable Cover, Depreciation Cover, Engine Protect, Key Replacement, Return to Invoice, Road Side Assistance
# : For the covers opted as shown in Add On Cover Details Table
Geographical Area INDIA Additional Excess ₹ 0 Compulsory Deductibles ₹ 1,000

Voluntary Deductible ₹ 0 Voluntary Deductible for Depreciation Cover ₹ 0 Total Deductible ₹ 1,000

The insurance coverage provided under this Policy is only for Own Damage of the Vehicle and does not cover any other liability/third party liability in respect of the insured vehicle.

INTERMEDIARY DETAILS

Intermediary Code 3 1 0 1 5 4 0 0 0 0 Intermediary Name BAJAJ CAPITAL INSURANCE BROKING LTD

Intermediary's Mobile No. 7 6 7 8 1 2 3 1 2 3 Intermediary's Landline No.

Kotak Mahindra General Insurance Company Limited

CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneral.com IRDAI Reg. No. 152
 THIRD PARTY(TP) POLICY DETAILS AS SUBMITTED BY THE PROPOSER
Name Of Insurer ICICI LOMBARD GENERAL INSURANCE CO. LTD.
Policy Number 3001/222643296/00/000
Policy Start Date 25/06/2021
Policy End Date 24/06/2024

* In case above mentioned information is found to be incorrect, all benefits under the policy shall stand forfeited and this policy shall be void ab- initio.
Customer needs to ensure that there is a valid TP cover at all times.

ADD-ON COVER DETAILS

Sr. No. Add-On Cover Sum Insured (₹) Premium (₹) Remarks
Return to Invoice
1 NA 606.56
UIN:IRDAN152RP0012V01201920/A0017V01201920
Consumable Cover
2 NA 454.92
UIN:IRDAN152RP0012V01201920/A0015V01201920
Road Side Assistance
3 NA 500.00
UIN:IRDAN152RP0012V01201920/A0018V01201920
Depreciation Cover No. Of Claims:2
4 NA 4,094.28
UIN:IRDAN152RP0012V01201920/A0014V01201920 Voluntary Deductible: 0
Engine Protect
5 NA 454.92
UIN:IRDAN152RP0012V01201920/A0016V01201920
Key Replacement
6 25,000 233.75
UIN:IRDAN152RP0012V01201920/A0020V01201920

Kotak Mahindra General Insurance Company Limited

CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneral.com IRDAI Reg. No. 152
CUSTOMER DECLARATION FOR CNG/ PNG KIT

I/ We agree and undertake to immediately inform the Company in case of change on account of addition of CNG/PNG kit and obtain necessary endorsement in the
Policy.

DISCLAIMER

For complete details on terms and conditions governing the coverage and NCB please read the Policy Wordings. This document is to be read with the Policy
Wordings(which are also available on the Company website i.e. www.kotakgeneralinsurance.com). Please refer to the claim form for necessary documents to be
submitted for processing the claim.

PUC DECLARATION

This policy has been issued subject to valid Pollution Under Control (PUC) Certificate/Fitness Certificate disclosed to our representative / declared by You prior to
commencement of risk under this policy and further undertaking to renew and maintain a valid PUC throughout the duration of the Policy.

LIMITATIONS AS TO USE

The policy covers use of the vehicle for any purpose other than: (a) Hire or reward (b) Carriage of goods (other than samples or personal luggage) (c) Organized racing (d)
Pace making (e)Speed testing (f) Reliability trails (g)Use in connection with Motor Trade. Note: In case of vehicles used for Driving Tuition the words “other than for the
purpose of driving tuition” to be read after the words „hire or reward.

DRIVER'S CLAUSES

Any person including the insured: Provided that a person driving hold an effective Driving License at the time of accident and is not disqualified from holding or obtaining
such a license. Provided also that the person holding an effective Learners’ License may also drive the Vehicle and that such a person satisfies the requirements of Rule
3 of the Central Motor vehicles Rules 1989.

NO CLAIM BONUS SCALE

Number of Claims % of Discount on Own Damage Premium

No claim made or pending during the preceding full year of insurance 20%

No claim made or pending during the preceding 2 consecutive years of insurance 25%

No claim made or pending during the preceding 3 consecutive years of insurance 35%

No claim made or pending during the preceding 4 consecutive years of insurance 45%

No claim made or pending during the preceding 5 consecutive years of insurance 50%

*No Claim Bonus (NCB) is subject to no claim on the previous policy. Benefits under the policy will be forfeited if claim is/was made in previous policy. Please contact
our Customer Care team in case of wrong NCB % mentioned.

IMPORTANT NOTICE

Subject to I.M.T. Endt.Nos. & Memorandum GR27, 7 Printed/herein/attached hereto Under Hire Purchase Agreement with NA

TAX DETAILS

Service Tax/GST Registration No. 0 7 A A F C K 7 0 1 6 C 1 Z V Category : General Insurance Services

SAC Code 997134 Description Motor vehicle insurance services

Invoice Number 2367756200

DECLARATION

I/We hereby certify that the policy to which the certificate relates as well as the certificate of insurance are issued in accordance with the provision of chapter X, XI of
M.V.Act 1988.

In Witness whereof this Policy has been signed for and behalf of H - 78, 7Th Floor, 23 Himalaya House Kg Marg Delhi Delhi 110001. at Mumbai this 25 day of June of
2022

Stamp Duty of 0.50 is paid as provided under Article 47(B) of Indian Stamp Act, 1899 and included in Consolidated Stamp Duty Paid to the Government of Maharashtra
Treasury vide Order of Addl. Controller Of Stamps, Mumbai at General Stamp Office, Fort, Mumbai - 400001., vide this Order No. (LOA/CSD/373/2022/2021/Validity
Period Dt. 10/06/2022 To Dt. 31/12/2022 (O/w.No. 2486)/Date: 08/06/2022).

For Kotak Mahindra General Insurance Company Limited

Authorised Signatory

This document is digitally signed, hence counter signature / stamp is not required.
Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneral.com IRDAI Reg. No. 152
 Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneral.com IRDAI Reg. No. 152
 Transcript of Online Proposal - Kotak Car Secure - OD Only

Important Information For The Insured:

1. This is a transcript of the details declared by you on the e-proposal and shall be the basis of underwriting of the policy. Request you to carefully review the complete
information provided under this transcript and get back to us within 15 days of issuance of this document, in case there is any discrepancy found.
2. The policy is subject to receipt of complete premium and the risk under the Policy shall commence only from the date as specified in the policy schedule.
3. This document has to be read in conjunction with the policy schedule/document.
4. Refund, if any, with regard to the premium paid, would be processed in the same source / account (net banking / credit card / debit card) from where the premium
payment has been originally made subject to policy terms and conditions.
5. The policy is subject to the underwriting guidelines of the Company and the details as declared by the Insured under the e-proposal.
6. Online premium payment should be made by the policyholder himself. No third party payment should be made using this mode of payment.
7. The Policyholder/ Insured has fully understood the terms and conditions of the Policy including all the features available thereunder.

Proposal for : Rollover Policy

15,163.00 Premium Amount (Inclusive of all applicable Taxes)

Type of cover: OD Only

Invoice Date (For New Vehicle Make/Model/

Registration No. Type Of Body Cubic Capacity Fuel Type
Vehicle) Variant

KIA /SONET/HTX 1.0 IMT

UP32MD9520 22/07/2021 998 Petrol
G

Year of Manufacture Insured Declared Value (IDV) Engine Number Chassis Number

2021 892000 G3LCMM287996 MZBFF811LMN091692

Special conditions :

PROPOSER / OWNER’S DETAILS

1. Title and Name of the Insured: SANJAY SINGH

2. Insured Permanent Address* J - 213 SECTOR J ASHIYANA BANGLA BAZAR LDA COLONY Lucknow - 226001 District: LUCKNOW UTTAR PRADESH,
(where vehicle is normally kept) : India

If Correspondence Address different from J - 213 SECTOR J ASHIYANA BANGLA BAZAR LDA COLONY Lucknow - 226001 District: LUCKNOW UTTAR PRADESH,
Permanent Address,please provide*: India

3.Phone 4.Mobile * 8447631105 5.Email ID* SANJAYSIGH2888@GMAIL.COM

6.Gender 7.Date Of Birth * 8.Nationality Indian Resident

9.Marital Status 10.Occupation 11.Profession Others

Proposal Date & Time: 25/06/2022 19:18

Policy Start Date: 25/06/2022 02:13

Policy Expiry Date: 24/06/2023 at midnight

Limitation as to use (Private Car): The policy covers use of the vehicle for any purpose other than: (a) Hire or reward (b) Carriage of goods (other than samples or
personal luggage) (c) Organized racing (d) Pace making (e)Speed testing (f) Reliability trails (g)Use in connection with Motor Trade. Note: In case of vehicles used for
Driving Tuition the words “other than for the purpose of driving tuition” to be read after the words „hire or reward.

Driver’s Clauses: Any person including insured: Provided that a person driving hold an effective Driving License at the time of accident and is not disqualified from holding
or obtaining such a license. Provided also that the person holding an effective Learners’ License may also drive the Vehicle and that such a person satisfies the
requirement of Rule 3 of the Central Motor Vehicle Rules, 1989.

STATUTORY WARNING PROHIBITION OF REBATES (Under Section 41 of Insurance Act 1938)

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 published prospectuses or
tables of the Insurer.
2) Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to ₹ 1,000,000/­
Kotak Mahindra General Insurance Company Limited
CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneral.com IRDAI Reg. No. 152
 VEHICLE DETAILS

Registration Authority and RTO Date of CNG/LPG/Bi Lease / Hire / Hypothecation (Name Color of Seating
Location Registration Fuel and address of concerned parties) Vehicle Capacity
LUCKNOW 22/07/2021 Petrol CENTRAL BANK OF INDIA 5

*Non - Electrical *Electrical & Electronic

*Insured Declared
Accessories Accessories *Trailer *CNG / LPG Kit *Total Value
Value
fitted to the Vehicle (in fitted to the Vehicle (in (in INR) (in INR) (in INR)
of the Vehicle (in INR)
INR) INR)

892000 0 0 0 0 8,92,000

PUC - NO

OPTIONAL ADD-ON COVERS

1. Depreciation Cover# 2. Engine Protect #If Depreciation cover is selected: Voluntary Deductible opted under the
“Depreciation Cover”, which would be applied over and above the Compulsory
3. Return to Invoice 4. Consumable Cover Deductible? No

6. Key Replacement
5. Road Side Assistance
Sum Insured 25000
7. Loss of Personal Belongings
8. Tyre Cover
Sum Insured Select..
9. Daily Car Allowance 10. NCB Protect

PREVIOUS INSURANCE DETAILS

1. Name and Address of Previous Insurer ICICI-LUCKNOW

2. Previous Policy Type 1+3 3. Previous Policy Number 3001/222643296/00/000 4. Existing bonus 0 %

5. Period of Insurance 25/06/2021 To 24/06/2022

6. Details of claims taken in previous policy: No

Whether you are entitled to No Claim Bonus? Yes NO

THIRD PARTY(TP) POLICY DETAILS (MANDATORY)

Name Of Insurer ICICI LOMBARD GENERAL INSURANCE CO. LTD.

Policy Number 3001/222643296/00/000
Policy Start Date 25/06/2021
Policy End Date 24/06/2024

* In case above mentioned information declared by the Insured is found to be incorrect, all benefits under the policy in respect of Section I shall stand forfeited and this
policy shall be void ab- initio.

Policyholder declares that there shall be a valid Third Party liability cover for the above said vehicle at all times.

DETAILS OF DEPRECIATION
Table 1:Schedule of depreciation for arriving at IDV:
The Insured's declared value (IDV) of the vehicle will be deemed to be the 'Sum insured' and it will be fixed at commencement of each policy period for each insured
vehicle
Age of The Vehicle % of Depreciation for fixing IDV Age of The Vehicle % of Depreciation for fixing IDV
Not exceeding 6 Months 5% Exceeding 2 years but not exceeding 3 years30%
Exceeding 6 months but not exceeding 1 15% Exceeding 3 years but not exceeding 4 years40%
year
Exceeding 1 year but not exceeding 2 years 20% Exceeding 4 years but not exceeding 5 years50%
Note: IDV of obsolete models of vehicles (i.e. Models which the manufacturers have discontinued to manufacture) and vehicles beyond 5 years of age will be
determined on the basis of an understanding between the insurer and the insured.

Kotak Mahindra General Insurance Company Limited

CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneral.com IRDAI Reg. No. 152
 PAYMENT DETAILS

Payment Mode : PAYMENT AGGREGATOR, PAYMENT AGGREGATOR

Payment Reference No : 111545938724, 111543737732
Payment Amount: 363.00, 14,800.00
Payment/Transaction Date: 24/06/2022, 22/06/2022
Bank Details:

I confirm that the premium is paid out of my legitimate sources of fund and the Company has the right to call for documents to establish sources of funds. The
Company has the right to cancel the policy in case I am/have been found guilty by any competent authority or court of law of violating any law/regulation.

Intermediary Code: 3101540000

This electronic proposal is validated by an OTP sent on the registered mobile number of the customer.

Kotak Mahindra General Insurance Company Limited

CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneral.com IRDAI Reg. No. 152
 TAX INVOICE

Details of Receiver (Billed To) Details of Supplier (billed by)

Kotak Mahindra General Insurance
GSTIN/UIN Name :
Company Limited
Customer ID 1007448802 GSTIN : 07AAFCK7016C1ZV
Customer Name SANJAY SINGH Pan Number : AAFCK7016C
Email ID SANJAYSIGH2888@GMAIL.COM CIN: U66000MH2014PLC260291
H - 78, 7Th Floor, 23 Himalaya HouseKg
Contact No 8447631105 Address:
Marg Delhi Delhi 110001.
J - 213, SECTOR J ASHIYANA BANGLA
Address BAZAR LDA COLONY, LUCKNOW, Date of Invoice 25/06/2022
226001, UTTAR PRADESH, India
IMD Code 3101540000 Invoice No
Receipt No 1202300334082, 1202300334065 Proposal No 202206250045026
Partner Application No DEL0026550
State Code 09 State Code: 07
Place Of Supply Name UTTAR PRADESH - 09 State Name DELHI
IRN

HSN/SAC Description HSN / SAC Code Total Value of Supply (Rs.) Taxable value of Supply (Rs.) IGST Rate IGST Amt (Rs.)
997134 12849.61 12849.61 18% 2,312.93
Motor vehicle insurance services
Total 12849.61 12849.61 2312.93
Total Invoice Value (In Figure) 15,163.00
Total Invoice Value (In Words) Fifteen Thousand One Hundred Sixty Three
Whether Tax Payable on a Reverse Basis or Not No

For : Kotak Mahindra General Insurance Company Limited

Authorized Signatory

Kotak Car Secure - OD Only UIN:IRDAN152RP0012V01201920

Kotak Mahindra General Insurance Company Limited

CIN: U66000MH2014PLC260291, Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra East, Mumbai ­ 400051. Maharashtra, India.
Office: 8th Floor, Zone IV, Kotak Infinity, Building No.21, Infinity IT Park, Off Western Express Highway, General AK Vaidya Marg, Dindoshi, Malad(E), Mumbai ­ 400097. India.
Toll Free: 1800 266 4545 Email:care@kotak.com Website: www.kotakgeneral.com IRDAI Reg. No. 152