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The Oriental Insurance Co. Ltd.

Oriental House A-25/27, Asaf Ali Road NEW DELHI - 110002,DELHI
IRDA Registration Number: 556

Broker Details
TATA MOTORS INSURANCE BROKING AND ADVISORY SERVICES LTD, 1ST FLOOR, AFL HOUSE,
LOK BHARTI COMPLEX, MAROL MAROSHI ROAD, ANDHERI (EAST), MUMBAI - 400 059, 022– CIN Number: U50300MH1997PLC149349
62379515
License Validity: 13-MAY-23 To 12-MAY-
Category: Composite Broker IRDAI Lic. No: 375
26
Proposal Details
Cover Type. Own Damage Period 02- Period of Compulsory PA
Proposal No. Proposal Date. Motor Liability Period 02-
COMPREHENSIVE Jan-2024 To 01-Jan- Cover 02-Jan-2024 To
PPVBU16411599 30-Dec-2023 Jan-2024 To 01-Jan-2025
PACKAGE POLICY 2025 01-Jan-2025
Proposer Details
Address of the Proposer
Proposer Type Proposer Name Vehicle Usage
POOKKANDI HOUSE,CHALAKUNNU, THOTTADA, KANNUR
Individual Mr. PRAGEESH P Private
KERALA 670007
Nominee Details
Nominee Name Nominee Age Nominee Gender Relationship with Insured Name of Appointee Appointee Relation
PRATHYUSH 32 Male BROTHER --N.A-- --N.A--
Vehicle Details
Invoice Date Chassis No. Engine No. Make Model & Variant CC
24-Dec-2018 MAT626281JKNB0628 REVTRN02NRYKB2453 TIAGO TIAGO XZ 1.2 P 1199
Place of Registration Registration No. Invoice Value Year of Manufacture Seating Capacity
KANNUR KL-13-AN-8448 680000 2018 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
306000 0 0 0 306000
Premium Calculation
A.Own Damage Premium
Basic Premium Amount (Rs.) Deductibles Amount (Rs.)
Vehicle 2564 Voluntary Discounts Rs. (0) 0
Non Electrical Accessories 0 Anti Theft Device 65
Electrical Accessories 0 AA Membership 0
Bi Fuel Kit 0 NCB (0%) 0
Sub Total (Basic Premium) 2564 Handicapped Discount (0%) 0
Geographical Area Extension 0 Sub Total (Discounts) 65
IMT 23 Premium 0
Sub Total 2564
Add-Ons 0 Net Own Damage Premium(A) 2499
B. Liability Premium
Basic Third Party Liability Premium (including
3416 PA cover for Paid Driver (200000) 0
TPPD)
Third Party Liability For Bi-Fuel Kit 0 PA Cover (50000 Per Person) for 5 Persons 125
Third Party Liability For Geographical Area
0 Compulsory PA Cover for Owner Driver (1500000) 320
Extension
Sub Total (Third Party Liability) 3416 Sub Total (PA Cover) 445
Paid Driver 50
Employees (for 0 persons) 0
Sub Total (Legal Liability) 50
Net Liability Premium(B) 3911

Total Premium 6410

IGST Premium (18%) 1154

Total GST Premium (18%) 1154

Gross Premium 7564

Payment Details ( PAYLINK )

MISP Details

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MISP Name: MISP Code: MISP Pan No:
KVR DREAM VEHICLES PVT LTD TMIBASL/MISP/AADCK1604J AADCK1604J

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 The Oriental Insurance Co. Ltd. and I/ we
agree that this proposal and declarations shall be the basis of contract between me/ us and the The Oriental
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: 30-Dec-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 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.

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