Mr. Sanjay Kumar Ram Barosh Singh Vill-Mainachatar Po-Kolhna Ps-Aliganj Jamui Aliganj Aliganj BIHAR India - 811301 9135

Trejhara
Mr. SANJAY KUMAR

RAM BAROSH
SINGH VILL-MAINACHATAR PO-KOLHNA
PS-ALIGANJ JAMUI ALIGANJ
ALIGANJ
BIHAR India - 811301
9135******
Welcome on board.
Your Reliance Commercial Vehicles
(Miscellaneous & Special Type) Package Policy -
Schedule, with Policy
Number 240522423430002021 is now live to
access your policy anytime, anywhere download
our Reliance Selfi App and enjoy a host of
special features.
Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off Western
Express Highway, Goregaon (East), Mumbai – 400 063.
Corporate Identity No. U66603MH2000PLC128300. UIN: IRDAN103P0012V02100001.. Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private
Limited and used by Reliance General Insurance Company Limited under. License RGI/MCOM/CO/2343/PS/Ver. 1.1/310118.
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Digitally signed by Reliance
General Insurance
Company Limited
Date: 2024.10.26 13:59:26
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Reliance Commercial Vehicles (Miscellaneous & Special Type) Package Policy- Schedule
Policy Number : 240522423430002021 Proposal/Covernote No: R26102445935

Insured Name : Mr. SANJAY KUMAR Period of Insurance : From 00:00 Hrs on 27-Oct-2024 to Midnight of
26-Oct-2025
Communication Address & Place of Supply : Policy Issuing Branch :
RAM BAROSH SINGH VILL-MAINACHATAR PO-KOLHNA PS-ALIGANJ JAMUI 4th floor, Horma Tower, Club Road, , RANCHI, JHARKHAND, 834001.
ALIGANJ ALIGANJ, JAMUI, BIHAR, India, 811301.
Mobile No : 9135****** Tax Invoice No. & Date: R26102445935 & 26 Oct 2024 01:59
Email-ID : s***************@gmail.com GSTIN/UIN of the Insured :
Insured Vehicle Details
Registration No. BR46G9953 Mfg. Month & Year APR-2022
Make / Model & Variant SWARAJ 735 FEE TRACTOR CC / HP 39
Engine No. / Chassis No. CJ1354NE003239 / MBNAK48ACNTE10471 GVW 1895
Type of Body /
NA/0 Manufacturer fully build in Yes
LCC(excluding driver)
RTO Location BIHAR - Jamui Total Premium ` 10,572.00
Vehicle subtype AGRICULTURAL TRACTORS IDV ` 600,000.00
Hypothecation/Lease NA
Insured Declared Value (IDV)

Chassis IDV ` 0.00 Non Electrical Accessories ` 0.00
Body IDV ` 0.00 CNG / LPG Kit ` 0.00
Vehicle IDV ` 600,000.00 Trailer ` 0.00
Electrical / Electronic Accessories ` 0.00 Total IDV ` 600,000.00
Premium Summary
Own Damage - Section I Amount (`) Liability - Section II Amount (`)
Basic OD 1,428.00 Basic Liability (TPPD 1) 7,267.00
Covers for Lamps Tyres/Tubes Mudguards/Bonet/Side Total Basic Liability Premium 7,267.00
parts etc (IMT-23) 214.20 PA Benefits - Section III
Total Basic Own Damage Premium 1,642.20 Legal Liability to paid driver and/or Conductor and/or
50.00
cleaner
TOTAL LIABILITY PREMIUM 7,317.00
TOTAL PACKAGE PREMIUM (Sec I + II + III) 8,959.00
IGST (@18.00%) 1613.00
TOTAL OWN DAMAGE PREMIUM 1,642.00

TOTAL PREMIUM PAYABLE (`) 10,572.00
Subject to I.M.T.Endt.Nos. & Memorandum printed/herein/attached hereto. IMT 47,40,23,21
GSTIN :20AABCR6747B1ZU
HSN : 997134, Description of services : Motor vehicle Insurance Service
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.
Consolidated Stamp duty Paid vide Letter of Authorization "NO LOA/ENF-1/CSD/62/2024-25/(Validity Period Dt. 01/10/2024 to Dt. 01/12/2025)/4634 Date 25-09-2024" at
General Stamp Office, Mumbai.** Not Applicable for the State of Jammu & Kashmir
13BRG488 / GIRNAR INSURANCE
7551196989 Support@insurancedekho.com
BROKERS PVT LTD
Intermediary Code/Name Intermediary Contact No. Intermediary E-mail ID POS UID Aadhaar No. / PAN No.
The Customer Information Sheet (CIS) for this product is available on our website
https://www.reliancegeneral.co.in/insurance/about-us/downloads.aspx
Special Conditions : This Tractor is rated as an agricultural tractor based on information of exclusive use for agricultural purpose provided to
Limits of liability : PA cover for owner driver under section III CSI ` 0 (a) Under Section II (1)(i) of the Policy-Death of or bodily injury toany
person so far as it is necessary to meet the requirements of the Motor Vehicle Act, 1988.
(b) Under Section II (1)(ii) of the Policy-Damage to property other than property belonging to the insured or held in trust or
in the custody of control of the insured up to the limits specified- (TPPD 1 Sum Insured - ` 7,50,000/-, TPPD 2 Sum
Insured - ` 6,000/-).
Limitations as to use : The policy covers the use only under a permit within the meaning of Motor Vehicle Act, 1988 or such a carriage falling
under sub-section (3) of Sec 66 of the Motor Vehicle Act, 1988. The Policy covers use for any purpose other than: (a)
Organized racing (b) Pace making (c) Speed testing (d) Reliability trials.
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103P0012V02100001. Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under. License RGI/MCOM/CO/2343/PS/Ver. 1.1/310118
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Deductible under Section-I : : (i) Compulsory deductible ` 3000/- (ii) Additional compulsory deductible ` 00/- (iii) Voluntary deductible ` 0/-
Persons/Classes of persons : When the vehicle is used for transport of goods Any person including insured:
entitled to drive: Provided that a person driving holds a valid driving license at the time of the accident and is not disqualified from holding
or obtaining such a license. Provided that the person holding a valid learner’s license may drive the vehicle when not used
for the transport of goods at the time of the accident and that such a person satisfies the requirements of Rule 3 of the
Central Motor Vehicles Rules, 1989.
Compulsory PA cover for owner driver :
Insured is not eligible for the Compulsory PA cover for owner driver in this policy as the same has not been opted for the reasons allowed as per motor tariff and relevant
circulars/notifications issued by the regulator in this regard.
In case you have missed it, please opt for the compulsory PA cover by payment of an additional premium of Rs. 750/-.Liability of insurance company shall commence
from the date of issuance of endorsement.
I/ We hereby declare that I/ we hold an effective Personal Accident Insurance Policy / Compulsory PersonaI Accident (CPA) for Owner-Driver in other vehicles covering
Death & Permanent Disability (Total and Partial) whereby the Sum Insured limit is of 1500,000 or more.
I/ We hereby declare that I/ we do not hold a valid Motor Driving license, and I/We am/are aware that Compulsory PersonaI Accident covering Death & Permanent
Disability (Total and Partial) for Owner-Driver of SI 1500,000 will not be applied to this policy.
"It is hereby declared and agreed that all pre-existing damages to the vehicle having occured prior to the commencement of cover are excluded from the scope of the
policy"
The NCB provided is on Basic OD Premium excluding Add-on wherever applicable. The policy wording with detailed terms, conditions and exclusions are available on
our website www.reliancegeneral.co.in
Statutory Provisions :
"As per Section 146 of the Motor Vehicle Act, 1988 it is Mandatory to have your vehicle insured against third party risk."
As per Section 196 of the Motor Vehicle Act, 1988 driving an uninsured vehicle is punishable with fine or Rs. 2000 and/or imprisonment up to 3 months for the first
offence and fine of Rs. 4000 and/or imprisonment up to 3 months for the second offence."
I/We hereby certify that the Policy to which the certificate relates as well as this certificate of insurance are issued in accordance with the provision of Chapter X and
Chapter XI of M.V. Act, 1988.
Note :In the event of dishonor of cheque, this policy document automatically stands cancelled from inception irrespective of whether a separate communication is sent
or not.
Safeguard your transaction by paying your premium via crossed cheque/DD in favour of Reliance General Insurance Co. Ltd.
The policy has been issued based on the information provided by you and the policy is not valid if any of the information provided is incorrect. Subject otherwise to the
terms, conditions and exclusions of the Reliance Miscellaneous and Special Types of Vehicles Package Policy Certificate Cum Policy Schedule. In witness whereof this
Policy has been signed at Mumbai on policy tax invoice date in lieu of Proposal/Covernote No. as mentioned in the policy.
This document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services Tax Rules 2017.
Updating Registration Number of vehicles within 15 days of policy inception is MANDATORY as per IRDA. Kindly provide the same to your Agent/Our Call
centre/Policy issuing Branch (Applicable for policies booked without Registration No of vehicles).
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'. For legal interpretation, English version will hold good.
In case of a renewal, the benefits provided under the policy and/or terms and conditions of the policy including premium rate may be subject to change
As per National Highways Authority of India, kindly ensure to affixed FASTag on your vehicle.
Grievance Clause : For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 02248903009 or may
write an email at rgicl.services@relianceada.com. In case the insured is not satisfied with the response of the office, insured may contact the
Nodal Grievance Officer of the Company at rgicl.grievances@relianceada.com. In the event of unsatisfactory response from the Nodal
Grievance Officer, insured may email to Head Grievance Officer at rgicl.headgrievances@relianceada.com. In the event of unsatisfactory
response from the Head Grievance Officer, he/she may, subject to vested jurisdiction, approach the Insurance Ombudsman for the redressal of
grievance. Details of the offices of the Insurance Ombudsman are available at IRDAI website www.irda.gov.in or on company website
www.reliancegeneral.co.in or on www.gbic.co.in. The insured may also contact the following office of the Insurance Ombudsman within whose
territorial jurisdiction the branch or office of the Company is located.
Office of the Insurance Ombudsman, 2nd floor ,north wing, Lalit Bhawan , Bailey Road , Patna 800 001. Tel.: 0612-2680952 Email:
bimalokpal.patna@cioins.co.in
Fast Tag ID -
The policy does not cover liability for death, bodily injury or damage as excluded under Section 150 (2) (ii) and (iii): b and C of the Motor Vehicles Act 1988 (Inserted
Vide GSR no 164 (f) dated 25.02.2022 w. e. f 01.4.2022)
In the unfortunate event of a claim, please call quoting your Policy No. on 022 48903009(Paid) and register your claim immediately within 7days from the date of loss.
Note: Kindly acknowledge the receipt of this policy. In case you find any variations against your proposal or any discrepancy in the policy, kindly contact us immediately.
In the absence of any communication from you within a period of 15 days of receipt of this letter, we will consider that the issued policy is in order and as per your
proposal.
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For Reliance General Insurance Co. Ltd.
Authorised Signatory
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0 0 0 Risk Assumption Letter

Dear Mr. SANJAY KUMAR
Thank you for choosing Reliance General Insurance.
Please find enclosed policy no.: 240522423430002021 which has been issued based on the details declared by the applicant.
Insured Vehicle Details

Registration No. BR46G9953 Mfg. Month & Year APR-2022
Make / Model & Variant SWARAJ 735 FEE TRACTOR CC / HP 39
Engine No. / Chassis No. CJ1354NE003239 / MBNAK48ACNTE10471 GVW 1895
Type of Body / LCC(excluding Manufacturer fully build in
NA/0 Yes
driver)
RTO Location BIHAR - Jamui Total Premium ` 10,572.00
Vehicle subtype AGRICULTURAL TRACTORS IDV ` 600,000.00
Insured Declared Value (IDV)

Chassis IDV ` 0.00 Non Electrical Accessories ` 0.00
Body IDV ` 0.00 CNG / LPG Kit ` 0.00
Vehicle IDV ` 600000 Trailer / Side Car ` 0.00
Electrical / Electronic Accessories ` 0.00 Total IDV ` 600,000.00
Previous Policy Details

Previous Year Policy No. Period of Insurance Previous Policy-Claim Status
Yes No
YOU HAVE OPTED FOR THE FOLLOWING COVERS
Standard Vehicle Own Damage + Third Party Coverage
Cover Electrical/electronic accessories
Non-electrical accessories
Bi-fuel kits comprising LPG/CNG systems
Add-on Covers
Additional towing Charges Provides cover for towing charges over and above the standard policy guideline as per the cover opted by customer (Sum
Insured - ` 0/-)
Emergency Hotel Provide allowance towards the Hotel accommodation insured vehicle met with accident/ stolen 200 kms away from the location
Accommodation provided in policy copy.
Additional Limit of TPPD Indemnify the Insured for an additional TPPD amount opted for damage to property other than the property belonging to the
Insured or held in trust or in custody of Insured.
Please take a moment to carefully check your policy details mentioned above and in the policy schedule. Kindly confirm that the same are in order. In case of
discrepancies, please let us know immediately. You can write to us at rgicl.services@relianceada.com or call us 022 48903009(Paid) for necessary
changes/rectification. In the absence of any communication from you within a period of 15 days of receipt of this letter, we will consider that the issued policy is in order
and as per your proposal. Non disclosure and/or misrepresentation of claims in the previous policy period can lead to cancellation of your policy or rejection of your
claims.
(Note-Warranted that the insured named herein/owner of the vehicle holds a valid Pollution Under Control (PUC) Certificate and/or valid fitness certificate, as applicable,
on the date of commencement of the Policy and undertakes to renew and maintain a valid and effective PUC and/or fitness Certificate, as applicable, during the
subsistence of the Policy. Further, the Company reserves the right to take appropriate action in case of any discrepancy in the PUC or fitness certificate.)
For Reliance General Insurance Co. Ltd.
Authorised Signatory
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Know your policy

Remember to carefully go through the Risk Assumption Letter and confirm your personal as well as your vehicle details.
In case of any discrepancy in the policy details, kindly revert within 15 days from the policy start date on 022 48903009 (Paid) or visit any of our branches.
Kindly refer to the Key Feature Document and Policy Wording at www.reliancegeneral.co.in to understand your policy better and learn more about the policy coverages,
add-on covers and Policy Exclusion. This document is a statement of the specific provisions that form the Terms and Conditions of this Policy.
What documents do you require for making any change to your policy
1. Changes in vehicle make & model/cubic capacity/seating capacity/engine & chassis no./year of manufacture/registration no./ location/address
Documents required :Letter for change, policy copy and registration certificate copy along with additional premium cheque, if applicable.
2. Changes in electrical and non electrical accessories/CNG/LPG kit
Documents required :Letter for addition, policy copy, invoice copy of accessories, endorsed registration certificate copy (for CNG/LPG kit) and cheque for additional
premium.
3. Changes in financier details (Hypothecation/Lease/Hire purchase)
Documents required :Letter for change, policy copy, endorsed registration certificate copy and no objection certificate from financier (not mandatory for deletion, if
registration certificate copy is endorsed).
How to register a Claim - Cashless
How to register a Claim - Reimbursement
What documents do you require to register a Claim

1. Claim form duly filled and signed (company stamp in case of company registered vehicles)
2. Registration copy
3. Driving License of the driver at the time of loss
4. Policy copy
5. Vehicle fitness certificate
6. Vehicle route permit
7. Vehicle carriage permit
8. Road tax copy
9. Load Challan (if applicable)
Note: 1. As soon as a claim occurs, please intimate immediately to our call centre 022 48903009 (Paid). Delay in intimation would result in the violation of policy
condition.
2. Any additional document, if required, will be informed.
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Proposal Form for POS Reliance Commercial Vehicles Package Policy

(Other than Motor Trade Internal Risks Policy)
(The queries made/details stated below are the minimum requirement to be furnished by a proposer.
The Insurer may seek any other information as desired for under for underwriting purpose.)
*(Applicable to all classes of vehicles with suitable amendments in 'Limitations as to Use')
PCV GCV MISC D Trailer
For Office Use Only

Policy Number 240522423430002021 Date
Savvion Reference No. Inspection Lead No.
Intermediary Details (To be filled in BLOCK LETTERS)

Intermediary Name GIRNAR INSURANCE BROKERS PVT LTD Code 13BRG488
Branch Name Ranchi Code 2405
Sales Manager Name Md Samaul Ansari Code 71004805
*POS PAN No. *POS UID Aadhaar No.
Details (To be filled in BLOCK LETTERS)

1. This Proposal is for A new Policy Renewal of Policy Endorsement Others (Please specify)
2a. Proposer's Full Name Mr. Mrs. SANJAY KUMAR
2b. Address Address for Communication Address where vehicle is normally kept and Used
Flat/Building/Door/Block No. RAM BAROSH SINGH VILL-MAINACHATAR

Road /Street/Sector PO-KOLHNA PS-ALIGANJ JAMUI ALIGANJ
Nearest Landmark
Area
City ALIGANJ
Pin Code 811301
State BIHAR
Country India
Phone Mobile 9135******
Emergency Contact No. Blood Group
Email s***************@gmail.com Fax
3. Period of Insurance From 27/10/2024 To 26/10/2025
4. Source of Funds Business Profession Salary Agricultural Income Savings Others
5. Monthly Income Upto `20,000 `20,001 to `50,000 `50,001 to `1,00,000 `1,00,001and above
6. UID Aadhaar No. 7. PAN No.
8. Fast Tag ID
Details of the Vehicle

9. Registration Number BR46G9953 10. Date of Registration 29/03/2023
11. Registering Authority & Location BIHAR - Jamui
12. Year & Month of Manufacture APR-2022 13. Cubic Capacity 39
14. Engine Number CJ1354NE003239
15. Chassis Number MBNAK48ACNTE10471
16. Make of Vehicle SWARAJ
17. Type of Body/Model NA/735 18. Seating Capacity including Driver 1
19. Gross Vehicle Weight (GVW)/Cubic Capacity (C.C.) 1895
20. Goods type (Applicable only if GVW+7500kgs) Hazardous Goods Non-Hazardous Goods
21. Is the Vehicle made in India? Yes No
22. Max. Licensed carrying capacity (No. of Passengers) in case of Passenger carrying vehicles 0
23. Vehicle Category Bus Taxi
Vehicle usage type (Applicable if bus) : Contract Carriage Stage Carriage Private Usage
Vehicle usage sub type (Applicable if Contract Carriage): School Bus Employee pickup Bus Others
24. Seating capacity (Including Driver) 1
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Details of the Vehicle Type and Use

25. a. Whether the Vehicle is driven by Non-conventional source of power? Yes No If yes Bi Fuel CNG LPG
Non - electrical accessories Electrical accessories fitted to Value of CNG/ LPG Kit Bi
Insured's Declared Value (IDV) of vehicle Total Value
fitted to the vehicle the vehicle Fuel
Chassis Body (₹) (₹) (₹) (₹)
0.00 0.00 0.00 0.00 0.00 600,000.00
Do you have a valid PUC? Yes No

((Note-Warranted that the insured named herein/owner of the vehicle holds a valid Pollution Under Control (PUC) Certificate and/or valid fitness certificate, as applicable, on
the date of commencement of the Policy and undertakes to renew and maintain a valid and effective PUC and/or fitness Certificate, as applicable, during the subsistence
of the Policy. Further, the Company reserves the right to take appropriate action in case of any discrepancy in the PUC or fitnesscertificate.)
26. Details of Driver : (a) Age of Owner Driver _________________ Others _________________
(b) Does the driver suffer from defective vision or hearing or any physical infirmity. Yes No
If "Yes" please give details.
________________________________
(c) Has the driver ever been involved for causing any accident or loss? Yes No
If "Yes" please give details as under including the pending prosecution, if any:-
________________________________
(d) D.O.B.
27. Add On Covers (Subject to availability and eligibility)
(a) Easy Monthly Instalment (EMI) Protection Cover: (RGI-MO-A00-00-17-V01-14-15)

If Yes, please choose any one option;
Plan I - 1 EMI, EMI Amount : ₹
Plan II - 2 EMIs, EMI Amount : ₹
Plan III - 3 EMIs, EMI Amount : ₹
(b) Additional Towing Charges No
(c) Nil Depreciation Cover: No
(d) Total Cover No
(e) Voluntary Deductible
Voluntary Deductible amount opted: ₹ ______________________
(f) Emergency Hotel Accommodation No
Benefit Amount: ₹
(g) Additional limit of TPPD No
Additional amount opted: ₹
(h) Personal Belongings Cover No
Benefit Amount: ₹
(i) Daily Allowance Benefit No
Per day allowance amount opted : ₹
Coverage Days opted:
(j) Daily Allowance Benefit Plus No
Per day allowance amount opted: ₹
Coverage Days opted:
(k) Tools and Equipment Cover
(l) Any other Details
___________________________________
28. Is the vehicle fitted with any Anti-theft device approved by the ARAI ? Yes No
If Yes,please attach certificate of installation in the vehicle,issued by automobile Association of India.
29. Are you a member of Automobile Association of India ? If Yes,please submit membership copy. Yes No
30. Whether the Vehicle is used for Driving Tuitions? Yes No
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31. Whether use of Vehicle is limited to Own Premises? Yes No

32. Whether the commercial vehicle is also used for Private purposes (excluding use for hire or reward)? Yes No
33. Are you entitled to No Claim Bonus ? Yes No
If Yes, please submit proof thereof
34. Whether the Vehicle is fitted with Fibre Glass Tank? Yes No
35. Whether the Vehicle belongs to the Embassy/Consulate of a Foreign Country? Yes No
If so, is the duty element included in the IDV?
36. Whether the Vehicle is design for use of Blind/Handicapped/Mentally Challenged Person? Yes No
37. Date of purchase of the Vehicle by the Proposer 29/03/2023
38. Whether the vehicle at the time of the purchase was New Second Hand
Risk Inclusions
39. Liability to third parties: The policy provides Third Party Property Damage (TPPD)
of ₹ 1 lakh (Two wheelers) and ₹ 7.5 lakhs (other class of vehicles)
Do you wish to restrict the above limits to the statutory TPPD Liability limit of Yes No
₹ 6000/- only?
Do you wish to cover legal liability to?
(a) Driver/Conductor /Cleaner (No. of persons) Yes No
(b) Other employees (No. of Persons) Yes No
(c) Non-fare paying passenger (No. of persons) Yes No
40. Do you wish to include personal Accident (P.A.) Cover for paid drivers, cleaners and conductors? Yes No
If Yes, give name and Capital Sum Insured (CSI) opted for. The maximum CSI available per person is ₹ 1 Lakh in the case of Motorised two wheelers and ₹ 2
lakhs for other classes of vehicles.
41. Personal Accident Cover for Owner Driver. Please give details of nomination
Name of the Appointee (if
Name Name of the Nominee Age of Nominee Relationship Address
Nominee is Minor)
(Note: 1. Personal Accident cover for owner driver is compulsory for Sum Insured of ₹ 15,00,000/- for Two Wheeler, Private Car, GCV, PCV and Misc-D
2. Compulsory PA cover for owner driver cannot be granted where a vehicle is owned by a company, a partnership firm or a similar body corporate or
where the owner-driver does not hold an effective driving license)
42. Do you wish to include Personal Accident cover Named Persons? Yes No
Name of the Appointee

Name CSI Opted Name of Nominee Age of Nominee Relationship Address
(If Nominee is Minor)
43. Extension of Geographical Area

Whether extension of Geographical Area to the following Countries required ?
1. Bangladesh
2. Bhutan
3. Maldives
4. Nepal
5. Pakistan
6. Sri Lanka
Details of Hire Purchase / Hypothecation / Lease
44. Please state if the vehicle is under Hire Purchase Lease Agreement Hypothecation Agreement
If so, give name and address of concerned parties.
45. Full Name
46. Address
Non - electrical accessories Electrical accessories fitted to Value of CNG/ LPG Kit Bi
Insured's Declared Value (IDV) of vehicle Total Value
fitted to the vehicle the vehicle Fuel
Chassis Body (₹) (₹) (₹) (₹)
0.00 0.00 0.00 0.00 0.00 600,000.00
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Note
The Insured's Declared Value (IDV) of the vehicle will be deemed to be the 'SUM INSURED' for the purpose of this tariff and it will be fixed at the commencement of
each policy period for each insured vehicle.
The IDV of the vehicle is to be fixed on the basis of manufacturers' listed selling price of the brand & model as the vehicle proposed for insurance at the commencement
of insurance / renewal, and adjusted for depreciation as per policy wordings.
Details of Previous Insurance

47. Full Name of previous insurer
48. Address -
49. Policy Number Previous Policy Expiry
50. Type of Cover Package Policy Liability only others (to be describe)
51. NO CLAIM BONUS allowed under previous policy (%) 0
52. Claims taken in previous policy Yes No
If yes, No. of Claims _______________________________ Claims Amount ` ______________________________
53. Are you entitled to No Claim Bonus Yes No
If yes, please submit/attached proof thereof
Payment Details
Cheque/ DD ________________________ Cheque/ DD No.

Cheque/ DD Date _________________________ Cash Credit Card Others
Proposer's Bank Details

54. Name of the Bank Account Holder Mr. Mrs. Ms. ______________________________
55. Bank Account No.: ____________________ 56. Account: Saving Current
57. Name of the Bank
58. Branch ____________________
59. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque
issued by the bank) ____________________
60. IFSC Code (11 character code appearing on your cheque leaf) _________________________
I understand that any refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank Account .*
* As per IRDAI, its mandetory that all payments made to the insured are only through electronic mode.
GENERAL DECLARATION:
I understand that as per the new AML/CFT Guidelines issued Reliance General Insurance Co. Ltd will be verifying my details pertaining to KYC and PAN provided at
the time of proposal.
I further, do hereby agree and consent that in the case of the event of a mismatch of information provided by me in the proposal form, identification proof, and address
proof at the time of issuance of the policy. I request Reliance General Insurance Company Limited to issue the policy with the details appearing as per my proposal
form. I will be solely responsible for any consequences arising out of the difference in detail given by me during the verification of supporting documents provided by
me at the time of issuance of the policy or otherwise.
PEP Declaration:
Are you a Politically Exposed Person (PEP)? Yes No
If yes, please mention the position held
Is any of your close relation or family member a PEP? Yes No
If yes, please mention the name and relation and the position held
by such close relative/family member.
I hereby declare that in future if me, any of my close relatives or any of my family member attains a position of PEP then I shall confirm the same to Reliance General
Insurance Co. Ltd as a mandate. I understand that this is a crucial information under the PMLA Rules and AML/ CFT Guidelines and shall confirm that the answers
given by me is true. In case the company comes to know that this is a misrepresentation and concealment of information then the policy shall be put on hold for
scrutiny by the company and I shall be solely responsible for the same.
Note :
“Politically Exposed Persons” (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign country, e.g., Heads of
States/Governments, senior politicians, senior government/judicial/military officers, senior executives of state-owned corporations, important political party officials,
etc (As per sub clause (xii) of 3(b) of Chapter I of Master Direction – Know Your Customer (KYC) Direction, 2016 issued by Reserve Bank of India (RBI).
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Declaration by Proposer
I/We hereby declare that the statements made by me/us in this Proposal Form are true to the best of my/our knowledge and belief and I/We hereby agree that this
declaration shall form the basis of the contract between me/us and RELIANCE General Insurance Company Limited. I/We also declare that, if any additions or
alterations are carried out after the submission of this proposal form, then the same would be conveyed to the insurers immediately. I/We hereby declare that the
contents of the form and documents have been fully explained to me/us and that I/We have fully understood the significance of the proposed contract. I/We agree to accept
a policy subject to the condition prescribed by the company. • I have read and understood the brochure, prospectus, sales literature & Policy wordings and confirm to
abide by the same. • I/We declare that the rate of NCB stated above by me/us is correct and that no claim has arisen in the expiring policy (copy of the policy enclosed). •
I/We further undertake that, if this declaration is found to be incorrect, all benefits under the policy in respect of section I of the policy will stand forfeited. • I/We further
understand and agree that RELIANCE General Insurance will seek confirmation of above stated details from my/our previous insurers. Pending receipt of necessary
confirmation, I/We agree that, though coverage under the policy will be available to me/us, RELIANCE General Insurance will be liable to release the payment towards
any claims under section I of the policy only after a confirmation in this regard is received. In the event this declaration is found to be incorrect, any and all coverage
available under section I of the policy from the date of commencement of the policy shall stand automatically forfeited. Further, any survey arranged/allowed by
RELIANCE General Insurance of the motor vehicle, pending confirmation of the declaration from my/our previous insurers, shall be without prejudice to any of the rights
and remedies available to RELIANCE General Insurance as contained herein and under the relevant laws and regulations. • I/We acknowledge and agree that, Pending
receipt of confirmation of the declaration from my/our previous insurers, the "cash-less repair facility" provided by RELIANCE General Insurance shall stand suspended.
• I/We also shall endeavour to procure the renewal notice and pass on the same to RELIANCE General Insurance immediately upon the receipt of such renewal notice.
Mode of Payment: Secure your payment by cheque/DD favouring Reliance General Insurance CO.Ltd. This policy shall be voidable at the option of the Company in the
event of mis-representation, mis-description of nondisclosure of any material particulars by the Proposer. Any person who, knowingly and with intent to defraud the
Insurance Company or other persons, files a proposal fo insurance containing any false information, or conceals for the purpose of misleading, information, information
concerning any fact material thereto, commits a fraudulent act which will render the policy voidable at the company's sole discretion and result in a denial of insurance
benefits.• I/We here by state that the above mentioned address shall be taken as address on record for the purpose of GST. • I/We hereby confirm that the contents of the
proposal form and connected documents have been fully explained to me/us and I/We have fully understood the significance of the proposed contract
This proposal form was completed by

You can support our Go Green Initiative by saying “No” to Policy kit, Renewal Notice and Other Communications hard copy. We will be sending you a
digitally signed soft copy on your registered Email ID & Mobile number.
Hard copy required Yes No
Name ____________________________ Place : ____________________________
Date : 26 Oct 2024 01:59 Date : 26 Oct 2024 01:59
Signature Signature of Proposer & Company Seal
Page 11 of 12
Trejhara
Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment ) Act, 2015
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.
Supporting Confirmation of Agent/Broker/SM/CSO

I confirm the above signature tobe of the registered owner of the vehicle proposed for insurance
Name of IRDAI Agent/ Broker Mr. Mrs.
Place
Date
(In case of Direct Business, Name & Signature of CSO /SM to be taken) Signature of IRDAI Agent/ Broker
The policy does not cover liability for death, bodily injury or damage as excluded under Section 150 (2) (ii) and (iii): b and C of the Motor Vehicles Act 1988 (Inserted
Vide GSR no 164 (f) dated 25.02.2022 w. e. f 01.4.2022)
Page 12 of 12

Mr. Sanjay Kumar Ram Barosh Singh Vill-Mainachatar Po-Kolhna Ps-Aliganj Jamui Aliganj Aliganj BIHAR India - 811301 9135

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Trejhara

Mr. SANJAY KUMAR

Policy Number : 240522423430002021 Proposal/Covernote No: R26102445935

Insured Declared Value (IDV)

TOTAL OWN DAMAGE PREMIUM 1,642.00

For Reliance General Insurance Co. Ltd.

0 0 0 Risk Assumption Letter

Insured Vehicle Details

Insured Declared Value (IDV)

Previous Policy Details

For Reliance General Insurance Co. Ltd.

Know your policy

How to register a Claim - Cashless

How to register a Claim - Reimbursement

What documents do you require to register a Claim

Proposal Form for POS Reliance Commercial Vehicles Package Policy

For Office Use Only

Intermediary Details (To be filled in BLOCK LETTERS)

Details (To be filled in BLOCK LETTERS)

Flat/Building/Door/Block No. RAM BAROSH SINGH VILL-MAINACHATAR

Details of the Vehicle

Details of the Vehicle Type and Use

Do you have a valid PUC? Yes No

27. Add On Covers (Subject to availability and eligibility)

(a) Easy Monthly Instalment (EMI) Protection Cover: (RGI-MO-A00-00-17-V01-14-15)

31. Whether use of Vehicle is limited to Own Premises? Yes No

Name of the Appointee

43. Extension of Geographical Area

Details of Previous Insurance

Cheque/ DD ________________________ Cheque/ DD No.

Proposer's Bank Details

Are you a Politically Exposed Person (PEP)? Yes No

If yes, please mention the position held

Is any of your close relation or family member a PEP? Yes No

This proposal form was completed by

Signature Signature of Proposer & Company Seal

Supporting Confirmation of Agent/Broker/SM/CSO

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