2312100304462800000

HDFC ERGO General Insurance Company Limited

Policy No. 2312 1003 0446 2800 000 Certificate of Insurance cum Policy Schedule

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Motor Insurance - Two Wheeler Comprehensive Policy

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Insured Name Mr S Ashrath RTO TIRUPATHI CHITTOOR PAN No.
MADANAPALLE
Corr.Address/ 8-122 B C Colony Kallur
Place of Supply CHITTOOR ANDHRA PRADESH 517113
Mobile 8328295430 Phone - E Mail [email protected] Registration No. AP-03-BB-4630
Period of Insurance From Date & Time 29/04/2018 00:01 hrs To Date & Time 28/04/2019 Midnight Policy Issuance Date 26/04/2018
Seats(Incl.
Make Model - Variant Engine No Chassis No Mfg Yr Body Type CC
of side car)
BAJAJ AUTO. PULSAR-150 DTSI DHZODL18839 MD2A11CZ3DCL27878 2013 2 OPEN 149

Insured's Declared Vehicle (`) Side Car (`) Non Electrical Acc. (`) Electrical Acc. (`) CNG/LPG Kit (`) Total IDV (`)
Value (IDV) 31,000 0 0 0 0 31,000
Named Persons & Nominee (IMT-15)
Nominee for Owner driver Appointee
Premium Details (`)
Own Damage Premium (a) Liability Premium (b)
Basic Own Damage: 362 Basic Third Party Liability: 720

PA Cover for Owner Driver of `100000 50

Total Basic Premium 362
PA Cover for un-named persons of `100000 each(for 2 Person) (IMT-16) 140

Sub Total – Addition 910

Net Liability Premium (b) 910

Total Package Premium (a+b) 1272

Integrated Tax 18% 229

Net Own Damage Premium (a) 362 Total Premium 1,501

Geographical Area India Compulsory Deductible (IMT-22) ` 100 Voluntary Deductible (IMT-22A) ` 0
Fund Transfer No.
Payment Details: Dated : 26/04/2018 Drawn on BizDirect Invoice No.: 100304462800000 HSN Code: 9971
TW1804522451

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 Trials g) Any purpose in connection with Motor Trade. Persons or Class of Persons entitled to drive: Any person including the insured, provided that a person driving holds an effective
driving license at the time of the accident and is not disqualified from holding or obtaining such a license. Provided also that the person holding an effective learner`s license 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. Limits of Liability 1. Under Section II-1 (i) of the
policy - Death of or bodily injury - Such amount as is necessary to meet the requirements of the Motor Vehicles Act, 1988. 2. Under Section II - 1(ii) of the policy -Damage to Third Party Property- ` 100000 3.P.A.
Cover under Section III for Owner - Driver(CSI): ` 100000 Terms, Conditions & Exclusions: As per the Indian Motor Tariff. A personal copy of the same is available free of cost on request & the same is also
available at our website.

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.The stamp duty of 0.50 paid
by Demand Draft, vide Receipt/Challan no. 6549803201718 dated 19-03-2018 as prescribed in Government Notification Revenue and Forest Department No. Mudrank 2004/4125/CR 690/M-1,dated 31/12/2004.Goods
and Service Tax Registration No: 27AABCL5045N1Z8. 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." Disclaimer: The Policy shall be void from inception if the premium in full is not realised by the company. In the event of misrepresentation, fraud or non-disclosure of material fact, the
Company reserves the right to cancel the Policy. Please note that the insured vehicle was pre-inspected and a report was prepared accordingly. The existing damages to the vehicle as mentioned in the report shall
not be paid by the Company. The policy is issued basis the information provided by you, which is available with the company. In case of discrepancy or non recording of relevant information in the policy, the insured is
requested to bring the same to the notice of the company within 15 days. Goods and Service Tax for this invoice is not payable under reverse charge basis.

Branch : LEELA BUSINESS PARK, 6TH FLR, ANDHERI - KURLA RD, MUMBAI, 400059. Phone No. : +91-22-66383600
Policy Issuing Office: Mumbai For HDFC ERGO General Insurance Company Ltd.

Signature Not Verified *1*

Digitally signed by Nagendra Saikumar
Date: 2018.04.26 08:30:14 IST
Reason: I'm the author
Location: India
#1# Duly Constituted Attorney
*$*NAGENDRA_SAI#$#

Registered & Corporate Office: 1st Floor, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai - 400020. Policy Issuing/Customer Service Address: D-301, 3rd Floor, Eastern Business District (
Magnet Mall), LBS Marg, Bhandup (West). MUMBAI - 400078. Maharashtra. Toll Free : 1800-2-700-700 (Accessible from India only) | Fax : 91 22 6638 3699 | [email protected] | www.hdfcergo.com CIN :
U66030MH2007PLC177117.| UIN : IRDAN125P0005V01200203
IRDAI Reg No. 146. (Formerly HDFC General Insurance Limited from September 14, 2016 and L&T General Insurance Company Limited upto September 13, 2016)
 2312100304462800000
HDFC ERGO General Insurance Company Limited

Motor Insurance - Proposal Form For Two Wheeler Package

Proposal No.2312 1003 0446 2800 000

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Insured Name Mr S Ashrath RTO TIRUPATHI CHITTOOR PAN No.
MADANAPALLE
Correspondence 8-122 B C Colony Kallur
Address CHITTOOR ANDHRA PRADESH 517113
Mobile 8328295430 Phone - E Mail [email protected] Registration No. AP-03-BB-4630
Period of Insurance From Date & Time 29/04/2018 00:01 hrs To Date & Time 28/04/2019 Midnight Proposal Issuance Date 26/04/2018
Seats(Incl.
Make Model - Variant Engine No Chassis No Mfg Yr Body Type CC
of side car)
BAJAJ AUTO. PULSAR-150 DTSI DHZODL18839 MD2A11CZ3DCL27878 2013 2 OPEN 149

Insured's Declared Vehicle (`) Side Car (`) Non Electrical Acc. (`) Electrical Acc. (`) CNG/LPG Kit (`) Total IDV (`)
Value (IDV) 31,000 0 0 0 0 31,000

Fuel Type Cover Type Date of Registration TPPD restriction Higher deductible
PETROL PACKAGE 19/03/2013 NA NA
Named Persons & Nominee (IMT-15)
Nominee for Owner driver Appointee
Premium Details (`)
Own Damage Premium (a) Liability Premium (b)
Basic Own Damage: 362 Basic Third Party Liability: 720

PA Cover for Owner Driver of `100000 50

Total Basic Premium 362
PA Cover for un-named persons of `100000 each(for 2 Person) (IMT-16) 140

Sub Total – Addition 910

Net Liability Premium (b) 910

Total Package Premium (a+b) 1272

Integrated Tax 18% 229

Net Own Damage Premium (a) 362 Total Premium 1,501

Geographical Area India Compulsory Deductible (IMT-22) ` 100 Voluntary Deductible (IMT-22A) ` 0
Payment Details: Fund Transfer No. TW1804522451 Dated : 26/04/2018 Drawn on BizDirect

Proposer declaration

DECLARATION ON BEHALF OF ALL PERSONS TO BE INSURED : I/We hereby understand, declare, consent and authorize the Company to use personal health details and financial information, as provided to
the Company for underwritingthe risk. I/We hereby also understand, declare, consent and authorize the Company that the Company shall have right to retain the aforementioned information anddisseminate the
same to its service provider(s) for providing services related to insurance.

Anti rebate clause

Prohibition of Rebates (Section 41 of Insurance Act, 1938 as amended) : 1. No person shall allow o r 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 o r 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: provided that acceptance by an
insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be acceptance of a rebate of premium within the meaning of this sub-section if
at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed by 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..

Disclaimer : Proposal Form and Policy Schedule have been generated basis details entered by proposer / insured on Online Platform (either on HDFCERGO.com or its affiliated Online Channels (IRDAI Licensed
Intermediaries). For any modification, kindly visit URL https://www.hdfcergo.com/customer-care/customer-support.html and register your service request or write to us at [email protected]

Customer Name: Mr S Ashrath PAN No. :

Registered & Corporate Office: 1st Floor, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai - 400020. Policy Issuing/Customer Service Address: D-301, 3rd Floor, Eastern Business District (
Magnet Mall), LBS Marg, Bhandup (West). MUMBAI - 400078. Maharashtra. Toll Free : 1800-2-700-700 (Accessible from India only) | Fax : 91 22 6638 3699 | [email protected] | www.hdfcergo.com
CIN : U66030MH2007PLC177117.| UIN : IRDAN125P0005V01200203
IRDAI Reg No. 146. (Formerly HDFC General Insurance Limited from September 14, 2016 and L&T General Insurance Company Limited upto September 13, 2016)