Digitally signed by

Reliance General
Insurance Company
Limited
Date: 2022.01.03

SID0103221
Reliance Commercial Vehicles (GCV Other than 3 Wheelers Private) Package Policy- Schedule
Policy Number: 110822123350004642 Proposal/Covernote No: R07042126909
https://rgiclse
Insured Name :MR.SAI RAMESH BANTU Period of Insurance: From 00:01 Hrs on 08-Apr-2021 to Midnight of 07-Apr-2022

0 Communication Address :H NO 14-203 VIVIEKANANDA Policy Issuing Branch :APPLE PLAZA, UNIT NO. 301, 302 AND 303, SENAPATI
NAGAR,GAJULARARMARAM ROAD MEDCHAL BAPAT MARG, DADAR WEST ,

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MALKAJGIRI,,RANGAREDDI,,TELANGANA,,INDIA,501401 MUMBAI,,MAHARASHTRA,400028
Mobile No :9963482589 Tax Invoice No. & Date :R07042126909 &07/04/2021

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Email-ID : [email protected] GSTIN/UIN & Place of Supply:TELANGANA

Insured Vehicle Details

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Registration No. TS08UH4787 Mfg. Month & Year MAR-2020
Make / Model & Variant Tata/Ace & Gold Bs Iv CC / HP 702
Engine No./Chassis No. S14237/A07046 LCC Including Driver 2
Type of Body NA GVW 1550

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RTO Location TELANGANA - Medchal Total Premium ` 11375.00
Carrier Type Private IDV `

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Hypothecation/Lease
Manufacturer fully build in 1 Yes NA
FINANCE_HIDE

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Vehicle Sub Class Pick Up Vans Goods Type

Insured Declared Value (IDV)

Chassis IDV ` 0.0 Non Electrical Accessories ` 0.0
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Body IDV ` 0.0 CNG / LPG Kit ` 0.0
Vehicle IDV ` 450000 Trailer / Side Car ` 0.0
Electrical / Electronic Accessories ` 0.0 Total IDV ` 450000.00
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Premium Summary

Own Damage - Section I Amount(`) Liability - Section II Amount(`)

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Basic OD 1630.80 Basic Liability (TPPD 1) 8438.00

Total Basic Own Damage Premium 1630.80 Total Basic Liability Premium 8438.00
TOTAL OWN DAMAGE PREMIUM 1630.80 PA Benefits - Section III
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TOTAL 0LIABILITY PREMIUM 8438.00

TOTAL 1PACKAGE PREMIUM (Sec I + II + III) 10069.00
IGST on1OD Premium (@18.00 %) 294.00
IGST on1TP Premium (@12.00 %) 1013.00
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TOTAL PREMIUM PAYABLE 1 11375.00

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Subject to0I.M.T.Endt.Nos. & Memorandum printed/herein/attached hereto. IMT 21
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GSTIN :27AABCR6747B1ZG,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"
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Consolidated Stamp duty Paid vide Letter of Authorisation No. CSD/242/2021/542 dated 12th Feb 2021** Not Applicable for the State of J&K

20BRG534 / Gramcover
9311672463 [email protected]
Insurance Broker Private Limited
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Intermediary Code/Name Intermediary Contact No. Intermediary E-mail ID POS UID Aadhaar No. / PAN No.

Limits of liability : PA cover for owner driver under section III CSI `0.0
(a) Under Section II (1)(i) of the Policy-Death of or bodily injury to any person so far as it is necessary to meet the
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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
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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
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racing (b) Pace making (c) Speed testing (d) Reliability trials.

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.

Page 1 of 9
Persons/Classes of persons : 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.
Deductible under Section-I : (i) Compulsory deductible `500.0/-(ii) Additional compulsory deductible `0 (iii) Voluntary deductible ` 0.0/-
Compulsory PA cover for owner driver :
Insured is not eligible for compulsory PA cover for owner driver in the policy as the same has not been opted for the reasons allowed as per motor tariff and/or basis
insured's declaration given below:

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"I/ we hereby declare that I/ we hold an effective personal accident insurance policy covering death and permanent disability (total & partial) and/ or compulsory
personal accident (CPA) for owner driver in other vehicles; whereby the Sum Insured limit is of Rs 1,500,000 or more in all such above mentioned conditions."

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In case you have missed it, please opt for the compulsory PA cover by payment of an additional premium as applicable.Liability of insurance company shall
commence from the date of issuance of endorsement.
"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

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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

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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.
*No Claim Bonus is subject to no claim on the previous policy. Benefits under the policy stands forfeited if claim is/was made in previous policy.

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Safeguard your transaction by paying your premium via crossed cheque/DD in favour of Reliance General Insurance Co. Ltd.
Subject otherwise to the terms, conditions and exclusions of the Reliance Miscellaneous and Special Types of Vehicles Package Policy Certificate Cum Policy

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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).
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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. 2335
As per National Highways Authority of India, kindly ensure to affixed FASTag on your vehicle.
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Grievance Clause :- For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 1800 3009 or
may write an email at [email protected]. In case the insured is not satisfied with the response of the office, insured may
contact the Nodal Grievance Officer of the Company at [email protected]. In the event of unsatisfactory response from
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the Nodal Grievance Officer, insured may email to Head Grievance Officer at [email protected]. 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,3rd
Ins

Floor,Jeevan Seva Annexe,S. V. Road,Santacruz (W), Mumbai - 400 054. Tel.: 022 - 26106552 / 26106960 Fax: 022 - 26106052 Email:
[email protected] | Shri. A. K. Sahoo Office of the Insurance Ombudsman,Jeevan Darshan Bldg.,3rd Floor,C.T.S. No.s. 195
to 198,N.C. Kelkar Road,Narayan Peth, Pune – 411 030. Tel.: 020-41312555 Email: [email protected]
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.
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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.
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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Special Conditions : NA
Policy has been issued with reference to vehicle inspection report, reference lead no.InspectionID_HIDE & special conditions.The
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inspection report remarks can be viewed on company's website by the lead no.
For Reliance General Insurance Co. Ltd.
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Authorised Signatory
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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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.

Page 2 of 9
 Risk Assumption Letter

Dear Mr. SAI RAMESH BANTU

Thank you for choosing Reliance General Insurance.
Please find enclosed policy no.: 110822123350004642 which has been issued based on the details declared by the applicant.

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Insured Vehicle Details

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Registration No. TS08UH4787 Mfg. Month & Year MAR-2020
Make / Model & Variant Tata/Ace & Gold Bs Iv CC / HP / Watt 702

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Engine No./Chassis No. S14237/A07046 LCC Including Driver 2
Type of Body NA GVW 1550
RTO Location TELANGANA - Medchal Total Premium ` 11375.00
Carrier Type Private IDV ` 450000.00

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Hypothecation/Lease
Manufacturer fully build in 1 Yes NA
FINANCE_HIDE

Insured's Declared Value (IDV)

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Chassis IDV ` 0.0 Non Electrical Accessories ` 0.0
Body IDV ` 0.0 CNG / LPG Kit ` 0.0

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Vehicle IDV ` 450000 Trailer / Side Car ` 0.0
Electrical / Electronic Accessories ` 0.0 Total IDV ` 450000.00

YOU HAVE OPTED FOR THE FOLLOWING COVERS

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Standard
Vehicle Own Damage + Third Party Coverage
Cover
NO Electrical/electronic accessories
NO Non-electrical accessories
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NO Bi-fuel kits comprising LPG/CNG systems

Add-on Covers NO NO
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Nil Depreciation Cover No deduction for depreciation on vehicle parts other than tyres and tubes with respect of approved partial loss claims.
Provides cover for towing charges over and above the standard policy guideline as per the cover opted by customer (Sum
Additional towing Charges
Insured - ` 0.0/-).
Indemnify the Insured for an additional TPPD amount opted for damage to property other than the property belonging to the
Additional Limit of TPPD
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Insured or held in trust or in custody of Insured. NO

Emergency Hotel Provide allowance towards the Hotel accommodation insured vehicle met with accident/ stolen 200 kms away from the
Accomodation location provided in policy copy NO
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 [email protected] or call us on 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
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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
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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.
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Authorised Signatory
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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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.

Page 3 of 9
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 4890 3009(Paid No) 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.

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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.

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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

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deletion, if registration certificate copy is endorsed).

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Ins
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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
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4. Policy copy
5. Vehicle fitness certificate
6. Vehicle route permit
7. Vehicle carriage permit
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8. Road tax copy

9. Load Challan (if applicable)
Note: 1. As soon as a claim occurs, please intimate immediately at our call centre 022 4890 3009(Paid No)Delay in intimation would result in the violation of policy
condition. 2. Any additional document, if required, will be informed.
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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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.

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 Proposal Form for 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')
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PCV GCV MISC D Trailer

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For Office Use Only
Policy Number Date 03-01-2022

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Savvion Reference No Inspection Lead No.

Intermediary Details (To be filled in BLOCK LETTERS)

Intermediary Name GRAMCOVER INSURANCE Code 20BRG534
Branch Name Mahim Code 1108

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Sales Manager Name Dineshkumar Ramsajiwan Tiwari Code 70309359
*POS PAN No. *POS UID Aadhaar No.

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Details (To be filled in BLOCK LETTERS)
1. This Proposal is for A new Policy Renewal of Policy Endorsement Others (Please specify)
2a.
2b.
Proposer's Full Name
Address
Mr. Mrs. SAI RAMESH BANTU
Address for Communication om Address where Vehicle is Normally Kept and Used
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Flat/Building/Door/Block No. H NO 14-203 VIVIEKANANDA
Road/Street/Sector NAGARGAJULARARMARAM ROAD MEDCHAL
Nearest Landmark
Used
Area
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City Mr.
Pin Code 501401
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State TELANGANA,
Country India
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Phone Mobile 9963482589

Emergency Contact No. Blood Group
Email [email protected] Fax
3. Period of Insurance From 08/04/2021 To 07/04/2022
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4. Source of Funds Business Profession Salary Agricultural Income Savings Others

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5. Monthly Income Upto ` 20,000 ` 20,001 to ` 50,000 ` 50,001 to ` 1,00,000 ` 1,00,001 and above
6. UID Aadhaar No. 7. PAN No.
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Details of the Vehicle

8. Registration Number TS08UH4787 9. Date of Registration 16-Mar-2020

10. Registering Authority & Location TELANGANA - Medchal
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11. Year & Month of Manufacture MAR-2020 12. Cubic Capacity 702
13. Engine Number S14237
A07046
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14. Chassis Number

15. Make of Vehicle TATA
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16. Type of Body/Model NA/ACE

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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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.

Page 5 of 9
17. Gross Vehicle Weight (GVW)/Cubic Capacity (C.C.) 1550
18. Goods type (Applicable only if GVW+7500kgs) Hazardous Goods Non-Hazardous Goods
19. Is the Vehicle made in India? Yes No
20. Max. Licensed carrying capacity (No. of Passengers) in case of Passenger carrying vehicles 1

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21. Vehicle Category Bus Taxi PICK UP

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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

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22. Seating capacity (Including Driver) 2
Details of the Vehicle Type and Use
24. a.Whether the Vehicle is driven by Non-conventional source of power? Yes No If yes Bi Fuel CNG LPG

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Insured's Declared Value Non - electrical
Electronic accessories Value of CNG/ LPG Kit Bi
(IDV) of vehicle Chassis accessories fitted to the Total Value (`)
fitted to the vehicle (`) Fuel (`)
Body vehicle (`)

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450000 0.0 0.0 0.0 450000.00
b. Do you have a valid PUC? Yes No

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(Note-Warranted that the insured named herein/owner of the vehicle holds a valid Pollution Under Control (PUC) Certificate and/or validfitness certificate, as
applicable, on the date of commencement of the Policy and undertakes to renew and maintain a valid and effectivePUC and/or fitness Certificate, as
applicable, during the subsistence of the Policy. Further, the Company reserves the right to takeappropriate action in case of any discrepancy in the PUC or
fitness certificate.)
25. Details of Driver : (a) Age of Owner Driver Others
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(b) Does the driver suffer from defective vision or hearing or any physical infirmity. Yes No
If "Yes" please give details.
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(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:-
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26 (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) Yes No
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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: `_______________
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(b) Additional Towing Charges

(c) Nil Depreciation Cover:
(d) Total Cover NO
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(e) Voluntary Deductible

Voluntary Deductible amount opted `_____________________
(f) Emergency Hotel Accommodation NO
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Benefit Amount: `0.0

(g) Additional Limit of TPPD NO
Additional amount opted: `0.0
(h) Personal Belongings Cover NO
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Benefit Amount: `0.0

(i) Daily Allowance Benefit NO
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Per day allowance amount opted `_______________________

Coverage Days opted _________________________________
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(j) Daily Allowance Benefit Plus NO

Per day allowance amount opted: `0.0
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Coverage Days opted: 0

(k) Tools and Equipment Cover
(l) Any other Details _____________________________________

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.

Page 6 of 9
 No
28. Is the vehicle fitted with any Anti-theft device approved by the ARAI? Yes
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If yes, please attach certificate of Installation in the vehicle, issued by Automobile Association of India.
No
29. Are you a member of Automobile Association of India? If yes, please submit membership copy. Yes
0.0
30. Whether the Vehicle is used for Driving Tuitions? Yes No 0
No
31. Whether use of Vehicle is limited to Own Premises? Yes

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0.0
32. Whether the commercial vehicle is also used for Private purposes (excluding use for hire or reward)? Yes No

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33. Whether the Vehicle is fitted with Fibre Glass Tank? Yes No
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34. Whether the Vehicle belongs to the Embassy/Consulate of a Foreign Country? Yes No
If so, is the duty element included in the IDV?
35. Whether the Vehicle is design for use of Blind/Handicapped/Mentally Challenged Person? Yes No 0.0

36. Date of purchase of the Vehicle by the Proposer 16-Mar-2020

Second

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37. Whether the Vehicle at the time of purchase was New
Hand
Risk Inclusions

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Liability to third parties: The policy provides Third Party Property Damage (TPPD) of ` 1 lakh (Two wheelers) and ` 7.5 lakhs (other class
38.
of vehicles)

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Do you wish to restrict the above limits to the statutory TPPD Liability limit of ` 6000/- only? Yes No
750000.0

Do you wish to cover legal liability to?

(a) Driver/Conductor /Cleaner (No. of persons) Yes No
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(b) Other employees (No. of Persons) Yes No0
(c) Non-fare paying passenger (No. of persons) Yes No0
39. Do you wish to include personal Accident (P.A.) Cover for paid drivers, cleaners and conductors? Yes No0.0
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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.
40. Personal Accident Cover for Owner Driver. Please give details of nomination
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Name of Appointee (if Nominee is

Name Name of Nominee Age of Nominee Relationship Address
Minor)

(Note: 1. Personal Accident cover for owner driver is compulsory for Sum Insured of `15,00,000/- for Two Wheeler, Private Car, GCV,
Ins

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)
41. Do you wish to include Personal Accident cover Named Persons? Yes No
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Name of
Name of Appointee (if
Name CSI Opted Age of Nominee Relationship Address
Nominee Nominee is
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Minor)

41. Extension of Geographical Area:

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Whether extension of Geographical Area to the following countries required?

INDIA
1. Bangladesh 2. Bhutan 3. Maldives 4. Nepal 5. Pakistan 6. Sri Lanka
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Details of Hire Purchase / Hypothecation / Lease

42. Please state if the vehicle is under Hire purchase Lease Agreement Hypothecation Agreement
FINANCE_HIDE
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If so, give name and address of concerned parties.

43. Full Name M/s
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44. Address
Insured's Declared Value
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Non - electrical accessories Electronic accessories Value of CNG/ LPG Kit Bi

(IDV) of vehicle Chassis Total Value (`)
fitted to the vehicle (`) fitted to the vehicle (`) Fuel (`)
Body
450000 0.0 0.0 0.0 450000.00

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.

Page 7 of 9
 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

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45. Full Name of previous insurer
46. Address -
47. Policy Number Previous policy Expiry

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48. Type of cover: Package Policy Liability Only Other (To be describe)
49. NO CLAIM BONUS allowed under previous policy (%)
50. Claims taken in previous policy 0 Yes No
If yes, No. of Claims Claims Amount `

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51. Are you entitled to No Claim Bonus 0.0 Yes No
If yes, please submit/attached proof thereof

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Payment Details

Cheque / DD Cheque / DD No.

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Cheque/DD Date Cash Credit Card Others

Proposer's Bank Details

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52. Name of the Bank Account Holder
53. Bank Account No.: 54. Account: Saving Current
55. Name of the Bank
56. Branch
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57. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank)
58. IFSC Code (11 character code appearing on your cheque leaf)
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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 mandatory that all payments made to the insured are only through electronic mode.
Declaration by Proposer
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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
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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
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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
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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
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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-
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representation, mis-description of nondisclosure of any material particulars by the Proposer. Any person who, knowingly and with intent to
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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
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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

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.

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 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 : Date :

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Signature Signature of Proposer & Company Seal

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Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015.

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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

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rupees.
Supporting Confirmation of Agent/Broker/SM/CSO

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I confirm the above signature to be of the registered owner of the vehicle proposed for insurance
Name of IRDA Agent/Broker Mr. Mrs. GRAMCOVER INSURANCE BROKER PRIVATE LIMITED

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Place :
Date :
(In case of Direct Business, Name & Signature of CSO / SM to be taken) Signature of IRDAI Agent/Broker
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* Mandatory details to be filled
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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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.

Page 9 of 9