DEVELOPMENT HOUSE, 24 Park Street , Kolkata -700016

(www.magmahdi.com)
IRDA REG NO. 149 DATED 22nd MAY,2012
CIN: U66000WB2009PLC136327
In case of any query, assistance or claims, please contact us at 1800 266 3202
UIN: IRDAN149RP0006V02201213
Date : 15/01/2023

To,
Mr SURENDRA NAG
S/O MAHESH RAM NAG H.NO-185 JAWAHAR WARD UTTAR BASTAR KANKER
KANKER
CHATTISGARH 494334
Mobile:6265482050

Agent/ Intermediary Name and Code:ZOPPER INSURANCE BROKERS PRIVATE LIMITED BRC0000504

Sub: Risk Assumption Letter

Dear Sir /Madam,

Thank you for choosing Magma-HDI General Insurance Company Limited as your preferred General Insurance Company. Please find enclosed Policy
No. P0023400015/4103/101702, which has been issued based on the details furnished to us as below:

Insured & Vehicle Details

Name of Insured Mr S U R E N D R A N A G

Period of Insurance 18/01/2023 TO 17/01/2024

Vehicle Make/Model MAHINDRA & MAHINDRA / BOLERO PICK UP FB PS 1.29T
RTO KANKER
Vehicle Registration No. CG - 19 - BJ - 8775
Vehicle Registration Date 15/03/2019
Engine No. TBK1A23387
Chassis No. MA1ZN2TBKK1A12596
Reason for not opting PA Cover of Owner Driver :
1) Do not hold a valid driving license
Previous Policy Details
Previous Policy No VGC0600065000102
Previous Policy Period 18/01/2022 TO 17/01/2023
Previous Year NCB% 35
Previous Insurer Name ROYAL SUNDARAM GENERAL INSURANCE CO. LTD .
Previous Policy Type Package

The information provided above is based on the information received from you and accordingly, the proposal has been processed.
Coverage of risk is subject to realisation of the full premium post which, insurance coverage under the policy would commence. In case the premium is not
received by us due to cheque dishonour or any other reason, the insurance cover shall be void ab-initio.
If you require any changes in the certificate of insurance cum policy schedule, you are requested to inform us by either writing to us at customercare@magma-
hdi.co.in or calling our toll free helpline on 1800 266 3202. Absence of any communication from you in this regard within a period of 20 days of date of this letter,
would mean that the issued policy is in order and as per your proposal. The Risk Assumption Letter is to be read in conjunction with the policy and shall be
considered as null and void without the same.

Thanking You,
Regards

For Magma HDI General Insurance Co Ltd.

Authorised Signatory
 DEVELOPMENT HOUSE, 24 Park Street , Kolkata -700016
In case of any query, assistance or claims, please contact us at 1800 266 3202
UIN: IRDAN149RP0006V02201213

COMMERCIAL VEHICLE CLASS (GCV) PACKAGE POLICY

CERTIFICATE OF INSURANCE CUM SCHEDULE /TAX INVOICE
Policy Servicing Office OFFICE NO. 501 & 509-512, 5TH FLOOR, ,DB CITY, CORPORATE PARK, PLOT NO. 1, BLOCK NO. 9, RAJBANDHU MAIDAN, RAIPUR ,RAIPUR -492001 ,CHATTISGARH , PH:
(1800) 2663202
Policy No P0023400015/4103/101702
Insured Mr SURENDRA NAG
Address S/O MAHESH RAM NAG H.NO-185 JAWAHAR WARD UTTAR
Period Of Insurance 00:00 Hrs of 18/01/2023
BASTAR KANKER
To Midnight of 17/01/2024
KANKER
Agent No.: BRC0000504
CHATTISGARH 494334
Mobile:6265482050
Hypothecation with MAHINDRA AND MAHINDRA FIN SER LTD
Contact Number 6265482050
Email ID: [email protected]
GST Number Unregistered
INSURED MOTOR VEHICLE DETAILS AND PREMIUM COMPUTATION
Registration Mark
Trolley Serial Trolley Chassis Year of
& No. & RTA Engine No. Chassis No. Make/Model/Type of Body GVW POLICY CLASS SEATING CAPACITY
ID No. Manufacture
Location
MAHINDRA & A1 GCV Public
CG 19 BJ 8775 /
2019 TBK1A23387 MA1ZN2TBKK1A12596 MAHINDRA BOLERO PICK UP FB 2990 Carriers other than 2
KANKER
PS 1.29T/PICKUP 3 wheelers
IDV (INSURED'S DECLARED VALUE)
Electrical/electronic
IDV of Chassis IDV of Body Trailers Non Electrical Accessories Bi-Fuel kit(LPG/CNG) Other accessories Total Value
Accessories
472000 0 0 0 0 0/0 0 472000
OWN DAMAGE(A) LIABILITY(B)
Basic - OD 2,036.68 Basic - TP 16,049.00
Loss/damage to lamps/tyres/mud guards etc. - IMT-23 305.50 Under WC act-Driver/cleaner/employees-IMT 28 100.00
Sub Total 2,342.18 Sub Total 16,149.00
Less:
No claim bonus 45% 1,053.98
Sub-Total Deductions 1,053.98
Total Own Damage Premium(A) 1,288.00
CGST @ 9% 115.92
SGST @ 9% 115.92
Total Liability Premium(B) 16,149.00
GST on TP Premium
CGST @ 6% 962.94
SGST @ 6% 962.94
GST on Other Liability Premium
CGST @ 9% 9.00
SGST @ 9% 9.00
Premium Computation
Total Package Premium(A+B) 17,437.00
TOTAL CGST 1,087.86
TOTAL SGST 1,087.86
TOTAL 19,613.00

LIMITATIONS AS TO USE - The Policy covers use only under a permit within the meaning of the Motor Vehicles Act, 1988 or such a carriage falling under Sub-section 3 of
Section 66 of the Motor Vehicle's Act 1988.
The Policy does not cover use for a) Organised racing, b) Pace Making, c) Reliability Trials, d) Speed Testing, e) Use whilst drawing a trailer except the towing (other than for reward) of any one
disabled Mechanically propelled vehicle (only for Passenger Carrying Vehicles).
Persons or classes
of persons entitled Any person including Insured:
to drive:
Provided that the 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
Goods carriage 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.
Provided that the 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
Non-transport
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
Vehicles
the requirements of Rule 3 of The Central Motor Vehicles Rules, 1989.
LIMITS OF LIABILITY
Under Excess in respect of each and every claim under Sec I of Under In respect of any one Under Damage to Third Party Property Rs. Under PA Owner – Driver as per
Section I motor policy Section accident -- As per Section 750000/- in respect of any one claim Section III: premium computation
Compulsory : Rs. 500/- Voluntary : Rs. 0/- Imposed : II-I (i) Motor Vehicle Act II-I (ii) or series of claims arising out of one table
Rs. 0/- Total : Rs. 500/- event.
Subject to I.M.T Endorsement Nos. IMT 7,IMT 21,IMT 23,IMT 28
Pollution Under Control(PUC)
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 at the time of issuance of policy.

I/We hereby certify that the Policy to which this Certificate relates as well as this Certificate of Insurance are issued in accordance with the provisions of chapter X and chapter XI of M.V. Act, 1988.
Premium Collection Details :- [Collection No - ReceiptDate - Amount] : P/400015/23/100879302- 15/01/2023 , 19613
Premium Amount in Word's ( ) :- Nineteen Thousand Six Hundred Thirteen Only
In case of Claims, please contact us at 1800 266 3202 For Magma HDI General Insurance Co. Ltd.

Date of Issue : 15/01/2023

Place : Kolkata
Consolidated Stamp Duty on the issue of General Insurance Policies Paid vide G.O No. 1662, dated 29.09.2022

GST Number of MHDI - 22AAGCM1685C1ZT

GST Invoice Number - POL2201230006626
Accounting Code for Service - 997134, Motor vehicle insurance services

Place of Supply:CHATTISGARH ( 22 )

Whether Tax is payable on Reverse Charge - No Authorised Signatory

UIN : IRDAN149RP0006V02201213
This is a valid Tax invoice in terms of Sub-rule 2 of Rule 54 of CGST Rule 2017. Further, being an Insurance Company, issuing of e-
invoice and QR Code are not applicable on us in terms of Notification No 13 and 14 of 2020 dated 21st March 2020 issued from
Central Board of Indirect Taxes and Customs. I/We hereby declare that though our aggregate turnover in any preceding financial year
from 2017-18 onwards is more than the aggregate turnover notified under sub-rule (4) of rule 48, we are not required to prepare an
invoice in terms of the provisions of the said sub-rule.
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 be good. Please note that any misrepresentation, non disclosure or withholding of material facts will lead to cancellation of policy ab initio with forfeiture of premium
and non consideration of claim, if any.

For Complete details of coverage , terms, conditions & exclusion please refer the standard policy wording attached with this schedule

IMPORTANT - 1) The Validity of this Certificate of Insurance cum Schedule is subject to realisation of the premium cheque.
2) No Claim Bonus will only be allowed provided the Policy is renewed within 90 days of the expiry date of the previous policy.
3) This document is digitally signed, hence counter signature / stamp is not required.
 We at MAGMA HDI prefer receiving premium amount through cheque
No. CV/202301150015073

Helpline No : 1800 266 3202

(Information for fields marked with asterisk [*] is mandatory)

Proposal Form for Commercial Vehicles

Customer ID 20013094104
*Proposal For: New Policy Roll- Over Renewal Endorsement

*Coverage Comprehensive Package Cover Third Party Liability only Cover Third Party, fire & theft only Cover
Required: Third Party and Fire only Cover Third Party and Theft only Cover
* Period of Insurance: 18/01/2023 Time: 00:00 ,To 17/01/2024
(Note: Cover shall not commence earlier than the date and time of acceptance of risk and/or issuance of cover note and subsequent to payment of premium)
Intermediary Code: BRC0000504 Intermediary Name: ZOPPER INSURANCE BROKERS PRIVATE LIMITED

1. *Proposer Details:
1. Name (Registered Owner of the Vehicle): Mr SURENDRA NAG

PAN No: *DOB: 15/08/1989 *Gender: M F *Occupation: Others *Marital Status: Married
Bank Name Branch Name A/c Type- Saving Current
Account No. MICR IFSC
2. *Address where Vehicle Registered and Based
S/O MAHESH RAM NAG H.NO-185 JAWAHAR WARD UTTAR BASTAR KANKER, KANKER, CHATTISGARH 494334, 6265482050, [email protected] ,Mobile:6265482050 Whatsapp Number:6265482050 Would you like to opt
for Whatsapp notification
GST Number Unregistered
3. *Communication Address (For policy dispatch)
185 JAWAHAR WARD, KANKER, CHATTISGARH 494334
GST Number Unregistered
4. City where the vehicle will primarily be used: KANKER
5. Have you previously insured this vehicle? Yes No Policy No. VGC0600065000102

If so, are you entitled to No Claim Bonus from your previous Insurer? Yes No

If Yes, Kindly indicate the percentage: 20% 25% 35% 45% 50% 55% 65%

I/We hereby declare that the rate of NCB claimed by me/us is correct and that NO CLAIM has arisen in the expiring policy period (Copy of Policy enclosed). I/We further undertake that if this declaration is found incorrect, all benefits under
the Policy in respectof Section1 of the Policy will stand forfeited.

Signature of Proposer
6. About the Motor Vehicle to be Insured
*Vehicle Type: 2 Wheeler 3 Wheeler 4 Wheeler More than four wheels *Vehicle Insured is: New Used

*Make MAHINDRA & MAHINDRA *Chassis No MA1ZN2TBKK1A12596 Speedometer reading as on date

*Model BOLERO PICK UP FB PS 1.29T RTO where vehicle will be registered KANKER *Vehicle IDV 0
*Year of Manufacture MARCH - 2019 Date of Registration /Purchase 15/03/2019 Trailer(s) Identification No. 1_________
*CC/GVW 2523 Licensed Carrying Capacity 2 2_________
(No of Passengers Including driver)
*Registration No. CG - 19 - BJ - 8775 Â 3_________
Type of Body PICKUP Colour of the vehicle 4_________
*Engine No. TBK1A23387 Vehicle Make (Indigenous or Imported) BOLERO PICK UP FB PS 1.29T
Note: Either Registration no or Engine and Chassis Number is mandatory
*Vehicle Rate Under: Zone -A Zone -B Zone -C
*Fuel Used: Petrol Diesel Bi Fuel LPG/CNG Electric Hybrid Others (please specify)
*Purpose of Use: Good Carrying (Private Carrier) Passenger Carrying (Private carrier) Good Carrying (Public Carrier)
Passenger Carrying (Public Carrier) Others (Please specify)
Proposed usage of the vehicle? (Applicable only to passenger carrying vehicles with seating capacity not exceeding 6)
Driven by the owner(s) only, Driven by the owner(s) only along with other drivers, Driven by other drivers, For rent to tourists, For rent to individuals for personal use,
Business purposes by Hotels, Business purposes by Corporates, Official purposes by foreign embassy/ consulate
*Type of Permit: Hilly National/State Highways City/Town Road District Roads Others
* Average Monthly usage : Less Than 500 Kms; Between 501 and 2500 Kms; Between 2501 to 5000 Kms ; Above 5001 Kms
Whether any modification or conversion has been done in the vehicle from the maker’s standard specification? Yes No
If Yes, please give details of such modifications/conversions .............................................
Is the vehicle in good state of repair? Yes No If No, please furnish details ..........................................

Nature of Goods carried by vehicle Hazardous Non-Hazardous

7. Financier Details: Hypothecation Hire Purchase Lease Financier Name : MAHINDRA AND MAHINDRA FIN SER LTD

8. Nominee Details : Nominee Name: DOB Relationship

Appointee Name & age *If Nominee is minor (below 18 yrs) Appointee Name is mandatory.
9. Insured Declared value of the Vehicle:
The IDV of the vehicle will be deemed to be the Sum-Insured for the purpose of the Policy and will be fixed on the basis of the manufacturer’s listed selling price of the brand and model as the vehicle proposed for insurance at the time of
commencement of insurance / renewal and adjusted for depreciation as per the schedule specified below.
Age of the Vehicle % of Depreciation *Vehicle Chassis Value 472000
Not exceeding 6 months 5% Vehicle Body Value

Exceeding 6 months but not exceeding 1 year 15% Non- Electrical Accessories (Other than factory fitted): Details

Exceeding 1 year but not exceeding 2 years 20% Electrical Accessories (Other than factory fitted) Details

Exceeding 2 years but not exceeding 3 years 30% Bi- Fuel/ CNG/LPG Kit

Exceeding 3 years but not exceeding 4 years 40% Trailer(s)/ Side Car Value (only for 2 wheelers):

Exceeding 4 years but not exceeding 5 years 50% Total IDV:

Note - For vehicles more than 5 years old, please contact the Company for fixing the IDV
 We at MAGMA HDI prefer receiving premium amount through cheque
10. Extended Covers/ Extra Benefits at Additional Premium:
Extension of Geographical Area: Vehicle is fitted with Fibre Glass Fuel Tank Yes No

Bangladesh Bhutan Nepal Vehicle will be used for Driving Tuitions Yes No

Maldives Pakistan Sri Lanka Imported vehicle without payment of customs duty Yes No

Compulsory Personal Accident (If owner has a valid driving license) Personal Accident Cover ( Max Rs 1 lakh for two-wheelers and Rs 2 Lakh for other class of vehicles each in multiples
Yes No of Rs. 10000/- ) for paid driver / cleaner / conductors

Multiple Vehicles Not Having Valid Driving License Driver has existing PA cover of Rs 15 lakhs No. of Persons. 0 CSI per person 0

Legal liability to paid driver/ conductor/ cleaner employed in operations of vehicle

No of Persons 2
Legal liability to employees travelling in/driving the vehicle other than paid driver. Legal liability non-fare paying passengers
No. of Persons No. of Persons. ___________________ CSI per person _______________________
Additional Towing charges: Amount: ..........
Vehicle used for Private and commercial purposes : Yes No

Cover for overturning of Mobile Cranes, Mechanical Navies, Shovels, Grabs, Rippers and Excavators, Dragline
Do you wish to cover for loss or damage to lamps, tyres, tubes, mudguard, bonnet
Excavators, Mobile Drilling Rigs and Mobile Plants?
side parts, bumper and paint work? ( Not applicable for taxis ) Yes No
Yes No
Do you wish to have an enhanced Personal accident cover for Yourself Do you wish to cover Hospital Cash for hospitalisation arising out of accident
Your Driver / unnamed occupants of the vehicle ? for Yourself / Your Driver / Unnamed occupants of the vehicle?
Yes No Yes No
If Yes, please provide the Sum Insured per person
11. Add On Coverage at additional :

12. Restrictions of Cover/ Discounts:

Vehicle fitted with Anti-theft device approved by ARAI : Yes No Is the vehicle specially designed for the use by a handicapped person and/ or owned by an institution
exclusively engaged in service of the blind, handicapped and mentally regarded children or adults?
Vehicle will be used within own premises : Yes No
Yes No
Third Party Property Damage cover restricted to 6000 Yes No

*Voluntary Deductible : Yes No

Amount: ..........
I hold a valid and effective PUC and/or fitness certificate, as applicable, for the vehicle mentioned herein above and undertake to renew the same during the policy period.
Signature of Proposer
13. Previous Insurance Details:
Previous Insurer Name: RSGICL Type of cover: Package
Policy/ Cover note number: VGC0600065000102 Period of Insurance: From 18/01/2022 To 17/01/2023
Has any Insurance Company ever: Claims reported in last 5 years
1) Declined the proposal Year 1 2 3 4 5
2) Cancelled & Refused to renew
3) Required an increase in Premium Type of Claims
4) Imposed special conditions or excess (OD/TP)
No. of Claims
Amount

14. Driver Details:

a. Age & Date of Birth of the Owner : Age:_______ Yrs DOB:_____/_____/_____
b. Age & Date of Birth of the Driver : Age:_______ Yrs DOB:_____/_____/_____
c. Does the driver suffer from defective
vision or hearing or any physical infirmity? Yes No
lf YES, please give details of such infirmity :
d. Has the driver ever been involved/convicted
for causing any-accident of loss? Yes No

lf YES, give details as under including the pending prosecutions:

-Driver's Name :
-Date of Accident:
-Loss / Cost ( Rs.)
-Circumstances of Accident / Loss

15. Premium Details

Total Premium (Including GST): 19,613.00 Payment Mode : Cash Cheque DD

Cheque/DD, Cheque No Bank/Branch Date.

Declaration: 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 thebasis of the contract between
me/us and the Magma HDI General Insurance Co. Ltd.
I/We also declare that any additions or alterations carried out after the submission of this Proposal Form would be conveyed to Magma HDI General Insurance Co. Ltd immediately.
I/We hereby agree to receive a One Page Motor Insurance Policy in Physical Form, to be read along with the detailed Terms and Conditions available on the website www.magmahdi.com
Yes No
I/We further confirm that the existing damages as per the pre inspection report, if any, have duly been shared with me & my consent has been obtained for the same.
I/We hereby declare and undertake that the amount paid by me/us as premium for the aforementioned vehicle is out of my/our lawful and declared source of Income.

I/We hereby agree to receive policy schedule in Soft Copy Form Only.
I wish to get all policy related communications on My Whatsapp Number:6265482050 and allow to make welcome calls, Services calls or any other communication(electronic or otherwise),subject to the provision of applicable law. The
salient features of the policy,terms and conditions of this proposal have been explained to me/us in___________________ language, and I/we agree to the same.

__________________________________
Place: Kolkata Date: 15/01/2023 Signature of Proposer
SECTION 41 INSURANCE LAWS (AMENDMENT) ACT, 2015 - 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 or 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
prospectus or tables of the Insurer.
2.If any person fails to comply with sub-regulation (1) above, he shall be liable to payment of a fine which may extend to Ten Lakh Rupees.
Name: SURENDRA NAG
Date & Time: 15/01/2023 9:18:43 PM
Place: KANKER
IP Address: 223.176.115.140