CAR SHIELD - PRIVATE CAR PACKAGE POLICY

PROPOSAL FORM
Proposal No.
FOR OFFICE USE ONLY Sales Reference: Policy No:
IMPORTANT (All Fields are mandatory)
 Please complete the form in CAPITAL LETTERS, using a black pen.  The liability of the Company does not commence until the Company has accepted the Proposal Form duly filled in all respects and the full
premium is paid. For any clarification on the cover, terms, etc., please contact Royal Sundaram. All questions in the form must be answered and it must be signed and dated. Continue on a separate sheet if
necessary and attach as part of the Proposal Form.  Attach latest proof of No Claim Bonus if applicable. Attach any other information material to the risk proposed. It is an offence under the Motor Vehicles
Act 1988 to make a false statement or withhold any material information for the purpose of obtaining a Certificate of Motor Insurance.

ABOUT YOURSELF
Title Mr. Mrs. Miss Others (please specify) ________________________________________________________________
Name
First Name Middle Name Last Name
Are you Married? Yes No
Permanent Address

Communication
Address

City
State Pincode
Daytime Phone(s) - Mobile No.
STD CODE
E-mail
KYC Documents (Mandatory)
PAN Form 60 Form 49A PAN No. DOB D D M M Y Y Y Y
CKYC Number
(For Individual Customer) (For Corporate Customer)
Driving License No Passport No Aadhar Number
Name as per Aadhar Passport File No Principal Officer nameas per Aadhar
Aadhar Number Registration Certificate Power of Attorney to transact business
Certification of Incorporation and Memorandum & Article of Association
Voter ID Card No NREGA Job Card Any official document identifies partners/trustee/Foundations
(please specify)_________________________________
Mobile/Telephone Bill Bank Passbook/Account Statement
Resolution of Board of directors to open account /
Electricity Bill Ration Card Employer Certificate Resolution of the managing body of the foundations/Association
Lease Agreement with Letter from any Public Partnership/Trust deed PAN allotment letter
Rent Receipt Authority or from UIDAI Activity proof 1(for sole proprietorship only
Activity proof 2(for sole proprietorship only
Others (please specify)___________________________________________
Others (please specify)___________________________________________
Occupation: Please tick  against the applicable description, if you fall under any of the below listed categories. If you fall under more than one of the listed titles
below, please tick against all the applicable heads.
Low Risk Category
Pvt. Sector Govt. Employee Self Employed RS Employee Head of State or of Government Employee - IT and ITES
Sports Persons Senior Government/Judicial/Military Officer Senior Executives of State - Owned Corporations Student
Retired Employee Company Owned Others (please specify)_____________________________________________________________
High Risk Category
Film Industry Real Estate Senior Politician Important Political Party Official House wife Jewellery Proprietor
Chit fund Proprietor Bullion Dealers Trust, Charities, NGO with Foreign Funding. Others (Pl specify___________________________)
GST NUMBER
Name as per
GST Certificate
Registered
GST Number
Address as per
GST Certificate

District and State

as per GST Certificate
ELECTRONIC INSURANCE ACCOUNT(EIA) NUMBER
Do you have Electronic Insurance Account Yes No (If yes please provide)
Account No

Repository Name

Nominee Name

Nominee Age Nominee Relationship

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ABOUT YOUR VEHICLE Please give full details:
Date of Registration D D M M Y Y Y Y Fastag ID._____________________________________________

Date of delivery of vehicle to proposer D D M M Y Y Y Y

Registering Authority:
The address is same as above Yes No (If ‘No’ please give full details)
Address as per
Registration
Certificate
City
State Pincode
Period of Insurance From H H M M am/pm D D M M Y Y Y Y To H H M M am/pm D D M M Y Y Y Y
Registration No. Engine Number
Make & Model Chassis Number
Year of Manufacture Y Y Y Y Cubic Capacity Seating Capacity (including driver)
Current Ownership New Vehicle Used Vehicle Type of fuel Petrol Diesel CNG LPG Others__________________
(Please Specify)
Ownership Serial Number 1 2 3 Others______________________________________ Date of Transfer D D M M Y Y Y Y
(Please Specify)
Was the ownership Transferred in the last 12 months? Yes No
Vehicle mostly driven on City roads Highways Hilly areas Village roads Airport/Airside Others

Present value of your car & accessories (Please tick as appropriate.)

For the Car For extra Electronic & Electrical For extra Non-Electrical Total ‘Insured’s Declared Value’
(Insured’s Declared Value) accessories fitted to the car* accessories fitted to the car* of the car including accessories
` ` ` `
* If extra accessories are to be insured please provide the details below (attach sheet if necessary):
Sl.No. Make Model Estimated Value `
If the car is fitted with a Bi-fuel system, Model Estimated Value `
please state: Type
1. Is the vehicle financed? Yes No
Hire Purchase Hypothecation Lease Name and Address of finance company:___________________________________________________
2. Is the car fitted with an anti-theft device approved by Automobile Research Association of India(ARAI), Pune and the installation certified by a
recognized Automobile Association? Yes No
If ‘Yes’ attach full details, including copies of by purchase & installation and Automobile Association approval documents.
3. Is there any other Safety features installed in your car? ABS Airbags Others (Please Specify)________________________________

4. Whether the vehicle is driven by non-conventional source of power? Yes No

If ‘Yes’ please give details_____________________________________
5. Whether the vehicle is used for driving tuitions? Yes No
If ‘Yes’ please give details_____________________________________
6. Whether extension of geographical area to the following countries required ? Yes No
Bangladesh, Bhutan, Maldives, Nepal, Pakistan and Sri Lanka.
If ‘Yes’ state the name of the countries 1)_____________________________ 2)_____________________________ 3)_____________________________
7. Whether use of vehicle is limited to own premises? Yes No
8. Whether vehicle is used for Commercial purposes ? Yes No
9. Whether vehicle belongs to foreign embassy / consulate ? Yes No
10. Whether the car is certified as Vintage car by Vintage and Classic Car Club of India ? Yes No
11. Whether vehicle is designed for use of Blind/ Handicapped/mentally challenged persons and duly endorsed as such by RTA ? Yes No
12. Whether the vehicle is fitted with fibre glass tank ? Yes No
13. Are you a member of Automobile Association of India? Yes No
If ‘Yes’ please state a) Name of Association____________________ b) Membership No.____________________ c) Date of expiry__________________

BENEFITS UNDER OUR POLICY:

 Registered owner has valid driving license Yes No
 Compulsory Personal Accident (CPA) Cover For Owner Driver Yes No
Nomination for PA Cover DOB Relationship Name of the Appointee (if Nominee is a minor)

If No, Tick any of the three options

Registered owner does not have valid driving license
Registered owner having CPA cover with other motor policies
Registered owner having PA cover of Rs.15 lakhs and above
 The Standard Coverage for Third Party Property Damage is
`7,50,000/-. Do you wish to restrict the same to `6,000/- only, as per Motor Vehicles Act to avail applicable discount Yes No

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 Personal Accident Cover: For a maximum capital sum insured of `2,00,000/- covering Death and Disablement benefits for:
a) Any named person other than paid driver and/or cleaner (Please enclose the details of the persons to be insured)
Name Nominee Relationship Capital Sum Insured `

b) Paid driver(s)
Yes No If ‘Yes’ Capital Sum Insured opted ` ___________________________________
c) Unnamed occupants other than the insured, his paid driver and/or cleaner, limited to the registered carrying capacity of the vehicle
Yes No If ‘Yes’ Capital Sum Insured opted ` ___________________________________
 Wider legal liability to paid driver Yes No Legal liability for your employees Yes No (Maximum restricted to seating capacity)
If ‘Yes’ number of employees ____
 Additional Towing charges of `500 or `1000 or `1500 opted for over and above the limit prescribed in the policy.
If you wish to include this cover, state the limits required. ` ____________________________
PRIVATE CAR PACKAGE POLICY PROPOSAL FORM FOR ADD-ON COVERS
These covers can be opted only for vehicles that are insured under a Package Policy with us.
This proposal is an addendum to the Private Car Package Proposal Form for insurance of your Private Car.

Cover Name Cover Code Description

Depreciation Waiver Clause RSMOAC001 Would you like the Depreciation applicable on parts to be waived, in case of a partial loss claim. Yes No
In the event of Breakage of Windshield Glass, would you like to avail
Windshield Glass Clause RSMOAC002 replacement without affecting your No Claim Bonus Yes No

In the event of the vehicle meeting with an accident, you may choose one of the following compensation slabs,
to reduce any inconvenience to you:
Facilities in lieu of Compensation Slabs in `. Per day
RSMOAC003 Example:
Spare Car Clause
`150 `300 `500 `600 `750 `1,000
Would you like to insure the vehicle for its full Invoice Price inclusive of Road Tax, Yes No
Registration' and insurance cost
Vehicle Replacement Value Plus RSMOAC012
*This add on is applicable for first *Plan 1 *Plan 2 *Plan 3 *Plan 4
owner only
*Plan 1 – Full Invoice Price
*Plan 2 - Full Invoice Price + Road Tax
*Plan 3 – Full Invoice Price + Road Tax + Registration charges
*Plan 4 - Full Invoice Price + Road Tax and registration charges + Insurance Cost
Would you like to opt for Voluntary Deductible under your policy.
Yes No
What limit would you like to opt for:
Voluntary Deductible Clause RSMOAC006
`1,500 `2,500 `5,000 `7,500 `10,000 `15,000
Would you like to cover your Baggage against accidental damage or loss whilst being kept in the
insured Car. Yes No
Loss Of Baggage Clause RSMOAC007 What limit would you like to opt for: (`)
Example:
`2,500 `5,000 `7,500 `10,000
No Claim Bonus Protector (Option I) RSMOAC008 Would you like to opt for No claim bonus protector? Yes No
Aggravation (Damage) Cover Clause
RSMOAC009 Would you like to opt for Aggravation (Damage) Cover? Yes No
(Without Deductible)
Would you like to opt for Tyre Cover?
Yes No
If Yes, please give following details
Tyre Cover Clause RSMOAC010 Make_________________________ Variant_______________________
Serial No of four tyres

Spare Tyre: Make_________________________ Variant_______________________ Serial No

Key Replacement Clause
RSMOAC011 Would you like to opt for Key Replacement? Yes No
(Without Deductible)
Would you like to opt for Enhanced PA Cover?
Yes No
What limit would you like to opt for PA to Owner-Driver (`) ___________________ (In lakhs)
What limit would you like to opt for PA to each Unnamed Passengers (`) ___________________ (In lakhs)
What limit would you like to opt for PA to Paid Driver (`) ___________________(In lakhs)
Enhanced PA Cover RSMOAC013
What limit would you like to opt for each Named Passengers (`) ___________________(In lakhs)
Name of the Occupant Limit Opted (In Lakhs)

Would you like to opt for Roadside Assistance Cover Clause? Yes No
Roadside Assistance Cover Clause RSAMOAC014 Please select the plan Plan A Plan B
I have read the literature explaining the above covers and have opted for them after fully understanding its benefits
PREVIOUS HISTORY
1. Is the car in a roadworthy condition and free from damage? Yes No If ‘No’ please give details
If ‘No’ please give full details:__________________________________________________________________________________________________________________________
2. Will the vehicle be used exclusively for:
a. Private, social, domestic, pleasure & professional purposes Yes No_____________________________________________________________________
b. Carriage of goods other than samples or personal baggage Yes No_____________________________________________________________________

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 If ‘No’ please give details
3. Type of cover Liability only cover Package cover Others (specify)____________________________________________________________________________
4. Name and address of the previous insurer of own damage cover___________________________________________________________________________________________
5. Policy No.____________________________________________________ Policy period _______________________________________________________________________
6. Add on covers in previous policy_______________________________________________________________________________________________________________________
7. Name and address of previous insurer of Liability cover __________________________________________________________________________________________________
8. Policy No.____________________________________________________ Policy period ________________________________________________________________________
9. Has any insurance company ever: a) Declined the proposal Yes No b) Cancelled & refused to renew Yes No
(If ‘Yes’ reasons there of _______________________________________________________________________________________________________________________________
c) Imposed special condition or excess Yes No (If ‘Yes’ reasons and details there of)_____________________________________________________________

DECLARATION - NO CLAIM BONUS

Are you entitled to No Claim Bonus Yes No (If ‘Yes’ please submit proof from your previous insurer.)
I hereby declare that I have not made claim (or) I have made claim under my previous Policy No ______________________________ issued by
_____________________________________________________________. I/We declare that the rate of NCB of________% claimed by me/us is correct and that
no claim has arisen in the expiring policy period (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.
Does the vehicle have valid Pollution Under Control (PUC) Certificate? Yes No*
PUCC Number:_______________________________________________ PUCC Expiry Date: D D M M Y Y Y Y
*"In line with the Central Motor Vehicle Act, 1989 and as per the directive of Hon'ble Supreme Court of India, it is mandated that insured must produce a valid "Pollution Under control" Certificate as and when
asked by the insurer and it is the responsibility of the insured to renew the same before expiry of the validity of the PUC certificate. Absence of Valid certificate may lead to cancellation of insurance"

PAYMENT DETAILS: Please tick (√) payment option

Cheque/DD Number Credit Card Debit Card Payzaap Paytm Bill Desk

Bank
NEFT RS Account No Transaction Ref No
Date D D M M Y Y Amount__________________________________ Cash Amount__________________________________
*Payment must be made favouring Royal Sundaram General Insurance Co. Limited

Authorization for electronic policy fulfilment and service communications (Please read carefully and put a check mark against each before signing)
I hereby consent that the proposal status, policy details and renewal reminders may be sent to me by email and SMS .
I hereby consent to and authorize Royal Sundaram General Insurance Co. Limited (Company) to make welcome calls, service calls or any other communication (electronic or
otherwise) with respect to the proposed or existing policy of Company from time to time.

PREMIUM COMPUTATION SUMMARY

Basic OD Premium Basic TP
Other OD Covers Other TP Covers
Total TP Premium
NCB % Total OD +TP Premium
Add on premium GST
Total OD Premium Premium inclusive of GST

COMPULSORY DEDUCTIBLE
The Policy excludes the first portion of each claim for loss or damage to the Motor Car. The amount of the Deductible is `1,000/- for cars with cubic capacity not exceeding 1500cc and `2,000/- for cars with cubic
capacity exceeding 1500cc.
ABOUT OUR POLICY
Usage of the car : The Policy covers use of the car for social, domestic and pleasure purposes and also for professional purposes of the Insured or use by the Insured’s employees for such purposes. The Policy does
not cover use for hire or reward, racing, pace making, reliability trial, speed testing, the carriage of goods (other than samples) in connection with professional purpose or use for any purpose in connection with
the Motor Trade.
DECLARATION
Before signing the Declaration check your answers carefully, particularly if this Proposal Form was completed by another person on your behalf. I/we declare that to the best of my/our knowledge and belief the
answers given are true and all material information has been disclosed. I/we agree that if any answers have been completed by any other person such person shall for that purpose be regarded as my/our agent and
acting on my/our behalf and not the agent of Royal Sundaram General Insurance Co. Limited.
I/we declare that this Proposal Form is for insurance in the normal terms and conditions of the Insurer’s Policy and shall be incorporated in and form part of the insurance contract. 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 agree to download the policy terms, conditions, exceptions and
applicable endorsements by logging on to the website www.royalsundaram.in (or) mail to [email protected] to obtain a hard copy of the same.
I / We have read and understood the Privacy Policy of your Company at https://www.royalsundaram.in and I hereby unconditionally agree and bind myself to all terms and conditions of your Privacy Policy, as
amended, from time to time.
I/we hereby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been/will be paid out of proceeds of crime related to any of the offence listed in Prevention of
Money Laundering Act, 2002.
I understand that the Company has the right to call for any documents to establish sources of funds.
The insurance company has right to cancel the insurance contract in case I am/have been found guilty by any competent court of law under any of the statutes, directly or indirectly governing the prevention of
money laundering in India

Date :

Place : Signature of the proposer (Vehicle Owner)

Section - 41 of Insurance Act, 1938 Prohibition of Rebates

1. No person shall allow or offer to allow either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India any rebate of the
whole or part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or continuing the policy accept any rebate except such rebate as may be allowed in accordance with the
published 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.
Insurance is the subject matter of solicitation.

Royal Sundaram General Insurance Co. Limited

(Formerly known as Royal Sundaram Alliance Insurance Company Limited)
Corporate Office: Vishranthi Melaram Towers, No. 2 / 319, Rajiv Gandhi Salai (OMR), Karapakkam, Chennai - 600097. Registered Office: 21, Patullos Road, Chennai - 600 002.
Royal Sundaram IRDAI Registration No.102 | CIN:U67200TN2000PLC045611
1860 425 0000 | 1860 258 0000 [email protected] www.royalsundaram.in
PR22005/NOV22/V2
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