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: IRDAN149RP0001V02201213
PRIVATE CAR PACKAGE POLICY
Date : 05/11/2023

To,
V. ILANGOVAN
QTR NO. TYPE 3 B-01 ALHW COLONY JUNGLIGHAT, PORT BLAIR ,WEST BENGAL
SOUTH ANDAMAN
ANDAMAN AND NICOBAR ISLANDS 744101
Mobile:9474219574

Agent/ Intermediary Name and Code:POLICYBAZAAR INSURANCE BROKERS PRIVATE LIMITED BRC0000434

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. P0224000100/4101/742158, which has been issued based on the details furnished to us as below:

Insured & Vehicle Details

Name of Insured V. ILANGOVAN

Period of Insurance 06/11/2023 TO 05/11/2024

Vehicle Make/Model MARUTI / ZEN ESTILO VXI
RTO PORT BLAIR
Vehicle Registration No. AN 01 F 5 9 9 0
Vehicle Registration Date 28/10/2010
Engine No. K10BN4141696
Chassis No. MA3EMDE1S00320442
Reason for not opting PA Cover of Owner Driver :
1) Own multiple vehicles and have opted for PA to Owner Driver cover in the another vehicle insurance policy
Previous Policy Details
Previous Policy No P0123000100/4101/742158
Previous Policy Period 06/11/2022 TO 05/11/2023
Previous Year NCB% 45
Previous Insurer Name MAGMA HDI GENERAL INSURANCE CO. LTD.
Previous Policy Type Package

The information received from you is reproduced in the proposal attached with this Risk Assumption Letter and your proposal has been processed accordingly.
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.
Dear Customer , Magma HDI general Insurance Company may be storing your AML/KYC details and might require you to update the information submitted from
time-to-time, in accordance with and requirements under the Master Guidelines on Anti-Money Laundering/ Counter Financing of Terrorism (AML/CFT), 2022
issued by the Insurance Regulatory Development Authority of India.

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: IRDAN149RP0001V02201213

PRIVATE CAR PACKAGE POLICY

CERTIFICATE OF INSURANCE CUM SCHEDULE /TAX INVOICE
Policy Servicing Office 4TH FLOOR, ANUJ CHAMBER, 24 PARK STREET ,KOLKATA -700016 ,WEST BENGAL , PH: (1800) 2663202
Policy No P0224000100/4101/742158
E Policy no. P0022000100/4101/742158
Insured V. ILANGOVAN
Address QTR NO. TYPE 3 B-01 ALHW COLONY JUNGLIGHAT, PORT
Period Of Insurance 00:00 Hrs of 06/11/2023
BLAIR ,WEST BENGAL
To Midnight of 05/11/2024
SOUTH ANDAMAN
Agent No.: BRC0000434
ANDAMAN AND NICOBAR ISLANDS 744101
Toll Free No.: 9314070708
Mobile:9474219574
Contact Number 9474219574
Email ID: [email protected]
GST Number Unregistered
INSURED MOTOR VEHICLE DETAILS AND PREMIUM COMPUTATION
Year of
Registration No. & RTA Location Engine No. Chassis No. Make/Model/Type of Body CUBIC CAPACITY SEATING CAPACITY
Manufacture
AN 01 F 5990 / PORT BLAIR 2010 K10BN4141696 MA3EMDE1S00320442 MARUTI ZEN ESTILO VXI/SALOON 998 5
IDV (INSURED'S DECLARED VALUE)
IDV of Vehicle Non Electrical Accessories Electrical/electronic Accessories Bi-Fuel kit(LPG/CNG) Other accessories Total Value
76506 0 0 0/0 0 76506
OWN DAMAGE(A) LIABILITY(B)
Basic - OD 470.90 Basic - TP 2,094.00
Sub Total 470.90 Sub Total 2,094.00
Less:
No claim bonus 50% 235.45
Sub-Total Deductions 235.45
Total Own Damage Premium(A) 235.00

Total Liability Premium(B) 2,094.00

Premium Computation
Total Package Premium(A+B) 2,329.00
IGST @ 18% 419.22
TOTAL 2,748.00

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)Use in connection with Motor Trade
Driver
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
Clause
holding an effective Learner's license may also drive the vehicle and that such a person satisfies 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. 1000/- 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. 1000/- event.
Subject to I.M.T Endorsement Nos. IMT 22
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.

Date of Signature of proposal 05/11/2023

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/200002/24/100608658- 05/11/2023 , 2748
Premium Amount in Word's ( ) :- Two Thousand Seven Hundred Forty-Eight Only
In case of Claims, please contact us at 1800 266 3202 For Magma HDI General Insurance Co. Ltd.

Date of Issue : 05/11/2023

Place : Kolkata

Consolidated Stamp Duty on the issue of General Insurance Policies Paid vide G.O No. 834, dated 18.05.2023 Authorised Signatory
GST Number of MHDI 19AAGCM1685C1ZG
GST Invoice Number - POL3510220000006
Accounting Code for Service - 997134, Motor vehicle insurance services

Previous GST Invoice No. -POL3510220000006

Place of Supply:ANDAMAN AND NICOBAR ISLANDS ( 35 )

Whether Tax is payable on Reverse Charge - No

UIN : IRDAN149RP0001V02201213
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.

As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 31st October of the next financial year.
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.
4) For detailed terms & conditions please refer our website www.magmahdi.com
 Magma HDI General Insurance Company Limited
Toll Free Number 1800-266-3202
Website - www.magmahdi.com

Policy Issuing Office KHODAL CHAMBERS, 2ND Policy Servicing Office 4TH FLOOR, ANUJ CHAMBER, 24
FLOOR, UNIT 203 & 204 R B PARK
MEHTA MARGNR. DHANJI DEVSHI STREET ,KOLKATA -700016 ,WEST
MUNICIPAL SCHOOL, BENGAL , PH: (1800) 2663202
GHATKOPAR (E)MUMBAI,
MAHARASHTRA, 400077
Policy Number P0224000100/4101/742158 Product Name PRIVATE CAR PACKAGE POLICY
Start Date & Time 06/11/2023 00:00 Expiry Date & Time 05/11/2024 23:59
Agent Name POLICYBAZAAR INSURANCE Agent Contact Number 9314070708
BROKERS PRIVATE LIMITED
Policy Holder Name V. ILANGOVAN Hypothecation
Address of Insured Person QTR NO. TYPE 3 B-01 ALHW COLONY JUNGLIGHAT, PORT BLAIR ,WEST BENGAL
SOUTH ANDAMAN
ANDAMAN AND NICOBAR ISLANDS 744101
Mobile:9474219574

Vehicle Detail
Vehicle RTO Manufacturer Model Variant Registration NoEngine Number Chassis Number Insured
Location Declare Value
PORT BLAIR MARUTI ZEN ESTILO VXI AN 01 F 5990 K10BN4141696 MA3EMDE1S0032044276506

Add on Cover:

Premium Details
Net Premium (Rs.) 2329
GST @ 18% (Rs.) 0
GST @ 18% (Rs.) 0
Total Premium (Rs.) 2748

Renew Your Policy on 06/11/2024 through

Our website:www.magmahdi.com
Email: [email protected]
Call us at: 1800 266 3202

How do you intimate an intimate claim?

Call us at: 1800 266 3202
 We at MAGMA HDI prefer receiving premium amount through cheque
No. Pvt./202311050061746

Call Us : 1800 266 3202

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

Proposal Form for PRIVATE CAR PACKAGE POLICY
Customer ID 20006533905
*Proposal For: New Policy Roll- Over Renewal Endorsement
*Type of Vehicle : Two Wheeler Private Car Three Wheeler *Vehicle Insured is: New Used
*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

Intermediary Code: BRC0000434 Intermediary Name: POLICYBAZAAR INSURANCE BROKERS PRIVATE LIMITED

* Period of Insurance: 06/11/2023 Time: 00:00 ,To Midnight of 05/11/2024

(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)

1. *Proposer Details:
1. Name (Registered Owner of the Vehicle): V. ILANGOVAN

PAN No: *DOB: 10/05/1963 *Gender: M F *Occupation: *Marital Status:

Bank Name Branch Name A/c Type- Saving Current
Account No. MICR IFSC
2. *Address where Vehicle Registered and Based
QTR NO. TYPE 3 B-01 ALHW COLONY JUNGLIGHAT, PORT BLAIR ,WEST BENGAL, SOUTH ANDAMAN, ANDAMAN AND NICOBAR ISLANDS 744101, 9474219574, [email protected] ,Mobile:9474219574 Whatsapp
Number:9474219574 Would you like to opt for Whatsapp notification
GST Number Unregistered
3. *Communication Address (For policy dispatch)
HOUSE NO. 17/20, J.N. ROAD, SOUTH ANDAMAN, ANDAMAN AND NICOBAR ISLANDS 744101
GST Number Unregistered
4. City where the vehicle will primarily be used: SOUTH ANDAMAN
5. Have you been previously insured in respect of this vehicle? Yes No Policy No. P0123000100/4101/742158

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
*Make MARUTI *Chassis No MA3EMDE1S00320442 Speedometer reading as on date
*Model ZEN ESTILO VXI RTO where vehicle will be registered PORT BLAIR *Vehicle IDV 76506
*Year of Manufacture OCTOBER - 2010 Date of Registration /Purchase 28/10/2010 Trailer(s) Identification No. 1_________
*CC/GVW 998 Licensed Carrying Capacity 5 2_________
(No of Passengers Including driver)
*Registration No. AN 01 F 5990 3_________
Type of Body SALOON Colour of the vehicle 4_________
*Engine No. K10BN4141696 Vehicle Make (Indigenous or Imported) ZEN ESTILO VXI
Note: Either Registration no or Engine and Chassis Number is mandatory
*Vehicle Rate Under: Zone -A Zone -B
*Fuel Used: Petrol Diesel Bi Fuel LPG/CNG Electric Hybrid Others (please specify)
*Type of Permit: Express Way National/State Highways City/Town Road District Roads Private Road
* Average Monthly usage : Less Than 50 Kms Between 50 and 100 Kms Between 101 and 250 Above 251 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 ................
Where will the vehicle be generally parked?

Roadside Public Parking Road Outside Parking lot open or covered Within compound of residence open

Within compound of residence covered

7. Financier Details: Hypothecation Hire Purchase Lease Financier Name :

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 76506
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 Yes No Is the vehicle Company Yes No
driving license) Maintained?

Multiple Vehicles Driver has existing PA cover of Rs 15

Not Having Valid Driving
lakhs
License
Will the vehicle be let out on occasional Hire? Yes No

Whether the vehicle is certified as Vintage Car by Yes No

Vintage and Classic Car Club of India ?
Vehicle used for commercial purposes: Yes No
Yes No Do you wish to include Personal Accident cover for unnamed occupants of the vehicle in excess of the compulsory
Do you want to opt for wider legal liability to Paid Driver Personal Accident cover for the Owner/Driver?

Yes No

Other employees Yes No Sum Insured per person to be Rs 0

(If Yes, No. of persons tobe covered.........) Nominee Details : Name _________________

Do you want to cover loss of accessories due Age _______________ Relationship _______________
to burglary, If yes, please indicate the Sum-Insured per person (In multiples of Rs.10000/- for a maximum of Rs.1 lakh per person
Yes No for Two Wheelers and Rs. 2 lakhs per person for Private Cars. The number of persons to be covered for the purpose of
housebreaking or theft?
this Add-on will be equivalent to the registered carrying capacity of the vehicle)
(Applicable only for Two-Wheelers)

Do you wish to have an enhanced Personal Do you wish to cover Hospital Cash for hospitalisation arising out of accident for Yourself/Your Driver/Unnamed
accident cover for Yourself/ occupants of the vehicle?
Your Driver/Unnamed occupants of the
Yes No Yes No
vehicle?

If Yes, please provide the Sum Insured per

person............
Do you wish to include Personal Accident cover for named persons? Yes No

If YES, give name and Capital Sum Insured (CSI) opted for :

Name CSI Opted (Rs.) Nominee Nominee Age/DOB Relationship

1)
2)
3)

(Note : The maximum CSI available per person is Rs. 2 lakhs in case of Private Cars and Rs.1 Lakh in the case of motorized Two wheeler)
11. Add On Coverage at additional :

12. Restrictions of Cover/ Discounts:

Is the vehicle designed for use of Blind / Handicapped/Mentally challenged persons and duly endorsed as such by RTA ?
Vehicle fitted with Anti-theft device approved by ARAI : Yes No
Yes No
Vehicle will be used within own premises : Yes No
Are you a member of Automobile Association of India? Yes No
Third Party Property Damage cover restricted to 6000 Yes No If yes, please state
(Third Party Property Damage cover of Rs 1 lakh for 2 wheelers and Rs 7.5 lakhs for Private cars) a. Name of Association
b. Membership No. c. Date of expiry
*Voluntary Deductible :
Private Car : None 2,500/- 5,000/- 7,500/- 15,000/-

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: MAGMA Type of cover: Package
Policy/ Cover note number: P0123000100/4101/742158 Period of Insurance: From 06/11/2022 To 05/11/2023
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): 2,748.00 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 wish to get all policy related communications on My Whatsapp Number:9474219574 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: 05/11/2023 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.