LIBERTY GENERAL INSURANCE LIMITED

PRIVATE CAR PACKAGE POLICY

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
IMPORTANT 1)The Validity of this Certificate of Insurance cum Schedule is subject to realization 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) In the event of misrepresentation, fraud or non-disclosure of material facts, the company reserves the right to cancel the policy from inception.
Policy issuing office :10TH FLOOR, TOWER A, PENINSULA BUSINESS PARK, GANPATRAO KADAM MARG,LOWER PAREL, MUMBAI, MAHARASHTRA-400013
Phone:+91 22 67001300 Fax: +91 22 06700 1606
Policy Servicing office :6-3-885/7, 3RD Floor, Sapphire Square,, Rajiv Gandhi Circle,Somajiguda,, , SOMAJIGUDA, HYDERABAD,TELANGANA-500082 PH:
+91 40 8655914119 Fax:
PolicyRef No. 201150010124702952200000 Period of Insurance From 00:00 Hrs of 03/09/2024 To Midnight of 02/09/2025
Geographical Area India
Insured CHAMUNDESWARI KAMAKSHI SIKHA Policy Issued on 14/08/2024
Address E504, OLYMPUS, SMR VINAY ICONIA, Covernote No 201150010124702952200000
MASJID BANDA ROAD, KONDAPUR,11 14
262 1 2 3 607 D MANJEERA HEIGHTS 2
CHITRA LAYOUT LB
NAGARHYDERABAD,TELANGANA,K.V.RA
NGAREDDY,Kondapur-500084
Contact Number (M) +9676764433 ECovernote Date 14/08/2024
Customer GSTIN
UIN CODES: IRDAN150RP0035V02201213 RTO Location RANGAREDDY Zone: Zone B
POSP Name
Aadhar Card
PAN Number
Agent Name D2C INSURANCE BROKING PRIVATE LIMITED
Agent Code IMD1012876 Agent Contact No 9810797219

INSURED MOTOR VEHICLE DETAILS AND PREMIUM COMPUTATION

Registration Year of Engine No. Chassis No. Make/Model/ Type of Body CC/HP/GVW Licensed Trailer Trailer
Mark & No. Manufacture/ Date Type of /KW Carrying capacity Registration Chassis No.
of Registration/ Vehicle including Driver No.
Invoice Date
TS-07-FT- 2017/07-09-2017/07-09- MAKGK785H HONDA/JAZZ/
L12B42035092 Hatch Back 1199.00 5 NA NA
2660 2017 H4112202 1.2 V CVT
IDV (INSURED’S DECLARED VALUE)
IDV Of Vehicle ` Trailers ` Non Electrical Accessories ` Electrical & Electronics Accessories ` Bi-Fuel kit(CNG/LPG) ` Total Value `
338,000.00 0 0 0 0.00 338,000.00
Own Damage Premium on Vehicle and accessories Section II - LIABILITY (B)
Section I - OWN DAMAGE (A) Third Party Premium
Basic Cover
`
Basic Cover
Basic OD 1,698.96
Basic TP ` 3,416.00
DISCOUNTS UNDER OWN DAMAGE SECTION
No claim bonus 25% ` 424.74 PA BENEFITS
TOTAL OWN­DAMAGE PREMIUM (A) ` 1,274.22 LEGAL LIABILITY
Section I ­ ADD ON COVERS (C) LLTo Paid Driver ` 50.00

Passenger Assist IRDAN150RP0035V02201213/A0020V02201213 ` 250.00 TOTAL LIABILITY PREMIUM (B) ` 3,466.00

Consumables Cover IRDAN150RP0035V02201213/A0015V02201213 ` 439.40 Section III - PA OWNER DRIVER (D)

Depreciation Cover IRDAN150RP0035V02201213/A0012V02201213 ` 3,042.00
PA to Owner Driver (D) ` 375.00
Liberty Complete Assistance(Plan A)(IRDAN150RP0035V01201213/A0008 ` 249.00
Net Premium (A+B+C+D)Taxable Value ` 10,985.00
Key Loss Cover (SI 10000 /-) IRDAN150RP0035V02201213/A0010V02201314 ` 199.00
State Cess ` 0.00
Engine Safe Cover IRDAN150RP0035V02201213/A0011V02201314 ` 1690.00
CGST(TELANGANA)(9%) ` 988.65
TOTAL ADD­ON COVER PREMIUM (C) ` 5,869.40
SGST(TELANGANA)(9%) ` 988.65

TOTAL POLICY PREMIUM ` 12,962.00

Hire Purchase/Lease/Hypothecated with :NA

LIMITATIONS AS TO USE -The Policy covers use of vehicle for any purpose other than: a) Hire or Reward b) Carriage of goods(other than sample of personal luggage)
c) Organized racing d) Pace Making e) Speed Testing f) Reliability Trial g) Use in connection with motor trade.
DRIVERS CLAUSE
Persons or Classes of Person entitled to drive: Any person including the insured provided that a person driving holds an effective driving license at the time of the accident
and is not disqualified from holding or obtaining such a license.Provided also that the person holding an effective learner's license may also drive the vehicle and that such
a person satisfies the requirements of Rule 3 of the Central Motor Vehicle Rules, 1989.
LIMITS OF LIABILITY
Deductible under Compulsory Deductible: Under Section II-I(i) Such amount necessary to Under Section II-I(ii) of 7,50,000.00 P.A. cover for owner- 15,00,000.00
section - I Rs 1000/- Voluntary of the policy(Death of meet the requirements of the policy(Damage to Driver under section-
Excess: Rs: 0/. Imposed or bodily injury): motor vehicle Act,1988. third party property) III: CSI
Excess : Rs 0/.
Subject to I.M.T Endorsement Nos. IMT 22, IMT 28, AD 01, AD 02, AD 04, AD 06, AD 07, AD 21
Passenger assist cover details:Hospital Cash: Rs 1500 per day for 30 days (per Pax.), Medical Expenses: Rs 10,000 (per Pax.), Ambulance Charges: Rs. 5000
NOMINATION DETAILS
Name of the Nominee Relationship with Insured Name of Appointee (if nominee is minor) Relationship with the Nominee
NA NA NA NA
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.
In witness whereof this Policy has been signed at Mumbai on 14/08/2024
Receipt No: CR202414089400
Invoice No: For Liberty General Insurance Limited
In case of claim ,Please contact us at : Toll Free No -18002665844,
Email id – [email protected] IRDA Registration No. 150
Insurance is the subject matter of solicitation;CIN No. U66000MH2010PLC209656
Date of Issue :14/08/2024
Place: HYDERABAD
Stamp duty for the said policy is paid vide GRASS DEFACE no.0004656521201617, Dt. 10/02/2017
as prescribed in Government Notification Revenue & Forest Department no. Mudrank
2004/4125/CR/690/M-1, Dt 31/12/2004.
LGI Branch GSTIN :36AABCL9950A1ZM
SAC Code:997134 Description of Service:General Insurance Service
Place of Supply : TELANGANA
Tax is not payable under reverse charge by the recipient. Authorised Signatory
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.

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313 292 m
313 404 325 453 432 529 c
478 561 504 597 504 645 c
504 736 440 760 391 760 c
286 760 271 681 265 626 c
265 625 l
100 625 l
100 828 253 898 381 898 c
451 898 679 878 679 650 c
679 555 628 499 538 435 c
488 399 467 376 467 292 c
313 292 l
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287 318 m
287 430 299 479 406 555 c
451 587 478 623 478 671 c
478 762 414 786 365 786 c
260 786 245 707 239 652 c
239 651 l
74 651 l
74 854 227 924 355 924 c
425 924 653 904 653 676 c
653 581 602 525 512 461 c
462 425 441 402 441 318 c
287 318 l
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B
Q

Digitally signed by: SACHIN JOSHI

Date: 2024-08-14 17:59:19 IST
Location: Mumbai
 Liberty General Insurance Limited
10th Floor , Tower A , Peninsula Business Park,
Ganpatrao Kadam Marg ,Lower Parel,Mumbai-400 013
Phone: +91 226700 1313 Fax:+91 22 6700 1606
Email:[email protected]
IRDA of India registration number : 150 .CIN : U66000MH2010PLC209656
PRODUCT UIN CODE: IRDAN150RP0035V02201213

PROPOSAL FORM PRIVATE CAR PACKAGE POLICY

Proposal for : o New Vehicle þ Rollover o Endorsement o Renewal (LGI Policy No.)
Note: 1) Please Complete the proposal form in BLOCK LETTERS and tick boxes whichever applicable
2) Attach additional sheets if space given is insufficient
3) The queries made/details stated below are the minimum requirements to be furnished by a proposer.(The Company may seek any other information a desired for underwriting purpose.)

Intermediary Details
IMD Name D2C INSURANCE BROKING PRIVATE LIMITED IMD Code: IMD1012876
Branch Name: HYDERABAD Branch Code: 500101
SM Name : SM Code : N1660610
Contact No: 9810797219
POSP Name : POSP Code :
PAN Card Number : or Aadhar Card No.:
(Mandatory to provide PAN Card No. or Aadhar Card No. in case of POSP)
Type of Cover : þ Package (Comprehensive) Policy for 1 year o Package (Comprehensive) Policy for 3 years o Bundled Cover (1year Own Damage & 3 years Third Party)
Vehicle Details
Year of
Manufacture Gross Vehicle Weight (GVW) Seating Capacity/LCC (Including
Vehicle Make Model Variant Cubic Capacity/KW Body Type
/ Invoice For Goods carrying Vehicle Driver/Cleaner)
Date
HONDA JAZZ 1.2 V CVT 2017/07-09- 1199.00 o 5 Hatch Back
2017

Insured Declared Value

Electrical Value of CNG/LPG kit
Year For Vehicle Rs. Non Electrical Accessories Trailer/Side Car (if any) Total IDV Rs.
Accessories (if not part of standard vehicle)
1 338000.00 0.00 0.00 0.00 0.00 338000.00

“Add On Covers” Selected: þ Depreciation Cover þ Consumable Cover þ Passenger Assist Cover o Road Side Assistance Cover þ Engine Safe Cover
þ Key Loss Cover o GAP(Incl. Taxes & Regn. charges) o GAP Value o Towing Expenses Cover
o EMI Cover Protection o Tyre Protection Cover þ Liberty Complete Assistance (Plan A)
UIN Code of Add On covers selected : IRDAN150RP0035V02201213/A0012V02201213,IRDAN150RP0035V02201213/A0015V02201213,IRDAN150RP0035V02201213/A0020V02201213,IRDAN150
RP0035V02201213/A0011V02201314,IRDAN150RP0035V02201213/A0010V02201314IRDAN150RP0035V01201213/A0008V01202223
Invoice Price Value Road Tax First time Registration Charges
Whether you have opted for any Add on Coverage’s last year. þ Yes o No
If yes, please specify the Add on Coverage’s NilDepreciationEngine Safe Cover,
Vehicle Registration No. TS-07-FT-2660 Colour of Vehicle :
Engine No. L12B42035092 Chassis No MAKGK785HH4112202
Place of Registration RANGAREDDY Date of Registration 07/ 09/ 2017

Trailer Chassis No. (if any) Vehicle type þ Indigenous o Imported Rated under: o Zone A þ Zone B
Is the vehicle attached with any of the Fleet? o Yes o No No. of vehicles attached with fleet Cubic Capacity : 1199.00
Is the vehicle made in India? þ Yes o No

Trade Logo displayed above belongs to Liberty Mutual and used by the Liberty General Insurance Ltd.
Financier Details : o Hypothecation Agreement o Hire Purchase o Lease Agreement Body Type :
Name of Financier & Address :
Name of Insured: (Mr/Mrs/M/s/Dr) CHAMUNDESWARI KAMAKSHI SIKHA
e-Insurance Accout Number : I would like to open e-Insurance account with Insurance Repository
(Mandatory to provide PAN card No.in case customer wishes to open E-Insurance Account.)
Name of Contact Person : (For Corporate)
Communication Address : E504, OLYMPUS, SMR VINAY ICONIA, MASJID BANDA ROAD, KONDAPUR11 14 262 1 2 3 607 D MANJEERA HEIGHTS 2 CHITRA LAYOUT LB NAGARHYDERABAD
Area/Landmark: State : TELANGANA City / District : K.V.RANGAREDDY Pin Code : 500084
Contact Details: Mobile No. : 9676764433 Residence:
Office : Email ID: [email protected] PAN No. BGTPS1955C

Date of Birth : 15/ 08/ 1973 Business/Occupation (For Individual Customer)

Aadhar No. :

Insurance is the Subject matter of Solictation.

Registration Address: E504, OLYMPUS, SMR VINAY ICONIA, MASJID BANDA ROAD, KONDAPUR 11 14 262 1 2 3 607 D MANJEERA HEIGHTS 2 CHITRA LAYOUT LB NAGARHYDERABAD

Any other details :

Period of Insurance for Package Policy of 1 year & 3 years :
From Time : 00:00 Date : 03/ 09/ 2024 To the Midnight of Date : 02/ 09/ 2025

Personal accident Cover for Owner Driver is compulsory in liability only Cover. Please give details of nomination:
Particulars Name of Passenger Name of Nominee/ Name of New Nominee Age Relationship Name of Appointee Relationship with the
Existing Nominee (In case of change of existing Nominee) (If Nominee is a minor) nominee
For PA to owner Driver NA NA NA NA NA
For PA to Named Passenger
(In case of more than 1 named passengers, please provide details in the above format on a separate sheet)

Note . Personal Accident Cover for Owner Driver is compulsory for Sum Insured of Rs 15,00,000/- for Private Car • Compulsory PA cover to Owner Driver cannot be granted where a vehicle owned
by a company, a partnership firm or a similar body corporate or where the owner driver does not hold an effective driving license.
or classes of Person entitled to drive: Please refer overleaf. Any Limitations as to use of Motor vehicle: Please refer overleaf.
In the event of dishonor of Cheque(s), insurance cover provided under this document automatically stands cancelled from inception irrespective of whether a separate communication is sent or not.

Premium Payment Details o Cash o Cheque o Demand Draft þ Credit Card Insured Bank Details:
o NEFT/RTGS
Premium Amount (including service tax): 12962.00 Bank Name and Branch
Cheque / DD No: NA Bank A/C No.:
Cheque / DD Date: NA IFSC Code
In case the annualized premium is more than Rs. 25000/-, the proposer is requested to provide a cancelled cheque of his/her bank account if the premium is not paid from the same

Electrical Accessories:
Item Details: Make & Model: Year of Manf.: IDV

Details of Non-Electrical Accessories:

Item Details: Make & Model: Year of Manf.: 2017 IDV

Call Toll Free No: 1800 266 5844 www.libertyinsurance.in

 Liberty General Insurance Limited
10th Floor , Tower A , Peninsula Business Park,
Ganpatrao Kadam Marg ,Lower Parel,Mumbai-400 013
Phone: +91 226700 1313 Fax:+91 22 6700 1606
Email:[email protected]
IRDA of India registration number : 150 .CIN : U66000MH2010PLC209656

(Note: The Motor Vhicle Act - 1988 under Sec. 147(1)(ii)(I)cover liability to employees who are
PRODUCT UIN CODE: IRDAN150RP0035V02201213 UIN: IRDAN150RP0035V02201213/A0012V02201213,IRDAN150RP0035V02201213/A0015V02201213,IRDAN150RP0035V02201213/A0020V02201213,IRDAN150RP0035V02201213/A0011V02201314,IRDAN150RP0035V02201213/A0010V02201314

Details of Vehicle Type and Usage

1. Fuel Type of the vehicle þ Petrol o Diesel o Any Other workmen within the meaning of Workmen Compensation Act - 1923.)
2 Whether the Vehicle driven by Non-Conventional source of Power o Yes þ No If yes please 8. Coverage for liability against Third Party Risks (Death or Bodily Injury) required in respect of

give details o Bi-fuel o CNG o LPG o Externally Fitted o Manufactured Fitted o Owner Driver only o Any person other than Paid Driver
If ‘YES’, give details of such other persons:
3 Will the vehicle be exclusively used for: a) Private, Social, Pleasure and Professional Purposes
Non fare Paying Passengers (No. of persons:
o Yes þ No b) Carriage of goods other than Samples or Personal Luggage
Note: 1. Section146 of Motor Vehicles Act-1988 makes it mandatory for the owner of the
o Yes þ No
vehicle to ensure that he or any other person authorized by him to drive a vehicle in public
4. Whether the vehicle is used for Commercial purposes? o Yes þ No
place has insurance against third party risks. The explanation to Section146 exempts the
5. Whether the vehicle is used for Driving tuitions ? o Yes þ No paid driver.) 2. As per Section 147 (2)(a) The liability is ‘as incurred’ in the case of
6 Whether the vehicle is limited to own premises? o Yes þ No death / bodily injury of a third party)
7 Whether the vehicle is specially designed for use of Blind/Handicapped/ Mentally Challenged Person Any other Coverage details
o Yes þ No If so, whether the same is endorsed as such by RTA?
o Yes þ No Break in Insurance Declaration
8. Whether the vehicle is certified as Vintage Car by Vintage & Classic Car Club of India ? “I/We hereby Declare and Undertake
o*That, the vehicle proposed to be insured had, during the period in which it was not covered by valid
o Yes þ No and effective insurance policy issued by any insurer/s, met with an accident on _________at________
9. Whether the rally cover is required? o Yes þ No Add more date/s with time if vehicle had metwith an accident more than once)
o *That, the vehicle proposed to be insured had, during the period in which it was not covered by valid
10. Whether the vehicle is fitted with Fiber Glass Tank? o Yes þ No
and effective insurance policy issued by any insurer/s, had NOT met with anyaccident
11. Whether the vehicle belongs to the Embassy/Consulate of a foreign country?
o Yes þ No If so, is the Duty element is included in the IDV? o yes o No (*Select the appropriate check box and provide relevant information against selectedentry)
I/we understand that all and/or any kind of liabilities arising out of accident/s which had occurred prior to
12. Whether insured is first registered owner of the vehicle? o Yes o No risk inception date and time as mentioned in the Policy Document issued by Liberty General Insurance
Limited in consideration of these presents will be completely out of ambit of said Policy and said
Previous Insurance Details Company will not be in any manner liable or held responsible therefore.
Name and Address of Previous Insurer ICICI Lombard
Policy/Covernote no. 3001/HA-100757636/00/000 I/we further undertake that if this declaration and/or any of its part is found to be incorrect in any manner,
all the benefits under the Policy will then stand forfeited and the contract of nsurance will be treated as
Type of Covers: þ Package (Comprehensive) Policy o Act only Policy o Bundle Policy void ab-initio”.
o Long Term Policy o SAOD Policy o Others NCB Declaration
NCB*/loading in expiring policy 20 % I / We declare that the rate of NCB claimed by me/us is correct and that no claim as arisen in the
Claim lodged in last three years: expiring policy period (copy of the policy enclosed) I/We further undertake that if this declaration
is found to be incorrect, all benefits under policy respect of Section I of the policy will forfeited.
Year Expiring Year (1) Expiring Year (2) Expiring Year (3)
No.of Claims: Declaration
Claim amount “I am/we are aware that the complete terms and conditions of this insurance policy are
available at the official website of the insurer (www.libertyinsurance.in). I/We hereby consent to
1. Date of purchase of the vehicle by the Proposer: 07/ 09/ 2017
receiving only the certificate and schedule of insurance upon the undertaking of the insurer that
2. Whether the vehicle was new or second hand at the time of purchase? the complete policy terms n conditions will made available free of cost upon my/our request”.
I hereby declare and confirm that the PUC certificate of the vehicle proposed for insurance is valid
o New o Second Hand
as on date.
3. Is vehicle in good condition? o Yes o No if No, Please Give details
Any other Material Information Declaration and Consent
4. Has any insurer ever declined/cancelled the insurance of the proposed vehicle?
I/We hereby declare that the statements, answers given by me /us in this proposal form aretrue to the
o Yes o No best of my knowledge and belief and I/We hereby agree that this declaration shall form the basis of the
5. Policy Period; From 03/ 09/ 2023 To 02/ 09/ 2024 contract between me/us and the Liberty General Insurance Ltd. It is hereby understood and agreed that
the statements, answersand particulars provided herein above are the basis on which this insurance is
Are you entitled for No Claim Bonus on Renewal ? þ Yes o No being granted and that if, after the insurance is effected, it is found that any of the statements, answers or
* If yes, Please mention the 25 % particulars are incorrect or untrue in any respect, the company shall have no liability under this Insurance.
6 Is the vehicle fitted with Anti - Theft Device which is approved by ARAI? o Yes þ No I/We agree and undertake to convey to Liberty General Insurance Limited any change / alterations
If answer of the above question is Yes, Please submit the certificate for the same. carried out in the risk proposed for insurance after submission of this proposal form.

Trade Logo displayed above belongs to Liberty Mutual and used by the Liberty General Insurance Ltd.
7. Are you a member of the Automobile Association of India? o Yes þ No “I/We have insurable interest in the subject matter of this insurance and we hereby declare that the Cost
If Yes, Please state of the same and the premium for this insurance is paid from legal sources of funds.
Name of Assocition

Insurance is the Subject matter of Solictation.

I, the undersigned proposer hereby declare and confirm that I have understood the features, terms and
Membership No . Date of Expiry conditions of the policy and questions contained in the proposal form. I also understand that the answers
Driver’s Detail to the questions contained in the proposal form, forms the basis of the contract of insurance. If any
information/statement given in proposal is found to be untrue, the policy shall be treated as void ab initio
1. Does the owner has a valid driving licence? þ Yes o No and the premium paid shall be forfeited to the Company.
2. Vehicle is primarily driven by: þ Registered Owner o Any other
Please give details, if you are politically exposed person or relative of politically exposed person.
Name Relationship: Age Yrs
3 Does the driver suffer from defective vision or hearing or any physical infirmity? -------------------------------------------------------------------------------------------------------------------------------------------
Please give details, if you are no profit organization.
o Yes þ No Give details
4. Drivers Qualification: Driver's experience: -------------------------------------------------------------------------------------------------------------------------------------------
5. Age & Date of Birth of the Owner: Age Yrs Date of Birth: þ I hereby agree to receive a one pager policy document
b. Age & Date of Birth of the Driver: Age Yrs Date of Birth: o I hereby confirm having a valid personal accident policy for sum Insured of minimum Rs.15 lakhs.
6. Has the driver ever been involved / convicted for causing any accident of loss? o Yes þ No Prohibition of Rebates (Section 41) of the Insurance Act-1938
If YES, give details as under including the pending prosecutions: 1. No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to
Driver Name: 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
Date of Accident :
the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate except
Loss / Cost (Rs.): such rebate as may be allowed in accordance with the prospectus or tables of the Insurer.
Circumstances of Accident or Loss
2. Any person making default in complying with the provision/s of this section shall be punishable with
Inspection Details fine, as may be prescribed under Insurance Act, 1938 or any amendment thereto for the time being in
1. Does the vehicle stands fit for insurance? þ Yes o No o Self Inspection force.

2. Inspection Reference No.: For use by intermediary

Conducted on (Mention Date & Time): Cover Note No. issued (if any)
Period of Insurance for Package Policy of 1 year & 3 years :
Additional Coverage Details
From (Time) (Date)
Do you require PA cover for Paid Driver, Cleaners and Conductors? o Yes þ No
To the midnight of date
Do you wish to cover Geographical Area Extension under your proposed insurance?
Premium Amount (in Rs.)
o Bangladesh o Bhutan o Nepal o Sri Lanka o Maldives o Pakistan
Bank Name :
Voluntary excess:Do you wish to take the Voluntary excess over an above the compulsory
excess. If Yes please mention SI 0
Cheque No. / DD No. / Cash:
o RS.2,500 o RS.5000 o RS.7,500 o RS. 15,000
Date
Do you require Unnamed PA Cover o Yes þ No
1. No. of Passengers NA
Sum Insured per person (unnamed passengers/hirer/pillion rider, two wheelers)
Name Sum Insured Name Sum Insured
3. Do you wish to cover Legal liability towards
a) Driver/Cleaner/Conductor (No. of Persons 1) þ Yes o No For Office use only
b) Unnamed Passengers (No. of Persons 0) o Yes þ No Customer ID
c) Other employees (No. of Persons:0) o Yes þ No Proposal Number:
d) Soldier/Sailor/Airman employed as Driver o Yes o No Policy / Cover Note Number: 201150010124702952200000
4. Do you wish to have the statutory Third Party Property Damage (TPPD) liability of Proposal Checked By:
Rs. 6,000/- only? (IMT 20) o Yes þ No Date of Receipt:
5. Do you require PA cover for named persons? o Yes þ No
Name: CSI Nominee: Relationshp Date : Place:
6. The Policy provides additional Third Party Property Damage liability limits of Proposer Name : Proposer’s Sign :
Rs.1,00,000/- for Two Wheelers and Rs. 7,50,000/- for other classes of vehicles. Do you wish
to cover the additional limit? þ Yes o No

7. Legal liability to persons employed in connection with operation of the vehicle who are workmen’.The lia
bility of the Employer under the Workmens’ Compensation Act-1923 is covered under the Motor Vehicles
Act -1988 o Yes þ No
Drivers (No. of persons: ) Employees (Workmen) (No. of persons: )

V-24032015

*I am Environment friendly Customer :

Otp Status OTP Generated Date & Time:
Phone No : OTP Entered Date & Time:
Date :
________________________________
Signature

Call Toll Free No: 1800 266 5844 www.libertyinsurance.in