Mrs. Aruna Santhanam Door No-70, 2Nd Floor, Re Apartment Arya Gowdar Road Opp Axis Bank Atm Chennai Chennai TAMIL NADU India - 600094 9841

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Mrs. ARUNA SANTHANAM

DOOR NO-70, 2ND FLOOR, RE APARTMENT
ARYA GOWDAR ROAD OPP AXIS BANK ATM
CHENNAI
CHENNAI
TAMIL NADU India - 600094
9841******
Welcome on board.
Your Reliance Two Wheeler Package Policy -
Policy Schedule, with Policy
Number 120322423120149795 is now live to
access your policy anytime, anywhere download
our Reliance Selfi App and enjoy a host of
special features.
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: IRDAN103RP0011V02100001. 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/2312/PS/VER. 1.0/310118.
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Digitally signed by Reliance
General Insurance
Company Limited
Date: 2024.10.23 12:09:54
Trejhara IST
Reliance Two Wheeler Package Policy - Policy Schedule

Important
1) The validity of this certificate of Insurance cum policy is subject to realization by the company of the premium cheque paid by the Insured.
2) Except as provided in GR 27 Rule (g) of Erstwhile Indian Motor Tariff (i.e. Sale of Vehicle), No NCB will be allowed when a policy is not renewed within 90 days of
its expiry.
Policy Number : 120322423120149795 Proposal/Covernote No: R23102406593

Insured Name : Mrs. ARUNA SANTHANAM Period of Insurance : From 00:00 Hrs on 28-Oct-2024 to Midnight of
27-Oct-2025
Communication Address & Place of Supply : Policy Issuing Branch :
DOOR NO-70, 2ND FLOOR, RE APARTMENT ARYA GOWDAR ROAD OPP H Block, 4th street, Door No 12, H 2035, 15th Main Road, Anna Nagar (West),
AXIS BANK ATM CHENNAI CHENNAI, TAMIL NADU, India, 600094. CHENNAI, TAMIL NADU, 600101.
Mobile No : 9841****** Tax Invoice No. & Date: R23102406593 & 2024-10-23 12:07:10.0
Email-ID : NA GSTIN/UIN & Place of Supply: TAMIL NADU
Insured's Blood Group :
Insured Vehicle Details
Registration No. TN09CE8563 Mfg. Month & Year JUN-2016
HERO MOTOCORP PLEASURE PLUS 110 CAST
Make / Model & Variant CC / HP / Watt 110
WHEEL
Engine No. / Chassis No. JF16EEGGF06391 / MBLJF16ENGGF02058 Seating Capacity Including Driver 2
Type of Body NA Total Premium ` 1344
RTO Location TAMIL NADU - Chennai West T Nagar IDV ` 17,748.00
Hypothecation/Lease NA
Insured Declared Value (IDV)

Vehicle IDV ` 17748 Non Electrical Accessories ` 0
Electrical / Electronic Accessories ` 0 Total IDV ` 17748
Premium Summary
Own Damage - Section I Amount (`) Liability - Section II Amount (`)
Basic OD including Add-on 111.38 Basic Liability (TPPD 2) 714.00
Total Basic Own Damage Premium 111.38 Less: Restricted Third Party Property Damage to
Less Rs 6000/-( IMT - 20) -50.00
Deduct 50 % for NCB -55.69 Total Basic Liability Premium 664.00
Sub Total of Deductions -55.69 PA Benefits - Section III
Compulsory PA cover to Owner Driver 375.00
100.00 Total PA Premium 375.00
TOTAL OWN DAMAGE PREMIUM
TOTAL LIABILITY PREMIUM 1,039.00
TOTAL PACKAGE PREMIUM (Sec I + II + III) 1,139.00
CGST (9.00%) 103.00
SGST (9.00%) 103.00
TOTAL PREMIUM PAYABLE (`) 1,344.00
Subject to I.M.T.Endt.Nos. IMT 20,15,22

GSTIN : 33AABCR6747B1ZN HSN : 997134,
Description of services : Motor vehicle Insurance Service As per
"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."
PA-Nominee Details Name Age Relation

1 HARISH NATARAJAN 40 Spouse
The Customer Information Sheet (CIS) for this product is available on our website
https://www.reliancegeneral.co.in/insurance/about-us/downloads.aspx
Add-on for Total Cover : Provides cover for registration charges, road tax and insurance premium (Total Cover Sum Insured - ₹ 0)
Limits of liability : (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
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 Insured - ` 1,00,000 /- ,TPPD 2 Sum Insured - ` 6,000 /-) (iii) PA cover for owner driver under section III
CSI ` 1500000.0/-
Consolidated Stamp duty Paid vide Letter of Authorization "NO LOA/ENF-1/CSD/62/2024-25/(Validity Period Dt. 01/10/2024 to Dt. 01/12/2025)/4634 Date 25-09-2024" at
General Stamp Office, Mumbai.** Not Applicable for the State of Jammu & Kashmir
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 Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0011V02100001 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/2312/PS/VER. 1.0/310118
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14A25239 / RAJANEESH
9840146717 [email protected]
RADHAKRISHNAN
Intermediary Code/Name Intermediary Contact No. Intermediary E-mail ID POS UID Aadhaar No. / PAN No.
Limitations as to use : The Policy covers use for any purpose other than: (a) Hire or Reward other than for the purpose of driving tuition, (b)
Carriage of goods (other than samples or personal luggage), (c) Organized racing, (d) Pace making, (e) Speed testing,
(f) Reliability trials, (g) Any Purpose in connection with Motor Trade .
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 ` 100/- (ii) Additional compulsory deductible ` 00/- (iii) Voluntary deductible ` 0/-
% of Discount on Own Damage Premium

Period of Insurance % of NCB on OD Premium
The Preceding Year 20%
Preceding Two Consecutive Years 25%
Preceding Three Consecutive Years 35%
Preceding Four Consecutive Years 45%
Preceding Five Consecutive Years 50%
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
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.
Note :In the event of dishonor of cheque, this policy document automatically stands cancelled from inception irrespective of whether a separate communication is sent
or not.
The policy has been issued based on the information provided by you and the policy is not valid if any of the information provided is incorrect. Subject otherwise to the
terms, conditions and exclusions of the Reliance Miscellaneous and Special Types of Vehicles Package Policy Certificate Cum Policy 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.
Safeguard your transaction by paying your premium via crossed cheque/DD in favour of Reliance General Insurance Co. Ltd.
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).
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.
As per National Highways Authority of India, kindly ensure to affixed FASTag on your vehicle.
Grievance Clause : For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 02248903009 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 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,Fatima Akhtar Court,4th Floor,453, Anna Salai,Teynampet,CHENNAI – 600 018. Tel.: 044 - 24333668 /
24335284 Fax: 044 - 24333664 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.
This document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services Tax Rules 2017.
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 subrule
(4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule
Fast Tag ID -
The policy does not cover liability for death, bodily injury or damage as excluded under Section 150 (2) (ii) and (iii): b and C of the Motor Vehicles Act 1988 (Inserted
Vide GSR no 164 (f) dated 25.02.2022 w. e. f 01.4.2022)
In the unfortunate event of a claim, please call quoting your Policy No. 022 48903009(Paid) on 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
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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.
Special Conditions : NA
Policy has been issued with reference to vehicle inspection report, reference lead no.InspectionID_HIDE & special conditions.The inspection
report remarks can be viewed on company's website by the lead no.
For Reliance General Insurance Co. Ltd.
Authorised Signatory
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Proposal Form For Reliance Two Wheeler Package Policy
Is the vehicle made in India? Yes No Type of vehicle: Two Wheeler Three Wheeler Four Wheeler
For Office Use Only

Policy Number 120322423120149795 Date
Savvion Reference No. Inspection Lead No.
Intermediary Details (To be filled in BLOCK LETTERS)

Intermediary Name RAJANEESH RADHAKRISHNAN Code 14A25239
Branch Name Chennai II Code 1203
Sales Manager Name Syed Gaffar Code 70706431
Details (To be filled in BLOCK LETTERS)

1. This Proposal is for A new Policy Renewal of Policy Endorsement Others (Please specify)
2a. Proposer's Full Name Mr. Mrs. Ms. ARUNA SANTHANAM
2b. Address Address for Communication Address where vehicle is normally kept and Used
Flat/Building/Door/Block No. DOOR NO-70, 2ND FLOOR, RE APARTMENT
Road /Street/Sector ARYA GOWDAR ROAD OPP AXIS BANK ATM
Nearest Landmark
Area
City CHENNAI
Pin Code 600094
State TAMIL NADU
Country India
Phone Mobile 9841******
Emergency Contact No. Blood Group
#Email Fax
3. Period of Insurance From 28/10/2024 To: Midnight of 27/10/2025

4. Source of Funds Business Profession Salary Agricultural Income Savings Others
5. Monthly Income Upto `20,000 `20,001 to `50,000 `50,001 to `1,00,000 `1,00,001and above
6. UID Aadhaar No. 7. PAN No.
8. Fast Tag ID
9. Do you have a GST Registration Number Yes No
If Yes, please specify
10. Related Party Yes No
#The Policy copy and all related documents shall be sent to the email ID provided above. If you wish to receive Policy copy and related documents in physical form to
the aforesaid communication address, please drop us an email at [RGI email address]
Details of the Vehicle

11. Registration Number TN09CE8563 12. Date of Registration 09/09/2016
13. Registering Authority & Location TAMIL NADU - Chennai West T Nagar
14. Year & Month of Manufacture JUN-2016 15. Cubic Capacity 110
16. Engine Number JF16EEGGF06391
17. Chassis Number MBLJF16ENGGF02058
18. Make of Vehicle HERO MOTOCORP
19. Type of Body/Model NA/PLEASURE PLUS 110 20. Seating Capacity including Driver 2
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Details of the Vehicle Type and Use

20. a. Whether the Vehicle is driven by Non-conventional source of power? Yes No If yes Bi Fuel CNG LPG
Insured declared
Non-electrical Accessories Electrical & Electronics Side Car(Two_wheeler)
value (IDV) of Value of CNG/ LPG Kit Total Value
fited to the Vehicle Accessories fited to the Vehicle Trailer(Pvt.Cars)
the Vehicle
17748 0 0 0 0 17748
b. Do you have a valid PUC? Yes No

(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 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.)
22. Age of Owner Driver _________________ 23. D.O.B. _________________
24. Add On Covers (Subject to availability and eligibility)
a. Assistance Covers No
b. Nil Depreciation Cover No
c. NCB Retention Cover (Applicable only for Annual Policy) No
d. Easy Monthly Instalment (EMI) Protection Cover:
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 : ₹
e. Total Cover No
f. Daily allowance benefits No
Per Day Allowance: ₹
Coverage Days :
g. Helmet cover: Sum Insured ₹ No
Number of Helmet Covered
h. Daily allowance benefits Plus No
Per Day Allowance: ₹
Coverage Days :
i. Voluntary Deductible
Voluntary Deductible amount opted: ₹ ______________________
j. Hospital Cash Cover (Applicable only for Annual Policy) No
Sum Insured: ₹
No of Days:
Convalescence Benefit SI: ₹
k. Emergency Hotel Accommodation No
Benefit Amount: ₹
l. Additional limit of TPPD No
Additional amount opted: ₹
m. Tyre Protector( Applicable only for annual Policy) No
Specifications of Tyres and Tubes:
For Tyre : Width in mm: ______________ Aspect Ratio: ______________
Tyre Serial Number 1 ______________ 2_______________
n. Rim Protector(Applicable only for annual Policy) No
Specification of Rims:
For Rim : Width in mm: ______________ Aspect Ratio: ______________
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Rim Serial Number 1 ________________ 2 _______________

o. Consumable Expenses No
p. Engine Protector No
q. Return to Invoice (Applicable only for Annual Policy) No
r. Loss of Personal belongings (Applicable only for annual Policy) No
Sum Insured: ₹
s. Any other Details
___________________________________
t. Battery Protection Cover No
u. Electric Motor Protection Cover No
v. EV Charger Cover No
w. Assistance Cover (Two Wheeler Shield) No
x. Assistance Cover - Two Wheeler Shield No
25. Is the vehicle fitted with any Anti-theft device approved by the ARAI ? Yes No
If Yes,please attach certificate of installation in the vehicle,issued by automobile Association of India.
26. Are you a member of Automobile Association of India ? If Yes,please submit membership copy. Yes No
27. Will the Vehicle be used exclusively for
a. Private,social,domestic,pleasure and professional purposed ? Yes No
b. Carriage of goods other than samples or personal luggage? Yes No
28. Whether the Vehicle is used for Driving Tuitions? Yes No
29. Whether use of Vehicle is limited to Own Premises? Yes No
30. Whether the Vehicle is fitted with Fibre Glass Tank? Yes No
31. Whether the Vehicle belongs to the Embassy/Consulate of a Foreign Country? Yes No
If so, is the duty element included in the IDV?
32. Whether the Vehicle is design for use of Blind/Handicapped/Mentally Challenged Person? Yes No
33. Date of purchase of the Vehicle by the Proposer 09/Sep/2016
34. Whether the Vehicle at the time of purchase was New Second Hand
Risk Inclusions
35. Please select the higher deductible if you wish to opt for over and above the compulsory deductible
Two wheeler
36. Liability to third parties : The policy provides Third Party Property Damage(TPPD) of ` 1 lakh (Two wheelers) and ` 7.5 lakhs (Private car) (Private car))
Do you wish to restrict the above limits to the statutory TPPD Liability limit of ₹ 6000/- only? Yes No
Legal Liability No of Person
Driver:
37. Personal Accident Cover for Owner Driver. Please give details of nomination
Name of the Appointee (if
Name Name of the Nominee Age of Nominee Relationship Address
Nominee is Minor)
HARISH NATARAJAN 40 Spouse
(Note: 1. Personal Accident cover for owner driver is compulsory for Sum Insured of ₹ 15,00,000/- for Two Wheeler, Private Car, GCV, 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)
38. Extension of Geographical Area

Whether extension of Geographical Area to the following Countries required ?
1. Bangladesh
2. Bhutan
3. Maldives
4. Nepal
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5. Pakistan
6. Sri Lanka
Details of Hire Purchase / Hypothecation / Lease

38. Please state if the vehicle is under Hire Purchase Lease Agreement Hypothecation Agreement
If so, give name and address of concerned parties.
40. Full Name
41. Address
Details of Previous Insurance

42. Full Name of previous insurer Reliance General Insurance Company Ltd.
43. Address H Block, 4th street, Door No 12, H 2035, 15th Main Road, Anna Nagar (West)
44. Policy Number 120322323120103918 Previous Policy Expiry 27/10/2024
45. Type of Cover Package Policy Liability only others (to be describe)
46. Claims taken in previous policy Yes No
If yes, No. of Claims Claims Amount `
47. Are you entitled to No Claim Bonus Yes No
If yes, please submit/attached proof thereof
48. NO CLAIM BONUS allowed under previous policy (%) 50
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
undertake that if this declaration id found incorrect, all benefits under this policy in respect of Section 1 of the policy will stand `forfeited.
Signature of the Proposer _______________________________________________________
Payment Details
Cheque/ DD Cheque/ DD No.
Cheque/ DD Date Cash Credit Card Others
Proposer's Bank Details

49. Name of the Bank Account Holder
50. Bank Account No.: 51. Account: Saving Current
52. Name of the Bank
53. Branch
54. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque
issued by the bank)
55. IFSC Code (11 character code appearing on your cheque leaf)
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 mandetory that all payments made to the insured are only through electronic mode.
GENERAL DECLARATION:
I understand that as per the new AML/CFT Guidelines issued Reliance General Insurance Co. Ltd will be verifying my details pertaining to KYC and PAN provided at
the time of proposal.
I further, do hereby agree and consent that in the case of the event of a mismatch of information provided by me in the proposal form, identification proof, and address
proof at the time of issuance of the policy. I request Reliance General Insurance Company Limited to issue the policy with the details appearing as per my proposal
form. I will be solely responsible for any consequences arising out of the difference in detail given by me during the verification of supporting documents provided by
me at the time of issuance of the policy or otherwise.
AML Guidelines
"I/ We herby confirm that all premiums have been/ will be paid from bonafide sources and no premium have been/ will be paid out of the 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 the documents to establish source of funds.
The insurance company has the right to cancel the insurance contract in case I am/ have been found guilty by any competent court of law under any of the statues,
directly/ indirectly governing the prevention of Money Laundering in India.
Nationality Indian Non-Indian, If Non Indian Please specify the

Type of organization Corporation Goverment Non Goverment Society Trust Partenership
International Organization Corporatives Section 25 Companies
PEP Declaration:
Are you a Politically Exposed Person (PEP)? Yes No
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If yes, please mention the position held
Is any of your close relation or family member a PEP? Yes No
If yes, please mention the name and relation and the position held
by such close relative/family member.
I hereby declare that in future if me, any of my close relatives or any of my family member attains a position of PEP then I shall confirm the same to Reliance General
Insurance Co. Ltd as a mandate. I understand that this is a crucial information under the PMLA Rules and AML/ CFT Guidelines and shall confirm that the answers
given by me is true. In case the company comes to know that this is a misrepresentation and concealment of information then the policy shall be put on hold for
scrutiny by the company and I shall be solely responsible for the same.
Note :
“Politically Exposed Persons” (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign country, e.g., Heads of
States/Governments, senior politicians, senior government/judicial/military officers, senior executives of state-owned corporations, important political party officials,
etc (As per sub clause (xii) of 3(b) of Chapter I of Master Direction – Know Your Customer (KYC) Direction, 2016 issued by Reserve Bank of India (RBI).
Declaration by Proposer
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 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 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 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 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-representation, mis-description of nondisclosure of any material particulars by the Proposer. Any person who, knowingly and with intent to 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 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

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 : 23 Oct 2024 12:07 Date : 23 Oct 2024 12:07
Signature Signature of Proposer & Company Seal
Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment ) Act, 2015
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 rupees.
Supporting Confirmation of Agent/Broker/SM/CSO

I confirm the above signature tobe of the registered owner of the vehicle proposed for insurance
Place
Date
(In case of Direct Business, Name & Signature of CSO /SM to be taken) Signature of IRDAI Agent/ Broker
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Mrs. Aruna Santhanam Door No-70, 2Nd Floor, Re Apartment Arya Gowdar Road Opp Axis Bank Atm Chennai Chennai TAMIL NADU India - 600094 9841

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Trejhara

Mrs. ARUNA SANTHANAM

Reliance Two Wheeler Package Policy - Policy Schedule

Policy Number : 120322423120149795 Proposal/Covernote No: R23102406593

Insured Declared Value (IDV)

TOTAL PREMIUM PAYABLE (`) 1,344.00

Subject to I.M.T.Endt.Nos. IMT 20,15,22

PA-Nominee Details Name Age Relation

% of Discount on Own Damage Premium

For Reliance General Insurance Co. Ltd.

Proposal Form For Reliance Two Wheeler Package Policy

For Office Use Only

Intermediary Details (To be filled in BLOCK LETTERS)

Details (To be filled in BLOCK LETTERS)

3. Period of Insurance From 28/10/2024 To: Midnight of 27/10/2025

Details of the Vehicle

Details of the Vehicle Type and Use

b. Do you have a valid PUC? Yes No

22. Age of Owner Driver _________________ 23. D.O.B. _________________

24. Add On Covers (Subject to availability and eligibility)

Rim Serial Number 1 ________________ 2 _______________

38. Extension of Geographical Area

Details of Hire Purchase / Hypothecation / Lease

Details of Previous Insurance

Signature of the Proposer _______________________________________________________

Proposer's Bank Details

Nationality Indian Non-Indian, If Non Indian Please specify the

Are you a Politically Exposed Person (PEP)? Yes No

If yes, please mention the position held

Is any of your close relation or family member a PEP? Yes No

This proposal form was completed by

Name ____________________________ Place : ____________________________

Signature Signature of Proposer & Company Seal

Supporting Confirmation of Agent/Broker/SM/CSO

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22. Age of Owner Driver _ 23. D.O.B. _

Rim Serial Number 1 __ 2 _

Name Place :