Signed by:Mukul

Kishore
Date:2015.02.26

Reliance MISC- D/ Special Class of vehicle Package Policy Certificate Cum Policy Schedule
Policy/Certificate No. :

2004552343000462

Proposal/Covernote No. :

W02261502700

Name of Insured :

Mrs. DHANPATI

Period of Insurance:

From 12:43 Hrs on 26-Feb-2015 to midnight of 25-Feb-2016

Address :

W/O SH ANIL KUMAR , VPOUMRA,TEH-HANSI,DISTT-HISAR ,

HANSI

Inspection Doc. No. :

NA

HANSI-125033 , HARYANA

Inspection Date :

Contact Details :

9355250343

Hypothecated with :

Email ID :

kumar.insurance1@gmail.com

Geographical Area :

Tata Capital Financial Services Ltd

Particulars of Vehicle Insured:

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NEWRTO-HARYANAHANSI

Make / Modal

Engine / Chassis

Year of MFG

GVW

LCC excluding Driver

Carrier

Net Premium Rs. Manufacturer fully

build in
NEW HOLLAND /
3630 | 50 cc

156086D / NH2312285

FEB-2015

1800

Public

8490

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655500

Yes

Limitations As To Use :
The policy covers the use only under a permit within the meaning of Motor Vehicle Act, 1988 or such a carriage falling under sub-section (3) of Sec 66 of the Motor Vehicles Act, 1988.The Policy covers use for any
purpose other than: a. Organized Racing, b. Pace making, c. Reliability Trials d. Speed testing.(E. Need to include Use for carriage of passengers for hire or reward)
Persons/Classes of Persons entitled to drive :
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VXFKDOLFHQVH3URYLGHGDOVRWKDWWKHSHUVRQKROGLQJDQHIIHFWLYH/HDUQHU
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Limits of Liability :
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LLRIWKH3ROLF\'DPDJHWRSURSHUW\RWKHUWKDQSURSHUW\EHORQJLQJWRWKHLQVXUHGRUKHOGLQWUXVWRULQWKHFXVWRG\RIFRQWURORIWKHLQVXUHGXSWRWKHOLPLWVVSHFLILHG5VRQO\
PA Cover for owner-driver under section IV CSI Rs. 200000 /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. No Claim Bonus will only be allowed, provided the policy
is renewed within 90 days of the expiry of the previous policy.
Deductible under Section(i)Compulsory deductible Rs. 3278/-(ii) Additional compulsory deductible Rs. 0/-(iii) Voluntary deductible Rs./It is hereby declared and agreed that all pre-existing damages to the vehicle having occurred prior to the commencement of cover are excluded from the scope of the policy
The policy wording with detailed terms, conditions and exclusions are available on our website www.reliancegeneral.co.in
Consolidated Stamp duty Paid vide GRAS GRN No. MH003534299201415E dated 28 October 2014**** Not Applicable for the State of Jammu & Kashmir
Nominee Details :
PA Owner Driver :

Nominee name :NA

Age:NA

Relationship with Owner Driver :NA

Insured's Declared Value

For the Vehicle
(Rs)

Chasis IDV

655500

Body IDV

For Trailers (Rs)

Manufacture

Non Elec.
Accessories(Rs)

Elec./Electronic
Accessories(Rs)including
driver

Total Cover SI (Rs)

Value of CNG/LPG Kit

(Rs)

Total IDV (Rs)

655,500.00

655500

Additonal Towing
Covers(Rs.)

Premium Schedule
Own Damage
Basic premium on Vehicle

Liability
6240 Basic Premium including for TPPD Vehicle

2100

Non Electrical Accessiories

0 Less : Restricted Third Party Property Damage

Electrical & Electronic

0 Liability Premium for Trailers

Bi-fuel Kit(CNG/LPG)

0 CNG/LPG Bi-fuel Kit

Trailers

0 Total

Total Net Basic Own Damage Premium

2100

6240 PA BENIFITS

Nil Depreciation

0 Compulsory PA covers for owner-driver

Fibre Glass Fuel Tanks

0 PA benifit to paid driver

60% on OD Premium for driving Tution

0 PA benefit to Conductor

Is Cover For Lamps Tyres/Tubes Mudguards, bumpers,

0 PA benefit to Cleaner

100
0
0

Liability Premium for geographical extension

Bonnet/SideParts,headlight and paint work of damaged portion

(IMT 23)?
Geographical Area Extn.

0 Is Discount Applicable for Vehicles Specifically Designed for

Blind,Handicapped and Mentally Challenged Persons?

Use of Vehicle Confined

0 Is Legal Liability to persons employed in connection with

Operations etc - Paid Driver Covered?

Loading 0%

0 Is Legal Liability to accidents to Passengers Covered?

(Applicable for Ambulance Hearses Only)

0
0
50
0
0

Is Indemnity to Hirer (For Agricultural Forestry Vehicles,

Mobile shops, Canteens etc covered?
6240 Is Legal Liability to NFPP of the insured who are not workmen

Total Schedule OD Premium

under WC Act covered?

Less

Is Legal Liability to persons employed in connection with

Operations etc - Cleaner, Conductor,Coolies Covered?

Discount for Anti-theft Devices

0 legel Liability to Commercial and Private Purpose vehicle

Automobile Association Discount

0 Total Legal Liability Premium

2250

Deduct 0% for NCB

0 PACKAGE PREMIUM(A+B)

8490

Sub Total(deduction)

0 Service Tax @ 12%

1019

Total Own Damage Premium(A)

6240 Educational Cess @ 2%

20
10

Higher Educational Cess @ 1%

Premium including S. Tax(Rs.)

9540

Subject to I.M.T. Endt.Nos. & Memorandum printed/herein/attached hereto.IMT 28, IMT 6HUYLFH7D[5HJ1R$$%&5%67
20,
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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.
Subject to Reliance GI Endorsement Numbers printed herein/attached here to 0
* No Claim Bonus is subject to no claim on the previous policy Benefits under the policy stands forfeited if claim is/was made in previous policy.
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 theReliance Passenger Carrying Vehicle Package Policy.In Witness where of this Policy has been signed at Mumbai on 2/26/2015 12:43:40 PM in lieu of Cover Note
No..Valuedated2/26/2015 12:43:40 PM
In the unfortunate event of a claim,Please call along with your Policy No.on 1800 103 1999(toll free) or 022 41112600(Standard STD Rates Apply) and register your claim immediately within 7 days
from the date of loss.For Customer service,Please call along with your Policy No. on 1800 300 28282(toll free)or 39898282(local charges apply)|www.reliancegeneral.co.in
IMPORTANT NOTICE :

For Reliance General Insurance Co. Ltd.

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Duly Constituted Attorney(s)

Reliance General Insurance Co. Ltd.

Registered Office:

Reliance Centre, 19, Walchand Hirachand Marg, Ballard Estate, Mumbai - 400 001

Policy Issuing Office :

570,Naigaum Cross Road, Next to Royal Industrial Estate,Wadala(W),Mumbai - 400 031

Branch Issuance Office :

SCO- 145 -146, 2nd Floor, Sector - 9 C, Madhya Marg , CHANDIGARH U.T.

Intermediary Code\Name:
Intermediary Contact No:

20A17811 / DEEPAK ARORA

9034660007

Dear DHANPATI
We thank you for placing your trust with Reliance General Insurance Company Limited
We are pleased to enclose as Proposed by you
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21/,1(352326$/)250IRUIXWXUHUHIHUHQFH*LYHQKHUHEHORZLVDQH[WUDFWRIWKHVDPHIRU\RXUUHFRUGVDQGUHIHUHQFH

(I) Details of Registered Owner/Insured

Name of the Insured

DHANPATI

Address

W/O SH ANIL KUMAR VPO-UMRA,TEH-HANSI,DISTT-HISAR HANSI City

State

HARYANA
HANSI

Landline number

kumar.insurance1@gmail.com

Mobile number

9355250343

Total Insured Declared Value (IDV)

655500

Total Premium amount

9540

Policy Start date

26/02/2015

Policy End date

25/02/2016

Hypothecation Type

Hypothecated

Name of Financial Institution

Tata Capital Financial Services Ltd

Renewal/Rollover/New

New Policy

Email

(II) Policy Details

Address of Financial Institution

(III) Vehicle Details

Make

NEW HOLLAND

Manufacturing Month/Year

FEB-2015

Model

3630

Date of Purchase/Registration

26/02/2015

Variant

| 50 cc

RTO Location

HARYANA-HANSI

Engine Number

156086D

Registration number

NEW

Chassis Number

NH2312285

Seating Capacity Including Driver

Vehicle IDV

655500

Value of Electrical Accessories

Value of CNG/LPG KIT

Value of Non Electrical Accessories

Electrical Accessories

NO

Legal Liability to Paid Driver

YES

Non Electrical Accessories

NO

Personal Accident Cover for unnamed Passengers

NO

CNG/LPG Kit Attached

NO

Extension in Geographical Area:

NO

Is Vehicle used for Driving Tuitions:

NO

Legal Liability to Employees:

NO

Fiber Glass Fuel Tank:

NO

If Yes Extension in Geographical Area:

NO

Personal Accident Cover for Named Passengers:

NO

Legal liability to Cleaner & conductor

NO

Legal liability to Non-Fare Passenger

No

Loading charged

NO

NO

Additional Towing Cover

NO

Additional Towing Cover Value

(IV) Additonal Cover/s Opted

(V) Add on Cover/s Opted

Nil Depreciation Cover

(VI) Discounts Claimed

Anti Theft Device Discount

NO

Automobile Association Disc

NO

Voluntary Deductible Discount

NO

Automobile Association Membership number

Against this discount you have accepted an additional voluntary deductible of Rs 0 against each claim
Restrict TPPD Liability To 6000:

NO

(VIl) PA to Owner Driver - Nominee Details

(VlIl) Payment Details

Payment Mode

Cash

Bank Name

Premium Amount

9540

Payment Date

26/02/2015

Policy Number

Previous Insurer Name

Policy Start date

Branch Name & Address

Policy End date

Current NCB %

Claim (Yes or No)

NCB% for this Policy

(lX) Previous Year Policy Details

Declaration
I agree that the insurance benefit available to me shall become voidable in the event of any untrue or incorrect statement, misrepresentation,non-description or non-disclosure in any particulars in the application form / personal statement, declaration and
connected documents or any material information has been withheld by me or anyone acting on my behalf to obtain insurance benefit. I hereby declare that I am not aware of any neglect and omission or error or existence of any circumstances likely to give
rise to a claim thereof. I hereby declare, incase of false declaration the Insurance Company shall have the right to cancel the policy. The insurance company shall have the right to change the premium and conditions agreed to subject to such terms and
conditions as has been communicated to me. I hereby agree that my enrollment for insurance would be at the sole discretion of the insurance company. I declare and warrant that the information I have given in this online form will be considered as the
proposal form in relation to myself (or other person or categories of persons to be insured) and any documentation of information accompanying it or arising out of the answers I have given is complete and accurate in all respects. I understand and agree
that this online form and other information and documentation I have given or will give,relating to myself or any other person to be insured, will be the basis of any insurance that you may issue, and I also understand the consequences of any default. I
further understand that the coverage offered is subject to realization of premium payment.
Online Transaction Facility - Terms and Conditions:
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UHDGDQGXQGHUVWRRGWKHVDOLHQWIHDWXUHVWHUPVDQGFRQGLWLRQVRIWKHSROLF\DVVWDWHGLQWKHEURFKXUH

Insured Name : DHANPATI

Date :

26/02/2015

The information that you give to Reliance General Insurance on this online form will be treated as the proposal form and details in any supplemental information form or documentation supplied by you or on your behalf will influence our decision to offer
insurance and the terms upon which to offer it. Further, any policy we issue will be based on what you have told us. It is therefore important that your answers are complete and accurate in all respect.
The questions in this online form are indicative rather than exhaustive. You must provide us with all information relevant to the risk to be insured,even if it is not the subject of a question in this online form. If you are in any doubt as to what information should
be given, please email us at services.rgicl@relianceada.com. Any failure to provide us with full and accurate material information may mean that your policy can be declared as void.
No insurance cover will be in force until we have approved it and the premium has been paid.

Statutory Warning - PROHIBITION OF REBATES (Under Section 41 of Insurance Act 1938)

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.
Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to five hundred rupees.
We hope the information shown above is found by you as correct
For detailed terms & condition (Policy Wordings) governing this policy, kindly refer our website.
In case of any query you may contact our customer care service numbers given on the face of the policy. We look forward to having a long term & fruitful relationship
Yours truly

Authorized Signatory
For Reliance General Insurance Co ltd