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Bajaj Allianz General Insurance Company Ltd.

Issuing Office:

Bajaj Finserv,1st Floor , Survey # 208/1-B, Behind Weikfield IT-Park, Viman Nagar, Pune411014, Contact No: 1800-209-0144
Reference No: SIR10582645
Generated by : ONLINE


Dear SIR ,
Re.: Your enquiry for premium quotation for vehicle
We thank you for your enquiry for quote on insurance premium for your registered as Private Car. Details of
your requirement are noted below Make





Year of


NCB at








Vehicle IDV

Value of Electrical

Value of Non-Electrical Value of CNG/LPG Unit

-extra fitted


Proposed Insurance
commencement date

Policy Expiry Date

Date of Vehicle




Total IDV

Pin Code of your

normal place of stay

Voluntary Excess


Based on the cited details, we are pleased to quote our premium as under: (* All figures in Rupees)
Net OD Premium

Net TP Premium

Total Premium

Service Tax

Swachh Bharat/
Education Cess

Final Premium







Add-On Covers : 24x7 SPOT ASSISTANCE,Depreciation Shield

Your Quote has been generated with Additional

Excess of Rs. 1000 and it will be deducted at the time each and every

Important Notes :
1. This quotation is based on information provided to us and is subject to relevant proofs being submitted
and inspection of vehicle at the time of issuance of policy. Quote is subject to change based on documentation and in case actual information at the time of issuance differs from the above.
2. This submission is only a quotation and not an insurance policy or cover note. The insurance coverage
would start only after issuance of policy and receipt of payment of premium subject to terms of policy.
3. This quote is valid for 30 days from Proposed Insurance commencement date noted above.
4. The premium quoted is for an insurance period from 20-MAY-16 to 19-MAY-17 .
5. You are requested to return duly signed copy of this quote as a confirmation of acceptance of the terms
and reconfirmation of information provided above.
6. Alternately you may send your objection, what so ever with regard to the above quote or the terms and
condition of policy issued, within 7 days from the date of this quote, failing which it will be concluded that
you are fully satisfied and have accepted the quote including the terms and condition of the policy and
the correctness of the information provided above.
7. Policy would be issued after tendering full premium quoted above and subject to inspection of vehicle
where required.
8. Please furnish us the following information for issuance of policy. a) Previous insurance policy copy /
Renewal Notice b) NCB confirmation letter c) Copy of Registration certificate d) Copy of driving license
9. Act 1938, Section 41- Prohibition of Rebates
10. The Above quote will be valid if the policy is bought online.

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 allowed in accordance with prospectus 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.
Thanking You,
Websales Team,
Bajaj Allianz General Insurance Company Limited.
This is an electronically generated quotation and does not require any signature.

Please turn overleaf

Registered & Corporate Office - G E Plaza, Airport Road, Yerwada, PUNE 411 006

Date: 20-APR-16
Reference No: SIR
Generated by : ONLINE

Bajaj Allianz General Insurance Co. Ltd.
I/We acknowledge receipt of your Quote-cum-Proposal and accept the terms and intend to insure my/our
vehicle detailed therein with you. I/We agree that this Proposal and the declarations shall be the basis of the
contract between Bajaj Allianz and me/us. I/We confirm that the vehicle is being used for private purposes
only. I/We warrant the truth of the forgoing statements in every respect and agree that if I/We have made
any false statement or provided false information, the claim shall be repudiated and premium forfeited. I/We
also declare that if any additions or alterations are carried out after the submission of this Quotecum-Proposal, then the same would be conveyed to Bajaj Allianz immediately.
Please find attached my/our remittance of premium of Rs.23998/- by Cash/Cheque No__________
dated____________ drawn on______________________________________ towards issuance of the
Policy with the following additional information.
Registration No: _______________ Engine No : _______________

Chassis No: _______________

Pin Code : 502103

Vehicle Model : ZEST

Vehicle Make : TATA

Sub Type : XT QUADRAJET 90 PS Fuel : Diesel

NCB : 20%
Total IDV : Rs.635000/-

Registration Date : 11-JUN-15

Voluntary Excess:

Proposed Insurance commencement date : 20-MAY-16

Policy Expiry Date : 19-MAY-17

Please mention your Name, Mobile Number and Reference Number on the reverse of cheque.

Date : ___________________

Signature of Proposer : ____________________

Note: Download charges apply as per your service provider.