Bajaj Allianz General Insurance Company Ltd.

Registered and Head Office: GE Plaza, Airport Road, Yerwada, Pune

Transcript of Proposal for Private Car - Package Policy

Dear DWARKA DASS,

We wish to inform you that the contract under policy number 'OG-15-1102-1801-00015362' has been finalized based on the information and
declaration given by you, the transcript whereof is mentioned below. You are requested to reconfirm the same. In case of any disagreement or
objection or any changes with respect to information mentioned below, we request you to please revert back within a period of 15 days from
date of your receipt of this, failing which it will be deemed that you are satisfied with the correctness of the details mentioned below. Kindly note
that as the contents and declarations contained in this transcript is the basis on which we have issued the policy to you, we advise you to please
ensure that you have provided/disclosed and or not withheld any material facts/information and declarations, as Policy becomes Void ab initio if
material facts are not provided/disclosed and or withheld and in such case no claim, if any, will be considered by us apart from forfeiture of the
premium.
Details provided by you:

A. Proposer details
1. Proposer Name

: DWARKA DASS

2. Proposer Address

: H. NO-3026/7-H. KH NO-406/399/7 2ND FLOOR SHIV CHOWK RANJEET NAGAR,

BALJEET NAGAR, , BALJEET NAGAR, DELHI-110008

3. Proposer Mobile Number

4. Proposer Residential Number

: NA

5. Proposer e-mail id

: NA

6. Proposer Profession

: NA

B.Vehicle Details
Registration
Number

Month / Year of Vehicle Make Vehicle Model

Regn

DL2CAG9678

FEB/2007

MARUTI

ZEN

Vehicle Sub
Type

Cubic Capacity

Fuel Type

Year of Manufacture

Seating Capacity

ESTILO LXI

1061

Petrol

2007

Engine Number

Chassis Number

Vehicle IDV (in Rs.)

Electrical
Accessories IDV
(in Rs.)

Non-Electrical
Accessories IDV
(in Rs.)

CNG/LPG Unit
(Extra fitted) IDV
(in Rs.)

Total IDV (in Rs.)

3265167

141272

120000

120000

C. Coverage opted
1. Period of Insurance

: From 20-FEB-2015 13:00 (Hrs) To 19-FEB-2016 Midnight

2. Is your vehicle fitted with external LPG/CNG kit

: No.

3. Electrical Accessories cover Opted (If Applicable)

: No.

4. Non - Electrical Accessories cover Opted (If Applicable):

: No.

5. Is Voluntary Excess opted

Amount of voluntary excess opted

: No.
: Rs.NA.

6. Whether PA cover is opted for owner-driver

: Yes.

7. Is any additional compulsory deductible imposed and agreed upon

Amount of additional compulsory deductible imposed

: No.
: NA.

8. Whether geographical area extension is opted

Details of Countries to which geographical area extension cover is given

: No.
: NA.

9. Is LL to person for Paid driver/Operation/Maintenance opted

: Yes.

10. Whether PA cover is opted for paid driver other than owner driver
Sum Insured for Paid Driver

: No.
: Rs.NA.

11. Whether PA cover is opted for passengers

Sum Insured per Passenger

: No.
: Rs.NA.

12. Is TPPD restricted to statutory limit of Rs.6000?

: No.

13. Pre Existing damages in the vehicle

: #REPAIR/ REPLACEMENT OF DENTED/CRACK PARTS AND

REPAIR/PAINTING OF DENTED/SCRATCHED PANELS
SUPPORTED BY PHOTOGRAPHS TAKEN AGAINST INSPECTION
REFERENCE NUMBER#2015-01526407#####.SHALL BE
EXCLUDED IN EVENT OF ANY CLAIM LODGED DURING THE
POLICY PERIOD#..

14. Premium for Liability coverage, quoted and agreed upon is

: Rs.1482.

15. Premium for OD coverage, quoted and agreed upon is

: Rs.2978.

16. Total Premium (excluding Service Tax and Education Cess) for Liability and OD coverages, quoted and agreed upon is : Rs.4460
17. NCB (No Claim Bonus) claimed by you and granted by us based on your declaration of no claim during your previous policy : 0 %.
18. About the last insurance company
(i) Insurance Provider : NA.
(ii) Previous Policy No : NA , Previous Policy Expiry Date : NA
19. Whether your vehicle is Hypothecated and if so the details of Pledgee whose name is registered by us: No.
Name of Pledgee : NA.
20. Add on Cover(s) opted : No.Plan name:NA
Please note Cover Note No. DY1301872974/20-FEB-2015 01:00 PM issued to you based on the above information.
In case of Disagreement or objection or any changes with respect to information and contents mentioned hereinabove, please contact our toll
free number & register your objections/changes/disagreement to the contents of this transcript or you may also send us email or written
correspondence at the following details within a period of 15 days from date of your receipt of this transcript along with Policy:
Toll free Number
Email address
Website

: 1800-22-5858,1800-102-5858,1800-209-5959
: customercare@bajajallianz.co.in.
: www.bajajallianz.com.

Contact our policy servicing branch at: 3rd Floor, JMD Regent Plaza, Sikanderpur, Mehrauli -Gurgaon road, Gurgaon-122002 PH:4064501.
For Bajaj Allianz General Insurance Co Ltd
Authorized signatory

 


BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of India [IRDA] vide Reg No.113)
Regd. Office: GE Plaza, Airport Road, Yerwada,Pune-411006(India)

Certificate of Insurance (Private Car Package Policy)

Policy Number: OG-15-1102-1801-00015362

Customer ID: 64551828

Particulars of Vehicle Insured:

Registration Number

Place of Registration

Engine Number

Chassis Number

Make & Model

3265167

141272

MARUTI - ZEN

DL2CAG9678

Sub Type

Year of Manufacturing

NCB %

CC

Seating Capacity

Final Premium

ESTILO LXI

2007

1061

Rs.5011.

Name of Registration Authority

Name and Address of Insured

Geographical Area
Business or Profession

:
: DWARKA DASS
: H. NO-3026/7-H. KH NO-406/399/7 2ND FLOOR SHIV
CHOWK RANJEET NAGAR, BALJEET NAGAR, , BALJEET
NAGAR, DELHI-110008
: India
: NA

Effective date of commencement of Insurance for the purpose of act:

Policy Inception Date: From 13:00 O' Clock on 20-FEB-2015
Policy Expiry Date: Midnight on 19-FEB-2016
Persons or Class of Persons entitled to drive:
Any person including the insured:
a) 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.
b) 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 Vehicles Rules, 1989.
Limitations as to Use:
The Policy covers use 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) Any purpose in connection with Motor Trade
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.
Full address of Issuing Office :
3rd Floor, JMD Regent Plaza, Sikanderpur, Mehrauli -Gurgaon road, Gurgaon-122002 PH:4064501
Date of issue :24-MAR-2015
For & On Behalf of
Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory

For help and more information:

Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, 1800-22-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call)
Email us at customercare@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 19-Jun-2015 14:19:46 PM- sarvinder kumar (Web) ()

 


BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of India [IRDA] vide Reg No.113)
Regd. Office: GE Plaza, Airport Road, Yerwada,Pune-411006(India)

PRIVATE CAR PACKAGE POLICY SCHEDULE

Policy Issuing Office

3rd Floor, JMD Regent Plaza, Sikanderpur, Mehrauli -Gurgaon road, Gurgaon-122002 PH:4064501
INSURED DETAILS

Insured Name

POLICY DETAILS

DWARKA DASS

Policy Number

OG-15-1102-1801-00015362

H. NO-3026/7-H. KH NO-406/399/7 2ND FLOOR SHIV

CHOWK RANJEET NAGAR, BALJEET NAGAR, ,
BALJEET NAGAR, DELHI-110008

Policy Issued on

24-MAR-2015 13:12 PM
From : 20-FEB-2015 13:00 (Hrs)

Insured Address
Period of Insurance

To : 19-FEB-2016 Midnight

Geographical Area

India

Cover Note Details

DY1301872974/20-FEB-2015 01:00 PM

Customer ID

64551828

Previous Policy No

Registration Number
DL2CAG9678

Place of Registration

Engine Number
3265167

Chassis Number
141272
Trailer Registration
Number
-,-

NCB %

CC

Seating Capacity

Year Of Manufacturing

1061

2007

Vehicle IDV

Value For Trailers

Non electrical accessories

120000

Own Damage Premium(Rs.)

Own Damage Premium
Special Discount
Total OD Premium - A
Total Premium (Net Premium) (A+B)
Service Tax
Education Cess
Final Premium Rs.

2978
0
2978
4460
535
16

Make & Model

MARUTI - ZEN

SubType
ESTILO LXI

Hypothecation Details

Electrical/Electronic
accessories
0

Value of CNG/LPG
kit
0

Total Value
120000

Liability Premium(Rs.)
Basic Third Party Liability
PA Cover for Owner-Driver
LL to person for Paid driver/Operation/Maintenance
Total Act Premium - B

1332
100
50
1482

5011 Final Premium (in Words): Rupees five thousand eleven Only

**Note: The above Total OD Premium is inclusive of all applicable Loading /Discounts viz (Automobile association membership, Voluntary Excess, Anti Theft, Handicap Person,
Driver Tuition, Fiber Glass, CNG/LPG Unit, Geographical Extension, Imported Vehicle Etc. wherever Applicable)

Agency 10026738/VINOD KAPOOR

Code&
Name
Limitation as to Use

Driver

Limits of Liability

No Claim Bonus

Existing Damage Details

Subject to Warranties/
IMT-Endorsements/Add on
Package

Contact No.

0/9212376025

E-Mail ID.

The Policy covers use of the vehicle for any purpose other than : Hire or reward, Carriage of goods( other than samples or personal luggage),Organised racing,Pace making, Speed testing, Reliability trials. Any purpose in connection with Motor Trade.
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 when not used for the transport of goods/passengers at the time of the accident and that such a person satisfies the requirements of
Rule 3 of the Central Motor Vehicle Rules, 1989.
Under section II-I(i) of the policy -> Death of or bodily injury : Such amount is necessary to meet there requirements of the Motor Vehicles
Act,1988. Under section II-I(ii) of the policy -> Damage to Third Party Property : Rs. 750000
The insured is entitled for a No Claim Bonus (NCB) on the Own Damage section of the policy, if no claim is made or pending during the
preceding year (s), as per the following: 1. The preceding year: 20% , 2. Preceding Two consecutive years: 25% , 3. Preceding Three consecutive years: 35%, 4. Preceding Four consecutive years: 45% , 5. Preceding Five consecutive years: 50% No Claim Bonus will only be
allowed provided the policy is renewed within 90 days of the expiry date of the previous policy.
Cost of Repair / Replacement towards the damaged parts noticed during the inspection of your vehicle prior to enrolment under this policy
as per Inspection report reference number 2015-01526407 duly signed by you or your representative as well as the photographs shall be
excluded in the event of any future claims.
22, 28

Additional Details

Coinsurance Details: - NA. Transaction Id: -

Premium Details

Receipt No. 1102-00240470, Date 24-FEB-15 ** If Premium paid through Cheque, the Policy is void ab-initio in case of dishonour of
Cheque.

Excess Details

Compulsory Excess: Rs.1000

ADDITIONAL EXCESS: Rs. 0

VOLUNTARY EXCESS: Rs.0

For help and more information:

Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, 1800-22-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call)
Email us at customercare@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 19-Jun-2015 14:19:46 PM- sarvinder kumar (Web) ()

 

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 & On Behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory
This document is digitally signed, hence counter signature / stamp is not required.
Consolidated stamp Duty paid vide Receipt No: .22 dated 20-FEB-15
Service Tax Reg. No. AABCB5730G-ST-001

For help and more information:

Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, 1800-22-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call)
Email us at customercare@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 19-Jun-2015 14:19:46 PM- sarvinder kumar (Web) ()

Bajaj Allianz General Insurance Company Ltd.

3rd Floor, JMD Regent Plaza, Sikanderpur, Mehrauli -Gurgaon road, Gurgaon - 122002 Contact No:
4064501,4064505; Fax No: 23351427

RECEIPT
Receipt Number

1102-00240470

Receipt Date

24/02/2015

Business Channel

ML

Received with thanks from

DWARKA DASS

(Customer ID : 64551828 ) a total sum of Rupees Five Thousand Eleven Only by,

Instrument
Type

Inst./Ref No

Instrument
Date

Cheque

928526

19/02/2015

Bank Name

Branch Name

INDIAN OVERSEAS PAYABLE AT PAR

BANK

Total Amount

Rs.

Amount
5,011

5,011.00

Note : 42197748

Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General
Insurance Company Limited. The insurance cover for the risk shall be as per the terms and
conditions of the Insurance Policy if and when issued.
* Cheque/DD/PO receipt is valid subject to realisation of the instrument.

For & on behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory
Regd.Office: GE Plaza,Airport Road, Yerwada, Pune - 411006
CIN:U66010PN2000PLC015329; E-mail: customercare@bajajallianz.co.in; Website:www.bajajallianz.com