Date : 08/06/2015

MRS DR CHARU GAHALOT GUPTA

89 SILVER HILLS

DHAR-454001

Dear MRS DR CHARU GAHALOT GUPTA

INVITATION TO RENEW YOUR MOTOR POLICY NO.I1662458

Thank you for insuring your motor vehicle with Bharti AXA General Insurance Co. Ltd. We
thank you for your patronage and hope that you will continue to remain our customer.
We wish to inform you that your SMART Motor Private Car Policy no. I1662458 is due to expire
on 09/07/2015 . The premium due on renewal is INR 9037 (incl of S.tax).
The renewal premium mentioned above is valid only if there is no change in any of the current
information before the expiry of the policy.
Payment Mode
Kindly issue cheque/DD in favor of "Bharti AXA General Insurance Co.Ltd."
The premium amount is computed based on the criteria mentioned below:
1) The premium quote is based on the claim experience under the current policy as on date of
generation of this renewal Notice.
2) If any claim is reported subsequently, No-Claim-Bonus benefit will not be applicable and
premium is subject to change.
3) In case, the renewal instruction is received by us later than 09/07/2015 , acceptance of the
vehicle would be subject to satisfactory inspection and underwriting guidelines effective on the
date of receipt of instruction.
4) Kindly check your vehicle details and policy details before signing the document/s and return
the document/s to our representative along with the premium payment.
5) Kindly issue the cheque/DD in favour of "Bharti AXA General Insurance Co. Ltd."
If you have any further enquiry or need any details on our other products please call our
Toll free No. 1800 103 2292

Your's Truly,

For Bharti AXA General Insurance Co. Ltd. (IRDA Regn. No.139 )

This is a computer generated letter.No signature is required.

a) IMD Code / Staff ID: M1000066 / 003054

b) Vehicle Details:
1) Make and Model: TOYOTA ETIOS VD
2) Year of Manf: 2012
3) CC/Tonnage: 1364 / 0
4) Seating Capacity: 5
5) Coverage: COMPREHENSIVE
6) Vehicle /Non Elec.Acc.IDV: INR 518854
7) Registration no: MP11CC0667
8) Chassis no: MBJB49BT000025739
9) Engine no: 1255888
10) Financing Institution: BANK OF MAHARASTRA

If any of the above mentioned details are found incorrect, kindly provide us with the correct
details in the sheet submitted to our representative.
Insurance is the subject matter of the solicitation.
Reference no: Date : 08/06/2015
Policy No: I1662458
Policy Expiry Date: 09/07/2015 Communication Address:
To: 89 SILVER HILLS
Client Number: 07296808
MRS DR CHARU GAHALOT GUPTA
DHAR-454001
IMD Code / Staff ID: M1000066 / 003054
Proposed Correction/ Changes on Renewal
Make and Model TOYOTA ETIOS VD Registration No MP11CC0667
Year of Manf 2012 Regn Location/Zone MP11 / B
CC/Tonnage 1364 / 0 Chassis No MBJB49BT000025739
Seating Capacity/LCC 5 Engine No 1255888
BANK OF
Coverage COMPREHENSIVE Financing Institution
MAHARASTRA
Vehicle /Non Elec.Acc.IDV INR 518854 IDV Trailer/Side Car INR 0
Electrical Accessories IDV INR 0 Bi Fuel Kit IDV INR 0
Kindly submit RC Book copy for changes to be made in the above mentioned Vehicle details. And letter from Financier in case of any change in the
Financing Institution
Proposed Correction/ Changes on Renewal
Depreciated IDV INR 518854 Basic TP Premium INR 1598
Basic Premium INR 16556 Comp PA to Owner Driver INR 100
Electrical Accessories Premium INR 0 PA to Passengers INR 250
Bi Fuel Kit Premium(CNG/LPG) INR 0 Legal Liability to Paid Driver INR 50
Geographical Extn Premium INR 0 Liability for bi fuel Kit INR 0
Fibre Glass Premium INR 0 Geographical Extn Premium INR 0
Trailer OD Premium INR 0 Trailer/Side car TP Premium INR 0
Own Premises Premium INR 0 Restricted TPPD INR 0
IMT-23 Premium INR 0 LL to NonFare INR 0
AAI Discount Premium INR 0 Bi Fuel Kit TP Premium INR 0
Overturning Premium INR 0 Legal Liability to Others INR 0
Voluntary excess Premium INR 0 Total Liability Premium INR 1998
Anti Theft Discount INR 0 Total:- OD and TP Premium INR 7928
Handicapped Discount INR 0 Service Tax INR 1109
NCB Percentage 35%
NCB Amount INR 5794 Premium Payable INR 9037
Total OD Premium INR 5930
Proposed insurance period (In case of break in insurance) From:time _________ am/pm Date ____________ to midnight on_________________.

Additions (if any)

I/We wish to include the below mentioned Accessories/Coverage to my renewal policy. All the accessories stated by me are already installed by me/us
in the vehicle
Description Details Sum Insured Premium

Changed Communication Address:

Residence Telephone no: Office Telephone no:

Mobile no: Email ID:

Payment Details
Cheque/DD no. : Date :
Insured Bank Account Details
A/C no: Bank Name: IFSC Code:
Branch Name & Address:
I/We acknowledge receipt of the renewal notice in respect of my Motor Policy and agree to renew the said policy for one calender Year as per the
details provided herein.
I/We hereby declare that the information provided above is true and correct.

CC : 0 Date: Signature of the Insured.