Trejhara

Mrs. RUPALI MAHESH SADARE

149/4527 KANNAMWAR NAGAR -1
VIKHROLI EAST
MUMBAI
MAHARASHTRA
India
400083
8286005252

Welcome on board.
Your Reliance Commercial Vehicles (GCV Other
than 3 Wheelers Public) Package Policy -
Schedule, with Policy Number
110322423340010405 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 Identification No. U66603MH2000PLC128300 UIN: IRDAN103RP0012V02100001 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/GCV/PS/Ver. 1.3/310118
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 Digitally signed by Reliance
General Insurance
Company Limited
Date: 2024.02.26 [Link]
Trejhara IST

Reliance Commercial Vehicles (GCV Other than 3 Wheelers Public) Package Policy - Schedule

Policy Number : 110322423340010405 Proposal/Covernote No: R26022452544

Insured Name : MRS. RUPALI MAHESH SADARE Period of Insurance : From 14:59 Hrs on 26-Feb-2024 to Midnight of
25-Feb-2025
Communication Address : Policy Issuing Branch :
149/4527 KANNAMWAR NAGAR -1 VIKHROLI EAST MUMBAI, MAHARASHTRA, Unit no- 202, 2nd Floor, Lotus IT Park, Road no- 16, Wagle Industrial Estate,
India, 400083. Thane (west), THANE, MAHARASHTRA, 400604.

Mobile No : 8286005252 Tax Invoice No. & Date: R26022452544 & 26 Feb 2024 03:00
Email-ID : RUPALISADARE@[Link] GSTIN/UIN & Place of Supply : MAHARASHTRA
Insured Vehicle Details
Registration No. NEW Mfg. Month & Year FEB-2024
Make / Model & Variant TATA ACE & GOLD IRISH CREAM PETROL BS6. CC / HP 698
Engine No. / Chassis No. 275MPFI03KWXSD0014 / MAT559036PVK55112 LCC Including Driver 2
Type of Body NA GVW 1680
MAHARASHTRA - Mumbai Eastern Total Premium `
RTO Location 21,598.00
Suburbs-Wadala-Worli
Carrier Type Public IDV ` 800,000.00
Yes Bank Limited. ,
Manufacturer fully build in Yes Hypothecation/Lease
MUMBAI
Vehicle Sub Class TRUCK Goods Type Non Hazardous

Insured Declared Value (IDV)

Chassis IDV ` 0.00 Non Electrical Accessories ` 0.00
Body IDV ` 0.00 CNG / LPG Kit ` 0.00
Vehicle IDV ` 800,000.00 Trailer / Side Car ` 0.00
Electrical / Electronic Accessories ` 0.00 Total IDV ` 800,000.00
Premium Summary
Own Damage - Section I Amount (`) Liability - Section II Amount (`)
Basic OD 2,256.69 Basic Liability (TPPD 1) 16,049.00
Covers for Lamps Tyres/Tubes Mudguards/Bonet/Side Total Basic Liability Premium 16,049.00
parts etc (IMT-23) 338.50 PA Benefits - Section III
Total Basic Own Damage Premium 2,595.19 Compulsory PA cover to Owner Driver 375.00
Total PA Premium 375.00
Legal Liability to paid driver and/or Conductor and/or
100.00
cleaner
TOTAL LIABILITY PREMIUM 16,524.00
TOTAL PACKAGE PREMIUM (Sec I + II + III) 19,119.00
CGST on OD Premium (@9.00 %) 276.00
SGST on OD Premium (@9.00 %) 276.00
CGST on TP Premium (@6.00 %) 963.00
SGST on TP Premium (@6.00 %) 963.00
TOTAL OWN DAMAGE PREMIUM 2,595.19
TOTAL PREMIUM PAYABLE (`) 21,598.00
Subject to [Link]. & Memorandum printed/herein/attached hereto. IMT 15,40,23,21,7
GSTIN :27AABCR6747B1ZG,HSN : 997134,
Description of services : Motor vehicle Insurance Service
"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." As per
PA-Nominee Details Name Age Relation
1 MAHESH SADARE 54 Spouse
Consolidated Stamp duty Paid vide Letter of Authorisation "NO ENF-1/LOA/ENF-1/CSD/52/2024/(Validity Period Dt.01/02/2024 to Dt.01/12/2024)/1163 Date 31-01- 2024”
at General Stamp Office, Mumbai. ** Not Applicable for the State of Jammu & Kashmir

17B37706 / YES BANK LIMITED yestouch@[Link]

Intermediary Code/Name Intermediary Contact No. Intermediary E-mail ID POS UID Aadhaar No. / PAN No.

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.
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Limits of liability : PA cover for owner driver under section III CSI ` 1500000 (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 - ` 7,50,000/-, TPPD 2 Sum
Insured - ` 6,000/-).
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 Vehicle Act, 1988. The Policy covers use for any purpose other than: (a)
Organized racing (b) Pace making (c) Speed testing (d) Reliability trials.
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 ` 500/- (ii) Additional compulsory deductible ` 0/- (iii) Voluntary deductible ` 0/-
The NCB provided is on Basic OD Premium excluding Add-on wherever applicable. The policy wording with detailed terms, conditions and exclusions are available on
our website [Link]
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.
*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.

Safeguard your transaction by paying your premium via crossed cheque/DD in favour of Reliance General Insurance Co. Ltd.
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.
This document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services Tax Rules 2017.
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.

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.
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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 [Link]@[Link]. In case the insured is not satisfied with the response of the office, insured may contact the
Nodal Grievance Officer of the Company at [Link]@[Link]. In the event of unsatisfactory response from the Nodal
Grievance Officer, insured may email to Head Grievance Officer at [Link]@[Link]. 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 [Link] or on company website
[Link] or on [Link]. 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,3rd Floor,Jeevan Seva Annexe,S. V. Road,Santacruz (W), Mumbai - 400 054. Tel.: 022 - 26106552 /
26106960 Fax: 022 - 26106052 Email: [Link]@[Link]
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.

In the unfortunate event of a claim, please call quoting your Policy No. on 022 48903009(Paid) 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
proposal.

Special Conditions : Additional Compulsory Excess of Rs.10000

Policy has been issued with reference to vehicle inspection report, reference lead no. & special [Link] inspection report
remarks can be viewed on company's website by the lead no.
For Reliance General Insurance Co. Ltd.

Authorised Signatory

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.
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0 0 0 Risk Assumption Letter

Dear Mrs. RUPALI MAHESH SADARE
Thank you for choosing Reliance General Insurance.
Please find enclosed policy no.: 110322423340010405 which has been issued based on the details declared by the applicant.

Insured Vehicle Details

Registration No. NEW Mfg. Month & Year FEB-2024
Make / Model & Variant TATA ACE GOLD IRISH CREAM PETROL BS6. CC / HP / Watt 698
Engine No. / Chassis No. 275MPFI03KWXSD0014 / MAT559036PVK55112 LCC Including Driver 2
Type of Body NA GVW 1680
MAHARASHTRA - Mumbai Eastern Total Premium `
RTO Location 21,598.00
Suburbs-Wadala-Worli
Carrier Type Public IDV ` 800,000.00
Yes Bank Limited. ,
Manufacturer fully build in Yes Hypothecation/Lease
MUMBAI

Insured's Declared Value (IDV)

Chassis IDV ` 0.00 Non Electrical Accessories ` 0.00
Body IDV ` 0.00 CNG / LPG Kit ` 0.00
Vehicle IDV ` 800000 Trailer / Side Car ` 0.00
Electrical / Electronic Accessories ` 0.00 Total IDV ` 800,000.00
YOU HAVE OPTED FOR THE FOLLOWING COVERS
Standard Vehicle Own Damage + Third Party Coverage
Cover Electrical/electronic accessories
Non-electrical accessories
Bi-fuel kits comprising LPG/CNG systems
Add-on Covers
Nil Depreciation Cover No deduction for depreciation on vehicle parts other than tyres and tubes with respect of approved partial loss claims.
Additional towing Charges Provides cover for towing charges over and above the standard policy guideline as per the cover opted by customer (Sum
Insured - ` 0.0/-).
Additional Limit of TPPD Indemnify the Insured for an additional TPPD amount opted for damage to property other than the property belonging to the
Insured or held in trust or in custody of Insured.
Emergency Hotel Provide allowance towards the Hotel accommodation insured vehicle met with accident/ stolen 200 kms away from the location
Accomodation provided in policy copy.

Please take a moment to carefully check your policy details mentioned above and in the policy schedule. Kindly confirm that the same are in order. In case of
discrepancies, please let us know immediately. You can write to us at [Link]@[Link] or call us 022 48903009(Paid) for necessary
changes/rectification. 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. Non disclosure and/or misrepresentation of claims in the previous policy period can lead to cancellation of your policy or rejection of your
claims.
(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.)

For Reliance General Insurance Co. Ltd.

Authorised Signatory

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.
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Know your policy

Remember to carefully go through the Risk Assumption Letter and confirm your personal as well as your vehicle details.
In case of any discrepancy in the policy details, kindly revert within 15 days from the policy start date on 022 48903009 (Paid No) or visit any of our branches.
Kindly refer to the Key Feature Document and Policy Wording at [Link] to understand your policy better and learn more about the policy coverages,
add-on covers and Policy Exclusion. This document is a statement of the specific provisions that form the Terms and Conditions of this Policy.

What documents do you require for making any change to your policy
1. Changes in vehicle make & model/cubic capacity/seating capacity/engine & chassis no./year of manufacture/registration no./ location/address
Documents required :Letter for change, policy copy and registration certificate copy along with additional premium cheque, if applicable.
2. Changes in electrical and non electrical accessories/CNG/LPG kit
Documents required :Letter for addition, policy copy, invoice copy of accessories, endorsed registration certificate copy (for CNG/LPG kit) and cheque for additional
premium.
3. Changes in financier details (Hypothecation/Lease/Hire purchase)
Documents required :Letter for change, policy copy, endorsed registration certificate copy and no objection certificate from financier (not mandatory for deletion, if
registration certificate copy is endorsed).

How to register a Claim - Cashless

How to register a Claim - Reimbursement

What documents do you require to register a Claim

1. Claim form duly filled and signed (company stamp in case of company registered vehicles)
2. Registration copy
3. Driving License of the driver at the time of loss
4. Policy copy
5. Vehicle fitness certificate
6. Vehicle route permit
7. Vehicle carriage permit
8. Road tax copy
9. Load Challan (if applicable)
Note: 1. As soon as a claim occurs, please intimate immediately at our call centre 022 48903009 (Paid No) Delay in intimation would result in the violation of policy
condition. 2. Any additional document, if required, will be informed.

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.
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Proposal Form for Reliance Commercial Vehicles Package Policy

(Other than Motor Trade Internal Risks Policy)
(The queries made/details stated below are the minimum requirement to be furnished by a proposer.
The Insurer may seek any other information as desired for under for underwriting purpose.)
*(Applicable to all classes of vehicles with suitable amendments in 'Limitations as to Use')
PCV GCV MISC D Trailer

For Office Use Only

Policy Number 110322423340010405 Date 26-02-2024
Savvion Reference No Inspection Lead No.

Intermediary Details (To be filled in BLOCK LETTERS)

Intermediary Name YES BANK LIMITED Code 17B37706
Branch Name Thane Lotus Code 1103
Sales Manager Name Arjunsingh Yadav Code 70901275
*POS PAN No. *POS UID Aadhaar No.

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. RUPALI MAHESH SADARE
2b. Address Address for Communication Address where vehicle is normally kept and Used

Flat/Building/Door/Block No.
Road /Street/Sector 149/4527 KANNAMWAR NAGAR -1 VIKHROLI
EAST
Nearest Landmark
Area
City MUMBAI
Pin Code 400083
State MAHARASHTRA
Country India
Phone Mobile 8286005252
Emergency Contact No. Blood Group
Email RUPALISADARE@[Link] Fax
3. Period of Insurance From 26/02/2024 To 25/02/2025
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.

Details of the Vehicle

8. Registration Number NEW 9. Date of Registration 26-Feb-2024
10. Registering Authority & Location MAHARASHTRA - Mumbai Eastern Suburbs-Wadala-Worli
11. Year & Month of Manufacture FEB-2024 12. Cubic Capacity 698
13. Engine Number 275MPFI03KWXSD0014
14. Chassis Number MAT559036PVK55112
15. Make of Vehicle TATA
16. Type of Body/Model NA/ACE
17. Gross Vehicle Weight (GVW)/Cubic Capacity (C.C.) 1680
18. Goods type (Applicable only if GVW+7500kgs) Hazardous Goods Non-Hazardous Goods
19. Is the Vehicle made in India? Yes No
20. Max. Licensed carrying capacity (No. of Passengers) in case of Passenger carrying vehicles 1
21. Vehicle Category Bus Taxi
Vehicle usage type (Applicable if bus) : Contract Carriage Stage Carriage Private Usage
Vehicle usage sub type (Applicable if Contract Carriage): School Bus Employee pickup Bus Others
22. Seating capacity (Including Driver) 2

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.
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Details of the Vehicle Type and Use

23. a. Whether the Vehicle is driven by Non-conventional source of power? Yes No If yes Bi Fuel CNG LPG
Non - electrical accessories Electronic accessories fitted Value of CNG/ LPG Kit Bi
Insured's Declared Value (IDV) of vehicle Total Value
fitted to the vehicle to the vehicle Fuel
Chassis Body
(₹) (₹) (₹) (₹)
800,000.00 0.00 0.00 0.00 800,000.00

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.)

24. Details of Driver : (a) Age of Owner Driver Others

(b) Does the driver suffer from defective vision or hearing or any physical infirmity. Yes No
If "Yes" please give details.

(c) Has the driver ever been involved for causing any accident or loss? Yes No
If "Yes" please give details as under including the pending prosecution, if any:-

(d) D.O.B

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

(a) Easy Monthly Instalment (EMI) Protection Cover: (RGI-MO-A00-00-17-V01-14-15) Yes No
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 : ₹ __________________________
(b) Additional Towing Charges
(c) Nil Depreciation Cover:
(d) Total Cover
(e) Voluntary Deductible
Voluntary Deductible amount opted ₹_____________________________________
(f) Emergency Hotel Accommodation
Benefit Amount: ₹0.0
(g) Additional Limit of TPPD
Additional Limit opted: ₹0.0
(h) Personal Belongings Cover
Benefit Amount: ₹0.0
(i) Daily Allowance Benefit
Per day allowance amount opted ₹__________________________________
Coverage Days opted ____________________________________________
(j) Daily Allowance Benefit Plus
Per day allowance amount opted: ₹0.0
Coverage Days opted:0
(k) Tools and Equipment Cover
(c) Any other Details_____________________________________-

26. 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.
27. Are you a member of Automobile Association of India ? If Yes,please submit membership copy. 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 commercial vehicle is also used for Private purposes (excluding use for hire or reward)? Yes No
31. Whether the Vehicle is fitted with Fibre Glass Tank? Yes No

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.
Page 8 of 11
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32. Whether the Vehicle belongs to the Embassy/Consulate of a Foreign Country? Yes No
If so, is the duty element included in the IDV?
33. Whether the Vehicle is design for use of Blind/Handicapped/Mentally Challenged Person? Yes No
34. Date of purchase of the Vehicle by the Proposer 26-Feb-2024
35. Whether the vehicle at the time of purchase was New Second Hand

Risk Inclusions
36. Liability to third parties: The policy provides Third Party Property Damage (TPPD) of ₹ 1 lakh (Two wheelers) and ₹ 7.5 lakhs (other class of vehicles)

Do you wish to restrict the above limits to the statutory TPPD Liability limit of
₹ 6000/- only? Yes No

Do you wish to cover legal liability to?

(a) Driver/Conductor /Cleaner (No. of persons) Yes No
(b) Other employees (No. of Persons) Yes No
(c) Non-fare paying passenger (No. of persons) Yes No

37. Do you wish to include personal Accident (P.A.) Cover for paid drivers, cleaners and conductors? Yes No

If Yes, give name and Capital Sum Insured (CSI) opted for. The maximum CSI available per person is ₹ 1 Lakh in the case of Motorised two wheelers and ₹ 2
lakhs for other classes of vehicles.
38. Personal Accident Cover for Owner Driver. Please give details of nomination
Name of Appointee (if
Name Name of the Nominee Age of Nominee Relationship Address
Nominee is Minor)
MAHESH SADARE 54 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)
39. Do you wish to include Personal Accident cover Named Persons? Yes No

Name of the Appointee

Name CSI Opted Name of Nominee Age of Nominee Relationship Address
(If Nominee is Minor)

40. Extension of Geographical Area

Whether extension of Geographical Area to the following Countries required ?

1. Bangladesh 2. Bhutan 3. Maldives 4. Nepal 5. Pakistan 6. Sri Lanka

Details of Hire Purchase / Hypothecation / Lease
41. Please state if the vehicle is under Hire Purchase Lease Agreement Hypothecation Agreement
If so, give name and address of concerned parties.
42. Full Name M/s. Yes Bank Limited.
43. Address MUMBAI
Non - electrical accessories Electronic accessories fitted Value of CNG/ LPG Kit Bi
Insured's Declared Value (IDV) of vehicle Total Value
fitted to the vehicle to the vehicle Fuel
Chassis Body
(₹) (₹) (₹) (₹)
800,000.00 0.00 0.00 0.00 800,000.00
Note
The Insured's Declared Value (IDV) of the vehicle will be deemed to be the 'SUM INSURED' for the purpose of this tariff and it will be fixed at the commencement of
each policy period for each insured vehicle.
The IDV of the vehicle is to be fixed on the basis of manufacturers' listed selling price of the brand & model as the vehicle proposed for insurance at the commencement
of insurance / renewal, and adjusted for depreciation as per policy wordings.

Details of Previous Insurance

44. Full Name of previous insurer
45. Address -
46. Policy Number Previous Policy Expiry 01-Jan-00
47. Type of Cover Package Policy Liability only others (to be describe)
48. NO CLAIM BONUS allowed under previous policy (%)
49. Claims taken in previous policy Yes No
If yes, No. of Claims Claims Amount `

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.
Page 9 of 11
 Trejhara

50. Are you entitled to No Claim Bonus Yes No

If yes, please submit/attached proof thereof

Payment Details

Cheque/ DD Cheque/ DD No.

Cheque/ DD Date Cash Credit Card Others
Proposer's Bank Details
51. Name of the Bank Account Holder
52. Bank Account No.: 55. Account: Saving Current
53. Name of the Bank
54. Branch
55. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque
issued by the bank)
56. 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 mandatory that all payments made to the insured are only through electronic mode.

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 [Link]. 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 : 26 Feb 2024 03:00 Date : 26 Feb 2024 03:00

Signature Signature of Proposer & Company Seal

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.
Page 10 of 11
 Trejhara

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
Name of IRDAI Agent/ Broker Mr. Mrs. YES BANK LIMITED
Place
Date 26 Feb 2024 03:00
(In case of Direct Business, Name & Signature of CSO /SM to be taken) Signature of IRDAI Agent/ Broker
* Mandatory details to be filled

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: IRDAN103RP0012V02100001. 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/GCV/PS/Ver. 1.3/310118.
Page 11 of 11