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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 NIRUPA D SHAH,

We wish to inform you that the contract under policy number 'OG-12-1901-1801-00030826' 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. On the first inception of the Policy, you have a period of 15 days from the date of receipt of the documents to review the terms and conditions of the Policy. Where you disagree to any of those terms or conditions, you have the option to return the Policy stating the reasons for your objection, wherein you shall be entitled to a refund of the premium paid, subject only to there being no claim made under the Policy and also subject to a deduction of the expenses incurred by us and the stamp duty charges

Details provided by you:

A. Proposer details

1. Proposer Name

: NIRUPA D SHAH

2. Proposer Address

: 9, GAJANAND NIWAS, LIBERTY GARDEN ROAD NO.2

 

 

., MALAD WEST, MUMBAI-400064

3.

Proposer Mobile Number

:

4.

Proposer Residential Number

: NA

5.

Proposer e-mail id

: NA

6.

Proposer Profession

: NA

B.Vehicle Details

Registration

Month / Year of

Vehicle Make

Vehicle Model

Vehicle Sub

Cubic Capacity

Fuel Type

 

Year of Manu-

Seating Capacity

Number

 

Regn

 

 

 

Type

 

 

 

 

 

 

facture

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MH04CJ3450

OCT/2005

HONDA

CITY ZX

 

EXI

 

1497

Petrol

 

2005

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Engine Number

 

Chassis Number

Vehicle IDV (in Rs.)

Electrical

 

Non-Electrical

 

CNG/LPG Unit

Total IDV (in Rs.)

 

 

 

 

 

 

 

Accessories IDV

Accessories IDV

 

(Extra fitted) IDV

 

 

 

 

 

 

 

 

(in Rs.)

 

(in Rs.)

 

 

(in Rs.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30054500

 

 

221682

282079

 

0

 

 

 

0

 

16000

298079

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Coverage opted

1.

Period of Insurance

: From 17-OCT-2011 00:00 (Hrs) To 16-OCT-2012 Midnight

2.

Is your vehicle fitted with LPG/CNG kit.

: Yes

3.

Electrical Accessories cover Opted (If Applicable)

: No.

4.

Non - Electrical Accessories cover Opted (If Applicable):

: No.

5.

Is Voluntary Excess opted

: No.

 

Amount of voluntary excess opted

: Rs.NA.

6.

Whether PA cover is opted for owner-driver

: Yes.

7.

Is any additional compulsory deductible imposed and agreed upon

: No.

 

Amount of additional compulsory deductible imposed

: NA.

8.

Whether geographical area extension is opted

: No.

 

Details of Countries to which geographical area extension cover is given

: 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

: No.

 

Sum Insured for Paid Driver

: Rs.NA.

11.

Whether PA cover is opted for passengers

: Yes.

 

 

Sum Insured per Passenger

: Rs.60000.

12.

Is TPPD restricted to statutory limit of Rs.6000?

: No.

13.

Premium for Liability coverage, quoted and agreed upon is

: Rs.1215.

14.

Premium for OD coverage, quoted and agreed upon is

: Rs.9278.

15.Total Premium (excluding Service Tax and Education Cess) for Liability and OD coverages, quoted and agreed upon is : Rs.10493

16.NCB (No Claim Bonus) claimed by you and granted by us based on your declaration of no claim during your previous policy : 0 %.

17.About the last insurance company

(i)Insurance Provider : RELIANCE General Insurance CO. Ltd..

(ii)Previous Policy No : 1105702311002623, Previous Policy Expiry Date :16-OCT-11

18.Whether your vehicle is Hypothecated and if so the details of Pledgee whose name is registered by us: No. Name of Pledgee : NA.

19.Add on Cover(s) opted : No.Plan name:NA

Please note Cover Note No. issued to you basing 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

:

1800-22-5858, 1800-102-5858 ,1800-102-5858,1800-209-5959

Email address

:

info@bajajallianz.co.in.

Website

:

www.bajajallianz.com.

Contact our policy servicing branch at: 952/954, Appa Saheb Marathe Marg,, Near Chaitanya Tower,, Prabhadevi, ,, Mumbai-400025 PH:022-66628666.

For Bajaj Allianz General Insurance Co Ltd

Authorized signatory

 

 

 

 

 

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LTD.

 

CERTIFICATE CUM POLICY SCHEDULE

 

 

DUPLICATE COPY

 

Policy Servicing Office

952/954, Appa Saheb Marathe Marg,, Near Chaitanya Tower,, Prabhadevi, ,, Mumbai-400025

 

PH:022-66628666

Policy Number

OG-12-1901-1801-00030826

Period Of Insurance

From: 17-OCT-2011 00:00 (Hrs)

 

To: 16-OCT-2012 Midnight

Insured Name

NIRUPA D SHAH

Insured Address

9, GAJANAND NIWAS, LIBERTY GARDEN

 

ROAD NO.2 ., MALAD WEST, MUMBAI-

 

400064

Product

Private Car - Package Policy

Policy issued on

31-OCT-2011

Cover Note No.

 

Zone

A

Customer Id

 

 

41227450

 

 

 

 

 

 

 

Premium Payer Id

41227450

 

 

 

 

 

 

Application No

 

 

1904119805

 

 

 

 

 

 

 

Scrutiny No

 

 

14267740

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy Status

 

 

ISSUED

 

 

 

 

Coinsurance Details : NA.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Registration No

 

Make

 

Model

 

SubType

 

CC

 

 

Year Of Mfg

Seat Cap

Chassis number.

 

Engine No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MH04CJ3450

 

HONDA

 

CITY ZX

 

EXI

 

1497

 

 

2005

5

 

221682

 

 

30054500

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle IDV

 

Elec. Accessories

 

Non-Elec. Acc.

 

Trailer

 

 

CNG/LPG Unit

 

Total Sum Insured

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

282079

 

 

 

0

 

 

 

0

 

 

 

null

 

 

16000

 

 

298079

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCHEDULE OF PREMIUM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Own Damage

 

 

 

 

 

 

 

 

 

 

Liability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Own Damage Premium

 

 

9278

 

Basic Third Party Liability

 

 

 

 

 

880

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CNG/LPG Unit

 

 

 

 

 

 

60

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PA Cover for Owner-Driver of Rs. 200000

 

 

 

100

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PA Cover For 5 Passanger Of Rs. 60000 each

 

150

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LL to person for Paid driver/Operation/Maintenance

 

25

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Act Premium:

 

 

 

 

 

1215

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Premium

 

 

 

 

10493

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Special Discount

 

 

 

 

0

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Net Premium

 

 

 

 

10493

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service Tax

 

 

 

 

1049

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Edu Cess

 

 

 

 

31

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*** All Premium Figures are in Rupees

 

 

 

 

 

 

 

Final Premium Rs.

 

 

 

 

11573

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Geographical Area : India

 

No Claim Bonus : 0%

 

Voluntary Excess : Nil

 

 

 

 

Compulsory Deductible : Rs. 500

 

Additional Compulsory Deductible : Rs. 0

 

 

 

 

 

 

 

 

 

Previous Insurer - RELIANCE General Insurance CO. Ltd. Previous Policy No - 1105702311002623 Expiry On - 16-OCT-11

The above Total OD Premium is inclusive of all applicable Loading/Discounts viz (Automobile Association Membership,Voluntary Excess,Anti-Theft,Handicap Per- son,Driver Tution,Fibre Glass,Cng/Lpg Unit,Geographical Extn,Imported Vehicle etc wherever applicable)

LIMITS OF LIABILITY: 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

LIMITATION AS TO USE : 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 ra- cing, Pace making, Speed testing, Reliability trials, Any purpose in connection with Motor Trade.

DRIVER : Any person including the insured Provided that a person driving holds an effective driving licence at the time of the accident and is not disqualified from holding or obtaining such a licence. Provided also that the person holding an effective Learner's licence may also drive the vehicle and that such a person satisfies the requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.

Past Claim Reference :

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.

Subject to IMT Endorsement Nos: 22, 25, 16, 28 & Policy wordings attached herewith

Agency Code

 

Agency Name :

 

 

 

Contact No :

Email -

 

 

 

Premium Collection Details :- [Receipt No/Collection No/Amount] 1901-00858064,1901-00861027,/1,1,/ Rs.10133,1440,

*** If premium paid through cheque, the policy is void ab-initio in case of dishonor of cheque.

This certificate of insurance is issued in accordance with the provision of Chapter X and Chapter XI of M.V.Act, 1988.

In case of any claim, please contact our 24 Hour Call centre at 1800-22-5858, 1800-102-5858 ,1800-102-5858,1800-209-5959(Toll Free) / 91-020-30305858 (chargeable, add area code before this number in case of mobile call) or email us at 'info@bajajallianz.co.in'

14267740/1904119805/10000169/-/- Damage Details : -

PIN NO : NA Remarks :

Kindly contact our nearest / local office(s) for No Claim Bonus Confirmations.

This document is duplicate copy of the document and will not be valid unless QC Verified and Signed/Counter Signed by an authorized signatory of Bajaj Alli- anz General Insurance Co.Ltd.

For & On Behalf of Bajaj Allianz General Insurance Company Ltd.

Regd. Office : GE Plaza, Airport Road, Yerawada,Pune - 411006 (India)

Service Tax Reg. No. AABCB5730G-ST-001

 

-Latest Schedule- 31-Oct-2011 19:04:07 PM (Web)

Authorized Signatory

Printed , Signed and Executed at Pune

QC Verified and Signed/Counter Signed by

Regd Office : GE Plaza,Airport Road, Yerwada Pune-411006 (India)

.

Bajaj Allianz General Insurance Company Ltd.

952/954, Appa Saheb Marathe Marg,, Near Chaitanya Tower,, Prabhadevi, ,, Mumbai-400025 Contact

No:022-66628666, 022-66027777/67402424

 

RECEIPT

Receipt Number

1901-00861027

Receipt Date

28/10/2011

Business Channel

MD

Received with thanks from

NIRUPA D SHAH

(Customer ID : 41227450 ) a total sum of Rupees One Thousand Four Hundred Forty Only by,

Instrument

Instrument No.

Instrument

Bank Name

Branch Name

 

Amount

Type

 

Date

 

 

 

 

 

 

 

 

 

 

 

Cheque

000952

14/10/2011

BANK OF INDIA

MALAD (W)

 

1,440

 

 

 

 

(MAW)

 

 

 

 

 

 

 

 

 

 

 

 

Total Amount

Rs.

1,440.00

Note : SC-14060603

Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General In- surance Company Limited. The insurance cover for the risk shall be as per the terms and con- ditions of the Insurance Policy if and when issued.

* Receipt Subject to realisation of cheque(s)

For & on behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory

Regd.Office: GE Plaza,Airport Road, Yerwada, Pune - 411006

Regd. Office : GE Plaza, Airport Road, Yerawada,Pune - 411006 (India)

Service Tax Reg. No. AABCB5730G-ST-001

 

-Latest Schedule- 31-Oct-2011 19:04:07 PM (Web)

.

Bajaj Allianz General Insurance Company Ltd.

952/954, Appa Saheb Marathe Marg,, Near Chaitanya Tower,, Prabhadevi, ,, Mumbai-400025 Contact

No:022-66628666, 022-66027777/67402424

 

RECEIPT

Receipt Number

1901-00858064

Receipt Date

19/10/2011

Business Channel

MD

Received with thanks from

NIRUPA D SHAH

(Customer ID : 41227450 ) a total sum of Rupees Ten Thousand One Hundred Thirty Three Only by,

Instrument

Instrument No.

Instrument

Bank Name

Branch Name

 

Amount

Type

 

Date

 

 

 

 

 

 

 

 

 

 

 

Cheque

000899

16/10/2011

BANK OF INDIA

MALAD (W)

 

10,133

 

 

 

 

(MAW)

 

 

 

 

 

 

 

 

 

 

 

 

Total Amount

Rs.

10,133.00

Note : 14060603

Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General In- surance Company Limited. The insurance cover for the risk shall be as per the terms and con- ditions of the Insurance Policy if and when issued.

* Receipt Subject to realisation of cheque(s)

For & on behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory

Regd.Office: GE Plaza,Airport Road, Yerwada, Pune - 411006

Regd. Office : GE Plaza, Airport Road, Yerawada,Pune - 411006 (India)

Service Tax Reg. No. AABCB5730G-ST-001

 

-Latest Schedule- 31-Oct-2011 19:04:07 PM (Web)