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 JAIMINBHAI M PATEL,

We wish to inform you that the contract under policy number 'OG-11-2202-1801-00039677' 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 : JAIMINBHAI M PATEL

2. Proposer Address : 34/A MADHOVRUND SOCIETY, SWEETPARK SOCIETY NR K K NAGAR

., GHATLODIAAHMEDABAD, AHMEDABAD-380061

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

GJ01HQ4371 JAN/2008 SKODA OCTAVIA AMBIENTE 1.9 1896 Diesel 2008 5

TDI

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.)

22493 006104 743378 0 0 0 743378

 C. Coverage opted

1. Period of Insurance : From 30-MAR-2011 00:00 (Hrs) To 29-MAR-2012 Midnight

2. Is your vehicle fitted with 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 : 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.200000.

12. Is TPPD restricted to statutory limit of Rs.6000? : No.

13. Premium for Liability coverage, quoted and agreed upon is : Rs.3125.

14. Premium for OD coverage, quoted and agreed upon is : Rs.12467.

15. Total Premium (excluding Service Tax and Education Cess) for Liability and OD coverages, quoted and agreed upon is : Rs.15592

16. NCB (No Claim Bonus) claimed by you and granted by us based on your declaration of no claim during your previous policy : -35 %.

17. About the last insurance company

(i) Insurance Provider : Bajaj Allianz General Insurance Co Ltd..

(ii) Previous Policy No : OG-10-2202-1801-00028383, Previous Policy Expiry Date :29-MAR-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: 204,206 Time Square, Nr. Pariseema Complex, C.G Road, Ellisbridge, Ahmedabad-380006
PH:079-40076426,079-65100189.
For Bajaj Allianz General Insurance Co Ltd

Authorized signatory
 


BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LTD.

CERTIFICATE CUM POLICY SCHEDULE
DUPLICATE COPY
Policy Servicing Office 204,206 Time Square, Nr. Pariseema Complex, C.G Road, Ellisbridge, Ahmedabad-380006
PH:079-40076426,079-65100189
Policy Number OG-11-2202-1801-00039677 Product Private Car - Package Policy
Period Of Insurance From: 30-MAR-2011 00:00 (Hrs) Policy issued on 24-MAR-2011
To: 29-MAR-2012 Midnight Cover Note No.
Insured Name JAIMINBHAI M PATEL Zone A
Insured Address 34/A MADHOVRUND SOCIETY, SWEET-
PARK SOCIETY NR K K NAGAR ., GHATLO-
DIAAHMEDABAD, AHMEDABAD-380061
Customer Id 33419937 Premium Payer Id 33419937
Application No null Scrutiny No 10321349
Policy Status ISSUED
Coinsurance Details : NA.
Registration No Make Model SubType CC Year Of Mfg Seat Cap Chassis number. Engine No.
GJ01HQ4371 SKODA OCTAVIA AMBIENTE 1.9 1896 2008 5 006104 22493
TDI
Vehicle IDV Elec. Accessories Non-Elec. Acc. Trailer CNG/LPG Unit Total Sum Insured
743378 0 0 null 0 743378
SCHEDULE OF PREMIUM
Own Damage Liability
Total Own Damage Premium 12467 Basic Third Party Liability 2500
PA Cover for Owner-Driver of Rs. 200000 100
PA Cover For 5 Passanger Of Rs. 200000 each 500
LL to person for Paid driver/Operation/Maintenance 25
Total Act Premium: 3125
Total Premium 15592
Special Discount 0

Net Premium 15592

Service Tax 1559
Edu Cess 47
Final Premium Rs. 17198 *** All Premium Figures are in Rupees
Geographical Area : India No Claim Bonus : -35% Voluntary Excess : Nil
Compulsory Deductible : Rs. 1000 Additional Compulsory Deductible : Rs. 0
Previous Insurer - Bajaj Allianz General Insurance Co Ltd. Previous Policy No - OG-10-2202-1801-00028383 Expiry On - 29-MAR-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 : OC-12-2202-1801-00007181
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, 28, 16, & Policy wordings attached herewith

Agency Code 10031474 Agency Name : PATHIK BHARATKUMAR PATEL

Contact No : 0/0 Email -
Premium Collection Details :- [Receipt No/Collection No/Amount] 2202-00766399,/1,/ Rs.17197,
*** 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'
10321349/-/10031474/0/-
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- 20-Oct-2011 11:50:46 AM (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.
204,206 Time Square, Nr. Pariseema Complex, C.G Road, Ellisbridge, Ahmedabad-380006 Contact
No:079-40076426,079-65100189,

RECEIPT

Receipt Number 2202-00766399

Receipt Date 24/03/2011
Business Channel ML

Received with thanks from JAIMINBHAI M PATEL

(Customer ID : 33419937 ) a total sum of Rupees Seventeen Thousand One Hundred Ninety
Seven Only by,

Instrument Instrument No. Instrument Bank Name Branch Name Amount

Type Date
Cheque 695776 23/03/2011 NAVNIRMAN CO-OP RANIP (RNP) 17,197
BANK
LTD,AHMEDABAD

Total Amount Rs. 17,197.00

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- 20-Oct-2011 11:50:46 AM (Web)