BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LTD.

Policy Servicing Office Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune-411014 PH:1800-209-0144
Policy Number OG-18-9906-1806-00031976 Product Two Wheeler -Liability Only Policy
Period Of Insurance From: 30-OCT-2017 (Hrs) Policy issued on 29-OCT-2017
To: 29-OCT-2018 Midnight Cover Note No. /
Insured Name K NARAYANA SAMY Zone B
Insured Address 154/236, PRAGATI NAGAR, STREET, RIS-
ALI, BHILAI TALUKA, DURG DISTRICT, , ,
RAIPUR, CHATTISGARH-490006
Customer Id 107567420 Premium Payer Id 107567420
Application No 0 Scrutiny No 76561888
Reference No : null
Policy Status ISSUED
GSTIN / UIN STATE CODE / NAME
Coinsurance Details : .
Registration No Make Model SubType CC Year Of Mfg Seat Cap Chassis number. Engine No.
CG04CF1603 HERO HONDA CD 100 STD 100 2004 2 04D14F00728 04D13E00522

Elec. Accessories Non-Elec. Acc. Side Car CNG/LPG Unit

0 0 0 0
SCHEDULE OF PREMIUM
Own Damage Liability
Total Own Damage Premium 0 Basic Third Party Liability 720
PA Cover for Owner-Driver of Rs. 100000 50
Total Act Premium: 770
Total Premium 770
Special Discount 0
Net Premium 770

Final Premium Rs. 909 *** All Premium Figures are in Rupees

Geographical Area : India Voluntary Excess : Nil

Compulsory Deductible : Rs. 0 Additional Compulsory Deductible : Rs. 0
Previous Insurer - Cholamandalam MS General Insurance Company Limited. Previous Policy No - NA Expiry On - 29-OCT-17
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. 100000
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.

Contact No : 0/1800-103-3999
Email -
Plan Description:
Premium Collection Details :- [Receipt No/Collection No/Amount] 9906-01490817,/76561888,/ Rs.909,
*** 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 'customercare@bajajallianz.co.in'
76561888/-/10043080/99060001/-
PIN NO : NA Damage Details: NA
Remarks : PDA MODULE
Kindly contact our nearest / local office(s) for No Claim Bonus Confirmations.
This is duplicate copy of the document and will not be valid unless QC Verified and Signed/Countersigned by an authorized signatory of Bajaj Allianz General Insurance Co.Ltd.

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

Authorized Signatory
Printed , Signed and Executed at Pune null
Regd Office : GE Plaza,Airport Road, Yerwada Pune-411006 (India)

Regd. Office : GE Plaza, Airport Road, Yerawada,Pune - 411006 (India),A Company incorporated under Indian Companies Act, 1956 and licensed by
Insurance Regulatory and Development Authority of India [IRDA] vide Reg No.113, Corporate Identification Number U66010PN2000PLC015329.
-Latest Schedule- 29-Oct-2017 18:54:51 PM (Web)
Generated by Silent_Printing
 Bajaj Allianz General Insurance Company Ltd.
Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune - 411014 Contact No:
1800-209-0144

COPY RECEIPT

Receipt Number 9906-01490817

Receipt Date 29/10/2017
Business Channel WS

Received with thanks from K NARAYANA SAMY

(Customer ID : 107567420 ) a total sum of Rupees Nine Hundred Nine Only by,

Instrument Inst./Ref No Instrument Bank Name Branch Name Amount

Type Date
Credit Card 3132844 29/10/2017 909

Total Amount Rs. 909.00

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