Bajaj Allianz General Insurance Company Ltd.

Issuing Office: Bajaj Finserv,1st Floor , Survey # 208/1-B, Behind Weikfield IT-Park, Viman Nagar, Pune-
411014, Contact No: 1800-209-0144
Date: 15-APR-18 Reference No: ARU19861978
Generated by : ONLINE
plot no 85 ,vgn platina
TIRUVALLUR
TAMIL NADU
Dear ARUN ,
Re.: Your enquiry for premium quotation for vehicle
We thank you for your enquiry for quote on insurance premium for your registered as Private Car. Details of
your requirement are noted below -
Make Model SubType CC Fuel Year of Registered NCB at
Manufacture Seating Renewal
MAHINDRA SCORPIO SLX TURBO 7 2609 Diesel 2007 7 50%
AND SEATER
MAHINDRA

Vehicle IDV Value of Electrical Value of Non-Electrical Value of CNG/LPG Unit Total IDV
Accessories Accessories -extra fitted
266035 0 0 0 266035

Proposed Insurance Policy Expiry Date Date of Vehicle Pin Code of your Vehicle Registration Voluntary Ex-
commencement date Registration normal place of city cess
stay
05-MAY-18 04-MAY-19 15-SEP-07 600077 CHENNAI 15000

Based on the cited details, we are pleased to quote our premium as under: (* All figures in Rupees)
Net OD Premium Net TP Premium Total Premium Integrated GST Final Premium
1880 7990 9870 1777 11647

Add-On Covers : 24x7 SPOT ASSISTANCE

Important Notes :
1. This quotation is based on information provided to us and is subject to relevant proofs being submitted
and inspection of vehicle at the time of issuance of policy. Quote is subject to change based on doc-
umentation and in case actual information at the time of issuance differs from the above.
2. This submission is only a quotation and not an insurance policy or cover note. The insurance coverage
would start only after issuance of policy and receipt of payment of premium subject to terms of policy.
3. This quote is valid for 30 days from Proposed Insurance commencement date noted above.
4. The premium quoted is for an insurance period from 05-MAY-18 to 04-MAY-19 .
5. You are requested to return duly signed copy of this quote as a confirmation of acceptance of the terms
and reconfirmation of information provided above.
6. Alternately you may send your objection, what so ever with regard to the above quote or the terms and
condition of policy issued, within 7 days from the date of this quote, failing which it will be concluded that
you are fully satisfied and have accepted the quote including the terms and condition of the policy and
the correctness of the information provided above.
7. Policy would be issued after tendering full premium quoted above and subject to inspection of vehicle
where required.
8. Please furnish us the following information for issuance of policy. a) Previous insurance policy copy /
Renewal Notice b) NCB confirmation letter c) Copy of Registration certificate d) Copy of driving license
Insurance.
9. Act 1938, Section 41- Prohibition of Rebates
10. The Above quote will be valid if the policy is bought online.
• 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 or 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 ex-
cept such rebate as may allowed in accordance with prospectus or tables of the Insurer.
• Any person making default in complying with the provisions of this section shall be punishable with fine,
which may extend to five hundred rupees.

Thanking You,
Websales Team,
Bajaj Allianz General Insurance Company Limited.
This is an electronically generated quotation and does not require any signature.
Please turn overleaf
Registered & Corporate Office - G E Plaza, Airport Road, Yerwada, PUNE 411 006
Date: 15-APR-18
Reference No: ARUN
Generated by : ONLINE

To,

Bajaj Allianz General Insurance Co. Ltd.

I/We acknowledge receipt of your Quote-cum-Proposal and accept the terms and intend to insure my/our
vehicle detailed therein with you. I/We agree that this Proposal and the declarations shall be the basis of the
contract between Bajaj Allianz and me/us. I/We confirm that the vehicle is being used for private purposes
only. I/We warrant the truth of the forgoing statements in every respect and agree that if I/We have made
any false statement or provided false information, the claim shall be repudiated and premium forfeited. I/We
also declare that if any additions or alterations are carried out after the submission of this Quote-
cum-Proposal, then the same would be conveyed to Bajaj Allianz immediately.

cash
Please find attached my/our remittance of premium of Rs.11647/- by Cash/Cheque No__________
dated____________ nil
17/04/2018 drawn on______________________________________ towards issuance of the
Policy with the following additional information.

Registration No: TN01AE7103 Engine No : B374M72027 Chassis No: MAITB2BSL82A68742

Pin Code : 600077 Vehicle Make : MAHINDRA AND Vehicle Model : SCORPIO
MAHINDRA
Sub Type : SLX TURBO 7 SEATER Fuel : Diesel Registration Date : 15-SEP-07

NCB : 50% Total IDV : Rs.266035/- Voluntary Excess: 15000

Proposed Insurance commencement date : 05-MAY-18 Policy Expiry Date : 04-MAY-19

Please mention your Name, Mobile Number and Reference Number on the reverse of cheque.

17/04/2018
Date : ___________________ Signature of Proposer : ____________________

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