THE NEW INDIA ASSURANCE CO. LTD.

(Government of India Undertaking)

POLICY SCHEDULE CUM CERTIFICATE OF INSURANCE

Two Wheeler Package Policy

Insured's Details Policy Details

Insured's Name: BENET PEREIRA Policy number: 76310031190100008909
Customer ID: PO62763643 (PAN No :NA) Period of cover: 04/09/2019 12:00:01 AM to 03/09/2020
11:59:59 PM
Insureds Address: KONATHU PURAYIDOM PUTHUKURICHY P Registration no. KL-22-E-9942
O TRIVANDRUM,,,
PUTHENCURICHY ,KERALA, 695303
Prev. Policy no. 76310031180100003089 Make/Model: HERO/GLAMOUR 125
Email: Receipt no. 76310081190000009548 - 02/09/19
Phone Number : / / 9447221918 Fax Number : NA / NA
GSTIN/UIN NA / NA
Issuing office New India Contact
Address TRIVANDRUM DO III (763100), Agent / Corp. Agent /
2ND FLOOR,TC 26/1436,GOVT. PRESS ROAD , , , Broker / Banc Ms. Reshma Krishnan J -
KERALA , 695001. Assurance / Referral
Code - Name /
(NIAAG00100331)
POS/IMF/SPECIFIED
PERSON/Designated
Person for MISP
Phone no / / 8943433235
Phone no 4712330741 Fax no. /
Fax no. NA / NA Email 15rk88@gmail.com /
Email nia.763100@newindia.co.in Development officer BRANCH MANAGER. DIRECT - (2D5602979)
level Name/Code/Web
Aggregator
Claim Contact Trivandrum Claim Hub (760002) Claim Contact Detail T.C. 26/1436,GOVT. PRESS
ROAD,;04712324058/04712324058/
GSTIN 32AAACN4165C4ZX
SAC 997139 (Other non-life insurance services excl RI)
Policy Details
Geographical Area / Zone: India/B Year of manufacture: 2013
Name of the Financier: Chassis no./Engine no.: MBLJA06ACDGG02131/JA06EJDGG0
2178
Type of fuel: Petrol Cubic capacity ( cc)/Wattage(kW): 125cc
Type of body: Metal/Petrol Variant: GLAMOUR 125 (125 CC)
Seating capacity including Driver: 2 Colour: BLACK WITH RED
Automobile Association none Name of registration authority: Thiruvananthapuram - Kazhakuttam
membership:
Cover Note No/Cover Note Issue /
Date:
IDV (in `)
Vehicle Trailer Non-Elec Acc Electrical Acc Bi-fuel kit Total Value
25600 0 0 0 0 25600

Schedule of Premium
Own Damage Liability
Basic OD Cover Basic TP Cover
Compulsory PA cover for Owner Driver
(Sum Insured `15,00,000)

OD Premium in ` 451 TP Premium in ` 1027

Net Premium in `: 1478
GST in `: 281
Total Payable in `: 1759
Total Payable in `(in words): RUPEES ONE
THOUSAND SEVEN
HUNDRED FIFTY-
NINE ONLY
Limitations as to use Limits of Liability

Signature Not
Verified
Digitally signed
by Srinivasan Policy No. : 76310031190100008909Document generated by AG_0108511 at 02/09/2019 12:26:47 Hours.
Vaideswaran Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Date: 2019.09.02
For 12:26:52
redressal of your grievance, if any,you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3. Head office.In case, you are not satisfied with
IST
our own grievance redressal mechanism; you may also approach Insurance Ombudsman. For details of our office addresses and addresses of office of Insurance Ombudsman, please
visit our website http://newindia.co.in.

Page 1 of 3
 THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

The Policy covers use of the vehicle for any purpose other than: a)Hire Limit of the amount the Company's Liability Under Section II 1(i) in
or Reward b)Carriage of goods (other than samples or personal respect of any one accident: as per the Motor Vehicles Act, 1988. Limit
luggage) c)Organized racing d)Pace making e)Speed testing f) of the amount of the Company's Liability Under Section II 1(ii) in
Reliability Trials g)Any purpose in connection with Motor Trade respect of any one claim or series of claims arising out of one event:
Up to ` 1,00,000
For individual covers (OD) in`: 25600
Imposed excess in `: 0
Voluntary excess in `: 0
Compulsory excess in `: 100
Persons or classes of persons entitled to drive
Any person including the insured provided that a person driving holds an effective driving license at the time of the accident and is not
disqualified from holding or obtaining such a license. Provided also that the person holding an effective Learner's License may also drive the
vehicle and that such a person satisfies the requirement of Rule 3 of the Central Motor Vehicles Rules, 1989.
PA cover for Owner Driver

Name of Nominee Age of Nominee Relationship with the Name of the Appointee (if Relationship to the
Insured Nominee is a minor) Nominee
EVILIN BENET 44 SPOUSE NA NA

PA cover for named persons

Name CSI Opted(`) Nominee Relationship
none 0 NA NA

Premium and GST Details

Rate of Tax Amount in INR
Premium ` 1478.00
SGST 9 133
CGST 9 133
IGST 0 0

KERALA FLOOD CESS 1 15

In witness where of this policy has been signed at Mumbai on this 02/09/2019
WARRANTED THAT IN CASE OF DISHONOUR OF THE PREMIUM CHEQUE, THIS DOCUMENT STANDS AUTOMATICALLY CANCELLED ABINITIO
This policy is subject to the Terms, conditions and exceptions applicable to Package/Liability policy attached/available on the web site
http://newindia.co.in; IMT Endorsement Number(s) printed herewith attached 22,25.
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 Vehicles Act, 1988 is recoverable from the
insured: see clause headed "AVOIDANCE OF CERTAIN TERMS AND RIGHTS OF RECOVERY". It is clarified that in case the declaration regarding
the ncb or other previous policy details made by the insured, is found to be incorrect, all the benefits (including claim) under section-1 of this
policy, will stand forfeited.

I/We hereby certify that the policy to which this Certificate relates as For and on behalf of The New India Assurance Company Limited
well as this Certificate of Insurance are issued in accordance with
the provisions of Chapter X and XI of M.V. Act, 1988.NIA S.T.REGN
No: AAACN4165CST178.
Date of Issue: 02/09/2019

(Mrs SHAILAJA SIVADASS)

[DIVISIONAL MANAGER]

Duly Constituted Attorney(s)

Policy No. : 76310031190100008909Document generated by AG_0108511 at 02/09/2019 12:26:47 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
For redressal of your grievance, if any,you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3. Head office.In case, you are not satisfied with
our own grievance redressal mechanism; you may also approach Insurance Ombudsman. For details of our office addresses and addresses of office of Insurance Ombudsman, please
visit our website http://newindia.co.in.

Page 2 of 3
 THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

Tax Invoice No : 76310019P0010747

IRDA Registration Number: 190

Policy No. : 76310031190100008909Document generated by AG_0108511 at 02/09/2019 12:26:47 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
For redressal of your grievance, if any,you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3. Head office.In case, you are not satisfied with
our own grievance redressal mechanism; you may also approach Insurance Ombudsman. For details of our office addresses and addresses of office of Insurance Ombudsman, please
visit our website http://newindia.co.in.

Page 3 of 3