Tata AIG General Insurance Company Ltd.

Policy No. : 0150127079 02 Date: 20/12/2008

Mr. MUKESH C. JETHWA
Chandralok-a,bldg. Room No. 8
97 Nepeansea Road
MUMBAI, 400006
MAHARASHTRA
Phone : 32975277/9819103535

Renewal Endorsement for Policy No. 0150127079

Dear Mr. MUKESH C. JETHWA,
We thank you for reposing your faith in us once again. As per your instructions in the Renewal Response Form, your
above mentioned policy has been renewed w.e.f. 19/12/2008. The insurance coverage, terms and conditions extended are
the same as opted by you in the previous policy and incorporates changes (if any) requested by you. The premium
computation of the policy is given below and your Certificate Of Insurance is attached. The details of your coverages and
the other guidelines regarding your policy can be had from the policy document sent to you at the inception of the policy
(and attached endorsements, if any).
Looking forward to a beneficial and long term association.
Sincerely Yours

Varun Tandon
Head Operations
Service Tax Registration No : Insurance/Tata/Mumbai-I/1542/2001-02.
The stamp duty of Rs.0.25/- paid in cash or demand draft or by pay order,vide Receipt/Challan no: 42130 dated the 20/11/2008
PREMIUM COMPUTATION TABLE
INSURED'S DECLARED VALUE
For the Vehicle For Trailers Non-electrical Electrical/Electronic Value of CNG/ Total Value
Policy No. accessories Accessories LPG Kit
(Rs.) (Rs.) (Rs.) (Rs.) (Rs.) (Rs.)
0150127079 02 1,50,400 1,50,400
SCHEDULE OF PREMIUM
A. OWN DAMAGE B. LIABILITY
Premium on Vehicle and non electrical Rs. 3,950.10 Basic Rs. 800.00
accessories
Less : 25.00% for NCB Rs. 987.52 Add:PA benefits as per Endt.IMT 16 No. Rs. 325.00
of Passengers : 5 Capital benefits Rs.
130000.00
A. TOTAL OWN DAMAGE PREMIUM Rs. 2,963.00 Add:Legal Liability to paid driver as per Rs. 25.00
(rounded off) Endt. IMT 28
Add: Compulsory PA Cover for Rs. 100.00
Owner-Driver Rs.2,00,000
B. TOTAL LIABILITY PREMIUM Rs. 1,250.00
COMPREHENSIVE PREMIUM(A+B) Rs. 4,213.00
NET PREMIUM Rs. 4,213.00
Add : 12.36% Service Tax Rs. 520.73
TOTAL PREMIUM Rs. 4,734.00

Ahura Centre 4th Floor, 82, Mahakali Caves Road, Andheri (E), Mumbai 400093. TOLLFREE HELP LINE: 1 800 119966
(Regd Office: Peninsula Corporate Park, Nicholas Piramal Tower, 9th Floor, Ganpatrao Kadam Marg, Lower Parel, Mumbai 400013)
DA14 Branch: 02 Insured Copy Page 1 of 1
 Tata AIG General Insurance Company Ltd.

RECEIPT

Receipt No. 02-30-00160324 Receipt Date 19/12/2008

Received with thanks from Mr. MUKESH C. JETHWA

a sum of Rs. 4,734.00 ( Rupees Four Thousand Seven Hundred Thirty Four and
Paise 00 Only )

vide Cheque no. 599789 dated 18/12/2008 drawn on UTI BANK LTD.,MUMBAI
branch towards
Sr.No. Policy No. Total Premium (Rs.) Utilised from Receipt (Rs)
1 0150127079 4,734.00 4,734.00

REVENUE
STAMP

Note:
1. This is a computer generated receipt and does not require a signature.
2. This receipt is issued subject to realisation of the cheque.
3. Upon issuance of this receipt, all previously issued temporary receipts, if any, related to this policy, are
considered null and void.
4. Any excess amount will be adjusted against subsequent policy applications, or will be refunded on demand.
Service Tax Registration No : Insurance/Tata/Mumbai-I/1542/2001-02.

P.O. Box No. 9407, Chakala MIDC- Post Office. Mumbai 400093 TOLLFREE HELP LINE: 1 800 119966
(Regd Office: Peninsula Corporate Park, Nicholas Piramal Tower, 9th Floor, Ganpatrao Kadam Marg, Lower Parel, Mumbai 400013) or Email us at
customersupport@tata-aig.com.
RP01 Branch: 02 Insured Copy Page 1 of 1
 Tata AIG General Insurance Company Ltd.

Certificate of Insurance
FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989

Certificate No. 0150127079 00 Policy No. 0150127079 02

Registration Mark, Number of the vehicle

and Place of Registration Total Premium (Rs.)

MH02NA2635, MUMBAI(WEST) 4,213.00

Description of the vehicle
Make and year of Cubic Carrying Capacity /
Model Engine Number Chassis Number Capacity Seating capacity
Manufacture
HYUNDAI 2003 SANTRO XING XP G4HD3C30957 1086 5
MALAA51HR3M3530
41
Name of Registration Authority: MUMBAI GEOGRAPHICAL AREA: INDIA
Name and address of the Insured Effective time and date of commencement of insurance

Name: MUKESH C. JETHWA

Address: Chandralok-a,bldg. Room No. 8 00:01 hours on 19/12/2008
97 Nepeansea Road
MUMBAI, 400006 Date of expiry of insurance, midnight on 18/12/2009
MUMBAI
MAHARASHTRA

Persons or class of persons entitled to drive: -

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.

Limitations as to use:

The Policy covers use for any purpose other than

a) Hire or Reward b) Carriage of goods (other than samples or personal luggage) c) Organised racing d) Pace Making
e) Speed testing f) Reliability Trials g) Any purpose in connection with Motor Trade.

I/We hereby certify that the policy to which this Certificate relates as well as this Certificate of Insurances are issued in accordance
with the provisions of Chapter X and XI of Motor Vehicles Act, 1988. For Tata AIG General Insurance Company Ltd.

Varun Tandon
Head Operations

Note: This attaches to and forms part of Policy No: 0150127079 01 and subject to I.M.T. Endorsement No(s). 16,22,28

Under Hire Purchase/Hypothecation/Lease with N/A

Service Tax Registration No : Insurance/Tata/Mumbai-I/1542/2001-02.
The stamp duty of Rs.0.25/- paid in cash or demand draft or by pay order,vide Receipt/Challan no: 42130 dated the 20/11/2008

Ahura Centre 4th Floor, 82, Mahakali Caves Road, Andheri (E), Mumbai 400093. TOLLFREE HELP LINE: 1 800 119966
(Regd Office: Peninsula Corporate Park, Nicholas Piramal Tower, 9th Floor, Ganpatrao Kadam Marg, Lower Parel, Mumbai 400013)
CA14 Branch: 02 Insured Copy Page 1 of 1