BAJAJ Allianz General Insurance Company Ltd.

Head Office:1st Floor,GE Plaza, Airport Road, Yerawada, Pune

411006
IRDA Regn. No. 113 dated 2nd May 2001

Private Car Package Policy CERTIFICATE CUM POLICY SCHEDULE

Certificate cum Policy No: FBA/1700007134

1st Floor, Municipal No.2-1-1 ( 1 to 3) Boloor B village Chilimbi, Opp More Super
Policy Issuing Office Code 575006 Policy Issuing Office Address
Market, DAKSHINA KANNADA
Broker Code 10034219 Broker Name TATA MOTORS INSURANCE BROKING SERVICES LTD.
Broker Telephone No 022-66207910 IRDA License No. 375
RTO Location MANGALORE
Period of Insurance From 16:03 10/07/2017 To 09/07/2018 Midnight Intermediary
201556331811
Code
Endorsement Effective Date NA
Insured Name JEANSON ARWIN VEIGAS Policy Issued On 10/07/2017
2-133-1B,PADU HOUSE, THOKUR, JOKATTE,0,KANARA -
Insured Address SOUTH (MANGALORE),KANARA - SOUTH
(MANGALORE),KARNATAKA, PIN - 574173
Nominee
Nominee Name PRECILLA SHANTHI VEIGAS Nominee Age 48 Mother
Relationship
Previous Policy
Previous Insurer Name BAJAJ ALIANZ FBA/1600008606
Number
Date Of Expiry of Previous Policy 09/07/2017
Hypothecated With STATE BANK OF INDIA KANKANADY
Invoice No :
Customer GSTN :
3436103848426
Place of Supply :
SAC Code : 997134 Description of Service : Motor Vehicle Insurance Services KARNATAKA (State
Code - 29)
GSTIN : 29AABCB5730G1ZT
Registration Number Make Model Type of body CC GVW Mfg Year Seating Capacity Chassis Number Engine Number
KA19MC6648 FORD FIGO - 1.4 EXI HATCHBACK 1399 1550 2012 5 MAJ1XXMRJ1CK89704 CK89704
Vehicle IDV Trailer Non-Electrical Accessories Electrical/Electronic Accessories CNG/LPG Unit Total Value
243,986.00 0 0 0 0 243,986.00

Own Damage(A) Liability(B)

Vehicle & Non Electrical Accessories 8,176.00 Basic Third Party Liability 2,863.00
Add Add
Less Legal Liability To Paid Driver/Conductor/Cleaner-IMT
50.00
Other Discount 1,635.00 28
Deduct NCB -20.00 % 1,308.00 P.A To Owner Driver Of Rs 2 Lakhs 100.00
Sub Total Subtotal(additional) 150.00
2,943.00
(Deduction) TOTAL LIABILITY PREMIUM(B) 3,013.00
TOTAL OWN DAMAGE PREMIUM(A) 5,233.00 PACKAGE PREMIUM(A+B) 8,246.00
NET PREMIUM 8,246.00
Add :GST@ 18% (incl. CGST and SGST) 1,484.00
( incl. CGST@ 9% 742.14)
( incl. SGST@ 9% 742.14)
( incl. NCC@ 0% 0.00)
TOTAL PREMIUM PAYABLE 9,730.00
Geographical Area : India Compulsory deductibles(IMT-22) : 1,000.00
LIMITS OF LIABILITY :
(a)Under Section II - 1 (i) of the policy -> Death of or bodily injury : Such amount as is necessary to meet the requirements of the Motor Vehicles Act, 1988.
(b)Under Section II - 1 (ii) of the policy -> Damage to Third Party Property Rs 750,000.00 ; PA Cover for Owner-Driver under section III: CSI Rs 2,00,000.00 ; Voluntary Deductable Rs. 0.00
LIMITATIONS 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), Organized racing, Pace making, Speed
testing, Reliability trials,Any purpose in connection with Motor Trade.
DRIVER'S CLAUSES: 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 requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.
Subject to IMT Endorsement Nos. & Memorandum printed herein / attached hereto : 28,22,7
Under Hire Purchase/Hypothecation/Lease Agreement with : STATE BANK OF INDIA
Premium Collection Details :- [Collection No / Amount / ReceiptDate] 1000961474 / Rs.9,730.00 / 10/07/2017
Received with thanks from JEANSON ARWIN VEIGAS an amount of Rs. 9,730.00 towards Insurance Premium. Consolidated Stamp Duty Paid.
WARNING THAT IN CASE OF DISHONOUR OF THE PREMIUM CHEQUE , THIS DOCUMENT STANDS AUTOMATICALLY CANCELLED 'AB-INITIO'
I/We hereby certify that the policy to which the certificate relates as well as the certificate of insurance are issued in accordance with the provision of chapter For Bajaj Allianz General Insurance Company
X,XI of M.V.Act 1988 Limited.

PAN No. : AACC592

Insurance Company PAN No. : AABCB5730G
Category : General Insurance Business Services - 00440005
Stampduty Challan No. : Authorised Signatory
Dealer Name: CAUVERY FORD MANGALORE
. In Witness whereof this Policy has been signed at KANARA - SOUTH (MANGALORE) this 10day of July of 2017 , 06:05:44 PM.
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". For legal
interpretation,English version will hold good.
Please call Toll Free No. 1800 258 2545 for all Insurance Related Assistance