BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LTD.

CERTIFICATE CUM POLICY SCHEDULE
Policy Servicing Office 4th Floor, Turquoise,, Nr. Panchvati Circle,, C.G Road, Ellisbridge, Ahmedabad-380006
PH:079-26408006/40028866
Policy Number OG-13-2202-1802-00060707 Product Two Wheeler - Package Policy
Period Of Insurance From: 14-DEC-2012 00:00 (Hrs) Policy issued on 13-DEC-2012
To: 13-DEC-2013 Midnight Cover Note No.
Insured Name NIRAV P NAGAR Zone A
Insured Address 28,TARUNSHAKTI SOCIETY B/H AL-
KAPURI, SOCIETY ., GHATLODI-
AAHMEDABAD, AHMEDABAD-380061
Customer Id 37160150 Premium Payer Id 37160150
Application No 0 Scrutiny No 22502778
Policy Status ISSUED
Coinsurance Details : NA.
Registration No Make Model SubType CC Year Of Mfg Seat Cap Chassis number. Engine No.
GJ01LK3900 HONDA ACTIVA STD 102 2009 2 L98292044 E0322323

Vehicle IDV Elec. Accessories Non-Elec. Acc. Side Car Trailer Reg No CNG/LPG Unit Total Sum Insured
24403 0 0 0 -,- 0 24403
SCHEDULE OF PREMIUM
Own Damage Liability
Total Own Damage Premium 271 Basic Third Party Liability 357
PA Cover for Owner-Driver of Rs. 100000 50
Total Act Premium: 407
Total Premium 678
Special Discount 0
Net Premium 678
Service Tax 81
Edu Cess 2
Final Premium Rs. 761 *** All Premium Figures are in Rupees
Geographical Area : India No Claim Bonus : -35% Voluntary Excess : Nil
Compulsory Deductible : Rs. 100 Additional Compulsory Deductible : Rs. 0
Previous Insurer - Bajaj Allianz General Insurance Co Ltd. Previous Policy No - OG-12-2202-1802-00054637 Expiry On - 13-DEC-12
The above Total OD Premium is inclusive of all applicable Loading/Discounts viz (Automobile Association Membership,Voluntary Excess,Anti-Theft,Handicap Per-
son,Driver Tution,Fibre Glass,Cng/Lpg Unit,Geographical Extn,Imported Vehicle etc wherever applicable)
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.
Subject to IMT Endorsement Nos: 22, & Policy wordings attached herewith

Broker Code 10029148 Channel Name : ML

Broker Name : Bajaj Capital Insurance Broking Ltd
Contact No : 011-61111111/9909437370 Email -
Premium Collection Details :- [Receipt No/Collection No/Amount] 2202-01071633,/22502778,/ Rs.761,
*** 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'
22502778/-/10029148/0/-
Damage Details : -
PIN NO :
Remarks :
Kindly contact our nearest / local office(s) for No Claim Bonus Confirmations.
This is a pre signed 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.

Stamp
Duty Rs.
0.25

Authorized Signatory
Printed , Signed and Executed at Pune
Regd. Office : GE Plaza, Airport Road, Yerawada,Pune - 411006 (India)
QC Verified and Signed/Countersigned by Consolidated stamp Duty paid vide Receipt No: .6 dated 03-OCT-12
Regd Office : GE Plaza,Airport Road, Yerwada Pune-411006 (India)
Service Tax Reg. No. AABCB5730G-ST-001
-Latest Schedule- 26-Dec-2012 15:51:33 PM (Web)
Generated by dinesh parghi
 .  

Bajaj Allianz General Insurance Company Ltd.

4th Floor, Turquoise,, Nr. Panchvati Circle,, C.G Road, Ellisbridge, Ahmedabad-380006 Contact
No:079-26408006/40028866,

RECEIPT

Receipt Number 2202-01071633

Receipt Date 13/12/2012
Business Channel ML

Received with thanks from NIRAV P NAGAR

(Customer ID : 37160150 ) a total sum of Rupees Seven Hundred Sixty One Only by,

Instrument Instrument No. Instrument Bank Name Branch Name Amount

Type Date
Cash 761

Total Amount Rs. 761.00

Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General In-
surance Company Limited. The insurance cover for the risk shall be as per the terms and con-
ditions of the Insurance Policy if and when issued.
* Receipt Subject to realisation of cheque(s)

For & on behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory

Regd.Office: GE Plaza,Airport Road, Yerwada, Pune - 411006

Regd. Office : GE Plaza, Airport Road, Yerawada,Pune - 411006 (India) Service Tax Reg. No. AABCB5730G-ST-001
-Latest Schedule- 26-Dec-2012 15:51:33 PM (Web)
Generated by dinesh parghi