The New India Assurance Co. Ltd.

Servicing Office of Insurer: DO 122200, NEW INDIA CENTRE, 1ST FLR, 17-A COOPERAGE ROAD, Mumbai,
Maharashtra (State Code:27) -400001, PH-022-22821458 Website: http://newindia.co.in
PAN: AAACN4165C , GSTIN: 27AAACN4165C3ZP Insurer's IRDA Registration Number:190
Tollfree Helpline 1800-209-1415 Email: nia.121404@newindia.co.in CIN : U9999 MH1919 GOI 000526

PRIVATE CAR-PACKAGE POLICY-CERTIFICATE CUM POLICY SCHEDULECUM RECEIPT

(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No 12220031181350037638 Proposal No. & Date PPVBU4766054, 27-JUL-2018

Policy Issued On 27-JUL-2018 (11:57) Period of Insurance 29-JUL-2018(00:00) To 28-JUL-2019(Midnight)

Insured Name MRS. KAVITA GOEL
Insured Add. 91A/UB, BLOCK- UB, JAWAHAR NAGAR , DELHI , DELHI (State Code:07) -110007
Previous Insurer NIA Previous Policy No. 12220031170350014740 29-JUL-2017 To 28-JUL-2018
Broker Details
IRDA Lic. No.: 375, CIN No.: U50300MH1997PLC149349 Broker Category: Composite Broker, Validity: 13-MAY-17 To 12-MAY-20
Name & Add.: TATA MOTORS INSURANCE BROKING & ADVISORY SERVICES LTD, 1ST FLOOR, AFL HOUSE, LOK BHARATI COMPLEX, MAROL MAROSHI ROAD,
ANDHERI (EAST), MUMBAI 400 059, INDIA

Make Model Sub Model Cubic Capacity Manufacturing Year Seating capacity

TATA MOTORS ZEST ZEST XTA QJT 90PS 1248 2016 5

Body Type Registration No. RTO Invoice Date Engine No. Chassis No.

SEDAN DL 01 CR 9162 DELHI NORTH 28-JUL-2016 101A2000-0631785 MAT624201GPD12558

Vehicle IDV CNG/LPG Kit Elec. Accessories Non-Elec. Accessories Total IDV

567,392 0 0 0 567,392

Schedule of Premium (Amount in Rs.)

Own Damage Premium (A) Liability Premium (B)
Basic Premium Basic Third Party Liability 2,863

Vehicle 5,589 Third Party Liability For Bi-Fuel Kit 0

Non-Elec. Accessories 0 Third Party Liability For Geographical Area Extension 0

Elec. Accessories (IMT-24) 0 PA Cover For Owner Driver Of Rs. 2 Lakh (IMT-15) 100

CNG/LPG Kit (IMT-25) 0 PA Cover For 5 Persons of Rs. 100000 Each (IMT-16) 250
Sub Total (Basic Premium) 5,589 PA cover for Paid Driver of Rs 2,00,000 (IMT± 0

Add On Coverages (Refer Note 5) 3,689 Legal Liability For Paid Driver (IMT-28) 50

Geographical Area Extension (IMT-1) 0 Legal Liability for Employees (for 0 persons) (IMT± 0

IMT 23 Premium 0 Net Liability Premium (B) 3,263

Sub Total-Addition 9,278 Total Premium (A+B) 12,401

Deductibles IGST (18%) 2233

Voluntary Deductibles (0) (IMT-22A) 0 Gross Premium Paid 14,634
Note: 1.Warning that in case of dishonour of the premium cheque, this document stands automatically
Anti Theft Device (IMT-10) 140 cancelled 'ab-initio

AA Membership (IMT-8) 0 2.Consolidated stamp duty paid to state exchequer

3.The policy is subject to compulsory deductible of Rs.1000 (IMT-22)
No Claim Bonus (0%) 0

Sub Total (Deductibles) 140 5.Add-on: Nil Depreciation:3689

6.The insurance company will display terms & conditions on its website http://newindia.co.in which can
be accessed by you online.
Net Own Damage Premium (A) 9,138 *Subject to IMT Endt. Nos.& Memorandum:7,10,16,22,28,23
Nominee Details
Name of Nominee Age Relationship with Insured Name of Appointee Relationship with Nominee
ANUJ GOEL 34 SPOUSE --N.A-- --N.A--
Limitations as to use: The policy covers use of the vehicle for any purpose other than (1) Hire or Reward (2) Carriage of goods (other than samples or personal luggage) (3) Organized racing
(4) Pace making (5) Speed testing (6) Reliability trials (7) Any purpose in connection with motor trade.
Driver¶s Clause: Any person including the insured: Provided that the person driving holds an effective driving license at the time of the accident and is not disqualified from holding or
obtaining such license. Provided also that the person holding an effective learners license may also drive the vehicle & that such a person satisfies the requirements of Rule 3 of the Central Mo
Limits of Liability Clause: 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 Vehicle Act 1988.Under Section
II-1 (ii) of the policy-Damage to third party property is Rs.7.5lakhs PA Cover Under Section III for Owner-Driver is Rs. 2.0lakhs.
Payment Details : UTR No.: 700201820836377957, Payment Date: 27-JUL-2018, Bank Name: HDFC BANK LTD, Bank City:
Hypothecation Details: STATE BANK OF INDIA - DELHI - DELHI
MISP Name: GLOBUS MOTOCORP P LTD, MISP PAN No: AAECG7889E, MISP Code: TMIBASL/MISP/AAECG7889E
Important Notice: The insured is not indemnified if the vehicle is used or driven otherwise than in accordance with the schedule. Any payment made by the company by reasons 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 ³AVOIDANCE OF CERTAIN TERMS &
RIGHT OF RECOVERY´For legal interpretation English version will hold good.
Note: This Schedule, the attached Policy and Endorsements mentioned herein above shall read together and word or expression to which a specific meaning has been attached in any part of
this policy or of the Schedule shall bear the same meaning wherever it may appear. Any amendments/modifications/alterations made on this system generated policy document is not valid and
Company shall not be liable for any liability whatsoever arising from such changes. Any changes required to be made in the policy once issued would be valid and effective, only after written
request is made to the Company and Company accepts the requested amendments/modifications/alterations and records the same through separate endorsement to be issued by the company.
In Witness whereoff this policy has been signed at NEW DELHI on 27-JUL-2018 11:57
SAC:997134, Description of Service :Motor Vehicle Insurance Services, Place of Supply :DELHI(State Code:07), Receipt No/Invoice No:23180030229
I/we hereby certify that the policy to which this certificate relates as well as this certificate of insurance are issued in accordance with the provisions of Chapter X and Chapter XI of Motor
Vehicle Act, 1988
For & On Behalf of The New India Assurance Co. Ltd.

Dealer Code : GLOBUS MOTOCORP P LTD - 300667000

In case of any claim or assistance required please contact our help line at 1800 209 0060 and you may also reach us at support@tatamotorsinsurancebrokers.com
 PRIVATE CAR PACKAGE POLICY: ADD ON COVERS

NIL DEP

Notwithstanding anything contained to the contrary in the within mentioned policy it is hereby declared and agreed that subject to the insured having
paid the additional premium as applicable the cover under Section I of the within mentioned policy is hereby extended to the effect that in the event
of any partial loss claim admissible under this policy no depreciation shall be deducted, except on tyres and tubes which are damaged in the accident
and are replaced. Subject to the condition that the above said coverage shall be applicable only for the first two partial loss claims admitted and
payable under the policy relating to accidents during the policy period.