Bajaj Allianz General Insurance Company Ltd.

Issuing Office: Bajaj Finserv,1st Floor , Survey # 208/1-B, Behind Weikfield IT-Park, Viman Nagar, Pune-
411014, Contact No: 020-66495000
Date: 05-JAN-13 Reference No: APO2336004
Generated by : ONLINE
,
BHILAI
MADHYA PRADESH
Dear APOORVA ,
Re.: Your enquiry for premium quotation for vehicle
We thank you for your enquiry for quote on insurance premium for your registered as Private Car. Details of
your requirement are noted below -
Make Model SubType CC Fuel Year of Registered NCB at
Manufature Seating Renewal
FIAT LINEA T-JET 1368 Petrol 2011 5 20%

Vehicle IDV Value of Electrical Value of Non-Electrical Value of CNG/LPG Unit Total IDV
Accessories Accessories -extra fitted
700000 0 0 0 700000

Proposed Insurance Policy Expiry Date Date of Vehicle Pin Code of your Voluntary Excess
commencement date Registration normal place of stay
06-JAN-13 05-JAN-14 04-JAN-12 490001 0

Based on the cited details, we are pleased to quote our premium as under: (* All figures in Rupees)
Net OD Premium Net TP Premium Total Premium Service Tax Education Cess Final Premium
8488 1025 9513 1142 34 10689

Add-On Covers : S1 - 24x7 SPOT ASSISTANCE

Important Notes :
1. This quotation is based on information provided to us and is subject to relevant proofs being submitted
and inspection of vehicle at the time of issuance of policy. Quote is subject to change based on doc-
umentation and in case actual information at the time of issuance differs from the above.
2. This submission is only a quotation and not an insurance policy or cover note. The insurance coverage
would start only after issuance of policy and receipt of payment of premium subject to terms of policy.
3. This quote is valid for 30 days from Proposed Insurance commencement date noted above.
4. The premium quoted is for an insurance period from 06-JAN-13 to 05-JAN-14 .
5. You are requested to return duly signed copy of this quote as a confirmation of acceptance of the terms
and reconfirmation of information provided above.
6. Alternately you may send your objection, what so ever with regard to the above quote or the terms and
condition of policy issued, within 7 days from the date of this quote, failing which it will be concluded that
you are fully satisfied and have accepted the quote including the terms and condition of the policy and
the correctness of the information provided above.
7. Policy would be issued after tendering full premium quoted above and subject to inspection of vehicle
where required.
8. Please furnish us the following information for issuance of policy. a) Previous insurance policy copy /
Renewal Notice b) NCB confirmation letter c) Copy of Registration certificate d) Copy of driving license
Insurance.
9. Act 1938, Section 41- Prohibition of Rebates
10. The Above quote will be valid if the policy is bought online.
No Person shall allow or offer to allow, either directly or indirectly as an inducement to any person to
take out or renew or continue an insurance in respect of any kind or risk relating to lives or property in
India, any rebate of the whole or part of the commission payable or any rebate of the premium shown
on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate ex-
cept such rebate as may allowed in accordance with prospectus or tables of the Insurer.
Any person making default in complying with the provisions of this section shall be punishable with fine,
which may extend to five hundred rupees.

Thanking You,
Websales Team,
Bajaj Allianz General Insurance Company Limited.
This is an electronically generated quotation and does not require any signature.
Please turn overleaf
Registered & Corporate Office - G E Plaza, Airport Road, Yerwada, PUNE 411 006
Date: 05-JAN-13
Reference No: APOORVA
Generated by : ONLINE

To,

Bajaj Allianz General Insurance Co. Ltd.

I/We acknowledge receipt of your Quote-cum-Proposal and accept the terms and intend to insure my/our
vehicle detailed therein with you. I/We agree that this Proposal and the declarations shall be the basis of the
contract between Bajaj Allianz and me/us. I/We confirm that the vehicle is being used for private purposes
only. I/We warrant the truth of the forgoing statements in every respect and agree that if I/We have made
any false statement or provided false information, the claim shall be repudiated and premium forfeited. I/We
also declare that if any additions or alterations are carried out after the submission of this Quote-
cum-Proposal, then the same would be conveyed to Bajaj Allianz immediately.

Please find attached my/our remittance of premium of Rs.10689/- by Cash/Cheque No

dated drawn on towards issuance of the
Policy with the following additional information.

Registration No: Engine No : Chassis No:

Pin Code : 490001 Vehicle Make : FIAT Vehicle Model : LINEA

Sub Type : T-JET Fuel : Petrol Registration Date : 04-JAN-12

NCB : 20% Total IDV : Rs.700000/- Voluntary Excess: 0

Proposed Insurance commencement date : 06-JAN-13 Policy Expiry Date : 05-JAN-14

Please mention your Name, Mobile Number and Reference Number on the reverse of cheque.

Date : Signature of Proposer :