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The Oriental Insurance Co. Ltd.

Divisional Office Shree Krishna Plaza, 100 Ft. Road Shobhagpura UDAIPUR - 110002,RAJASTHAN
IRDA Registration Number: 556

Broker Details
TATA MOTORS INSURANCE BROKING & ADVISORY SERVICES LTD, 1ST FLOOR, AFL HOUSE, LOK
BHARATI COMPLEX, MAROL MAROSHI ROAD, ANDHERI (EAST), MUMBAI 400 059, INDIA, 022– CIN Number: U50300MH1997PLC149349
62379515
License Validity: 13-MAY-17 To 12-MAY-
Category: Composite Broker IRDA Lic. No: 375
20
Proposal Details
Own Damage Period 09-Jun-2019 To Motor Liability Period 09-Jun-
Proposal No. PPVBU7255380
08-Jun-2020 2019 To 08-Jun-2020
Proposer Details
Address of the Proposer
Proposer Type Proposer Name Vehicle Usage
, VIRALIMALAI (PO) PUDUKOTTAI PUDUKOTTAI TAMIL
Corporate Lessee S.R.F. Private
NADU 621316
Vehicle Details
Invoice Date Chassis No. Engine No. Make Model & Variant CC
28-May-2016 MAT624001GLB03114 100A2000-0622508 ZEST ZEST XE QJT 75PS 1248
Place of Registration Registration No. Invoice Value/ Previous IDV Year of Manufacture Seating Capacity
PUDUKOTTAI TN-55-AU-4307 623350 2016 5
Insured Declared Value (IDV)
Vehicle Electrical Accessories Non-Electrical Accessories CNG/LPG Total IDV
374010 0 0 0 374010
Other Details
Branch/Office of HP/Lease/Hire
HP/Lease/Hire Pur. Agreement with Agreement Type Loan Account/Contract No
Purchaser
TATA MOTORS FINANCE LTD. Hypothecation TML789603
TRICHY - TRICHY
Premium Calculation
A.Own Damage Premium Amount (Rs.) B. Liability Premium Amount (Rs.)
Basic Premium Third Party Liability
Vehicle 4178 Basic Third Party Liability Premium (including TPPD) 2863
Non Electrical Accessories 0 Third Party Liability For Bi-Fuel Kit 0
Electrical Accessories 0 Third Party Liability For Geographical Area Ext. 0
Bi Fuel Kit 0 Sub Total (Third Party Liability) 2863
Sub Total (Basic Premium) 4178 PA Cover
Geographical Area Extension 0 Compulsory PA Cover for Owner Driver (0) 0
IMT 23 Premium 0 PA cover for Paid Driver (200000) 0
Sub Total 4178 PA Cover (100000 Per Person) for 5 Persons 250
Discounts Sub Total (PA Cover) 250
Voluntary Discounts RS. (0) 0 Legal Liability
Anti Theft Device 0 Paid Driver 50
AA Membership 0 Employees (for 0 persons) 0
NCB (20%) 836 Sub Total (Legal Liability) 50
Sub Total (Discounts) 836 Net Liability Premium(B) 3163
Add on (Nil Dep 2 To 5) 3581 Total Premium (A + B) 10086
Net Own Damage Premium(A) 6923 IGST Premium (18%) 1816
Add on: Nil Depreciation
Total GST Premium (18%) 1816
Gross Premium 11902
Payment Details ( Customer’s Cheque )
MISP Details
MISP Name: MISP Code: MISP Pan No:
KAVERI GARAGE PRIVATE LIMITED TMIBASL/MISP/AAGCK6120N AAGCK6120N
Declaration I/ we hereby declare and state that the above statements made by me/ us are true and complete. No part of it is false. I/ we desire to effect
an insurance as describe herein with The Oriental Insurance Co. Ltd. and I/ we agree that this proposal and declarations shall be the basis of contract
between me/ us and the The Oriental Insurance Co. Ltd. and I/ we agree to accept the policy subject to the condition specified by the Insurance Company.
I/ we agree to receive the policy document (without enclosing the terms and conditions of policy) from the company and authorise the company to display
Terms and Conditions of the policy on its website that enables access by me.
I hereby confirm that I have mandated to place my insurance cover and have read and agreed on the terms and conditions and also give my unconditional
consent for receiving a call from TATA MOTORS INSURANCE BROKING & ADVISORY SERVICES LTD or its affiliated entities on my number even if the number
is enrolled under NDNC/DND registry

Date: 23-May-2019
Proposer Signature/ Thumb Impression
INSURANCE ACT 1938, SECTION 41- PROHIBITION OF REBATES
1.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 of 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
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