PROPOSAL CUM QUOTATION

PROPOSER'S DETAILS
Name MRS KANIMOZHI P
Address D/O PONNUSAMY, NO 1/87 A, NEHRU NAGAR, POOLANGUDI COLONY, THIRUVARAMBUR, TRICHY.
Pin Code 620025 email id sundarammechanical@gmail.com
PAN No GSTIN No
Mobile No 9597040563 Aadhar No
Nominee's Name SUNDARAM Relation HUSBAND Nominee's Age 33 years
VEHICLE DETAILS
Model TVS MOTOR CO LIMITED TVS WEGO STD(110) Year of Make 2012
Reg No TN-45-BY-6009 Engine No OG4GC1398133 Chassis No MD626AG45C1G21895

Reg. Date 31/10/2012 Fuel PETROL Colour BLACK

Antitheft Device NO Automobile Association Membership NO
Finacier
IDV Rs. 25650
Accessories Electrical Rs. NIL Non-Electrical Rs. NIL Bi-fuel Kit Rs. NIL
POLICY/COVERAGE OPTION DETAILS
Type of Policy/Cover Required 1 Year PACKAGE Policy
Policy Required (period) From 09/06/2020 to 08/06/2021
Do you hold Dr. License for this vehicle class NO
Want WC Cover for Driver YES
Legal Liability to Employees NO
Legal Liability to Unnamed Passenger 0 Persons @ Rs. 100000 each
Retrict to Statutory TPPD cover YES Nil Depreciation NO NCB Protect NO
Nil Depreciation Plus NO Engine protect NO Invoice Protect NO
Registration Charges Rs. NIL Road Tax Rs. NIL
Voluntary Excess Rs. NIL
Geographical Area INDIA.
Wheather Nil Depriciation was covered in Previous Policy NO.
PREMIUM DETAILS
Total OD Premium Rs. 90.00 Total TP Premium Rs. 752.00 GST Rs. 152.00 Premium Payable Rs. 994.00
PREVIOUS POLICY DETAILS *
Previous Policy Type PACKAGE Previous Policy Expiring on 08/06/2020
Previous Policy No 64100031196260000348 issued by NATIONAL INSURANCE COMPANY LIMITED
Previous NCB % 50% Claims reported in Previous Policy NO
* Copy of Previous Policy/Renewal Notice to be attached
Declaration by the Insured

I/We hereby declare that the statements made by me/us in this Proposal Form are true to the best of my/our knowledge and belief and I/We hereby agree that
this declaration shall form the basis of the contract between me/us and National Insurance Company Ltd. I/We also declare that if any additions or alterations
are carried out after the submission of this proposal form then the same would be conveyed to National Insurance Company immediately.

Place :
Date : Signature of the Proposer/s.
nic/ubportal/proposal no. 64100060000025 Dt. 08/06/2020