E-Proposal - Policy Schedule Cum Certification of Insurance Motor Private Car Package Policy

CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED
Registered Office: 2nd Floor, "DARE House", 2, N.S.C. Bose Road,Chennai-600 001.
Toll free: 1800 208 5544, T: +91 (0) 44 4044 5400, F: +91 (0) 44 4044 5550
E: customercare@cholams.murugappa.com; website: www.cholainsurance.com
PAN: AABCC6633K GSTIN: 33AABCC6633K1ZQ CIN: U66030TN2001PLC047977
IRDAI Registration. No.123
REACH US THROUGH WHATSAPP
E-Proposal – Policy Schedule cum Certification of Insurance Motor Private Car Package policy
[UIN IRDAN123RP0001V03100001]
This is only an E Proposal form and not a valid policy certificate
Chola MS proposal number :INSD2C336200072596
Name of the Proposer Mr Rajesh Kannan

Address for
communication
(Address where vehicle Mr Rajesh Kannan,NO 62,MIDDLE ST, AGASAMPATTU ,NELLITHOPPE S.O,PONDICHERRY,PONDICHERRY,605005
is normally kept and
used):
City PONDICHERRY State PONDICHERRY PIN 605005
STD Code Phone 9865693539 Fax
E – mail rajeshrkg@gmail.com
Mobile Number 9865693539 Date of Birth 06 04 1986
Occupation / Business
Period of Insurance From: 27/09/2022 00:01 to 26/09/2023 23:59

Information about Vehicle Proposed for insurance:
Chassis No Engine No Registration No Year of Manufacture Registration Date
For Vehicle MA6HBEGAEDH023417 10CL2Z141880198 PY05V3123 2014 12 11 2015
Registering Authority & Location PONDICHERRY(OULGARET)
Make of Vehicle CHEVROLET
Type of DIESEL ENJOY - 1.3 LTZ 8 STR
Cubic Capacity(KW) 1248 Seating capacity including Driver 8

Insured’s Declared Value:
Non-electrical accessories fitted Electrical & electronic accessories
Insured’s Declared Value of Vehicle Value of CNG/LPG Kit Total Value
to the vehicle fitted to the Vehicle
Rs. 3,02,836 Rs. Rs. Rs. Rs. 3,60,336

Vehicle used for Driving tuitions No Whether vehicle is designed for use of blind /Handicapped /
Whether use of vehicle is limited to own premises? No mentally challenged persons and duly endorsed as such by RTA? No
Whether vehicle is used for Commercial purposes? No Whether extension of geographical area to the following countries
No
Whether vehicle belongs to foreign embassy/consulate? No required
Is the vehicle fitted with any Anti-theft device approved by
Bangladesh, Bhutan, Maldives, Nepal, Pakistan and Srilanka
the AARI? No
If Yes, state the name of the countries

Liability to Third Parties: The Policy provides Third Party
Property Damage (TPPD) of Rs.7.5 lakhs Do you wish to
Whether the car is certified as Vintage car by Vintage and Classic
restrict the above limits to the statutory TPPD Liability limit No No
Car Club of India?
of Rs.6000/- only?

If member of Automobile Association of India - Name of Association ________________________ Membership No.__________ expiry date______

Financier Name and Details:
HDFC BANK LTD, Pondicherry

Previous Policy No. Insurance Company No Claim Bonus Claims if any Claim Details
For Claims, please call 1800-208-5544 or mail to
45% customercare@cholams.murugappa.com. or visit
our website www.cholainsurance.com
Optional Add-on cover on payment of Additional Premium
Description Sum Insured (Rs,)
1. Full Depreciation Waiver Cover
2. Chola Value Added Services
Refer to our website www.cholainsurance.com for Policy wording, Add-on wording and the Ombudsman list.
Call Toll Free: 1800 208 5544 SMS CHOLA to 56677 | Visit www.cholainsurance.com | Email customercare@cholams.murugappa.com
Disclaimer: The Company may contact you for matters related to your policy or to provide details of products & services offered. To opt out from the facility, please register under Do Not Call section on our
website.

Toll free: 1800 208 5544, T: +91 (0) 44 4044 5400, F: +91 (0) 44 4044 5550

Compulsory Personal Accident cover for Owner-driver

Name of the Appointee (if Relationship to the
Name of the Nominee & Age Relationship
Nominees is a Minor) Nominee:
Pradeepa Spouse

If you already have Personal Accident (PA) policy please specify the following. If your PA cover Sum Insured is less than 15 lakhs, you have Yes
insure the difference (15 lakhs and SI under your existing PA cover) under our standalone PA cover - Chola Compulsory Personal Accident
(Owner-Driver) under Motor Insurance Policies
Name of the Company Policy Number Sum Insured (Rs.) Expiry Date

If you hold a valid driving license, Compulsory Personal Accident (CPA) cover for Rs.15 lakhs is mandatory as per IRDAI guidelines.

Do you wish to include Personal Accident (P.A.) Cover for Named Persons?
If yes, give name and Capital Sum Insured (CSI) opted for. The maximum CSI available per person is Rs.2 lakhs
Name CSI opted (Rs.)

Do you wish to include P.A. Cover for unnamed persons / hirer?
If yes, give the number of persons and Capital Sum Insured (CSI) opted. The maximum CSI available per person is Rs.2 lakhs Yes
Number of persons: 1 CSI opted (Rs.) 8,00,000
Premium
A. OWN DAMAGE B. LIABILITY
Sum Insured Premium Premium
IMT Sum Insured (Rs.) IMT
(Rs.) (Rs.) (Rs.)
Basic OD 3,02,836 12,449 Basic TP 3,416
Electrical or Electronic
24 2300 CNG Kit - TP 25 0
Accessories
Non Electronic /
24 0 LL to Paid Driver 28 50
Electronic Accessories
CNG Kit - OD 25 0 TOTAL 3,466
Geographical Extension -
TOTAL 12,449 1 0
TP
Geographical Extension
1 0
OD
Sub Total: (additions)
Less: Add:
Anti-Theft Device - OD 10 0 Sub Total: (additions)
Bonus Discount (50%) 6,225 TOTAL
Sub Total: (discounts) TOTAL PREMIUM (B) 3,466
Total C. PERSONAL ACCIDENT COVERS
Own Damage Premium 6,224 PA for owner driver 325
Experience based
4,669 TOTAL PREMIUM (C) 325
loading/discount (70%)
TOTAL (A) 1,555
Sum Insured Premium TOTAL PREMIUM (A+B+C+D) 5,845
D. ADD-ON COVERS Options
(Rs.) (Rs.)
0
CGST (9%) 0
2.Road Side Assistance

SGST (9%) 0

IGST (18%) 1,053

TOTAL AMOUNT COLLECTED 6,898
TOTAL PREMIUM (D) 99
I/We have read / agree to refer to the website of the Insurer: www.cholainsurance.com for the details of policy terms and conditions and also authorize the company to
issue a single page policy. YES / NO
website.
Toll free: 1800 208 5544, T: +91 (0) 44 4044 5400, F: +91 (0) 44 4044 5550
Declaration by 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 agreed that this declaration shall form the basis of the contract between me / us and the Cholamandalam MS General Insurance Company
Limited.
I/We also hereby declare that if any additions or alterations are carried out after the submission of this proposal form then the same would be
conveyed to the Insurance Company immediately.
Place: Chennai Date: 26/09/2022

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 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 the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may
be allowed in accordance with the published prospectuses or tables of the insurer:
(2) Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.

SCHEDULE OF DEPRECIATION FOR ARRIVING AT IDV NCB TABLE

% OF DEPRECIATION % OF DEPRECIATION
AGE OF THE VEHICLE AGE OF THE VEHICLE
FOR FIXING IDV FOR FIXING IDV
Not exceeding 6 months 5% No claim made or pending during the preceding full
20%
Exceeding 6 months but not exceeding 1 year 15% year of insurance
Exceeding 1 year but not exceeding 2 years 20% No claim made or pending during the preceding 2
25%
Exceeding 2 years but not exceeding 3 years 30% consecutive full year of insurance
Exceeding 3 years but not exceeding 4 years 40% No claim made or pending during the preceding 3
35%
consecutive full year of insurance
Exceeding 4 years but not exceeding 5 years 50%
No claim made or pending during the preceding 4
Note: The Insured’s Declared Value (IDV) of the vehicle will be deemed 45%
consecutive full year of insurance
to be the `SUM INSURED’ for the purpose of this tariff and it will be
No claim made or pending during the preceding 5
fixed at the commencement of each policy period for each insured consecutive full year of insurance
50%
vehicle. The IDV of the vehicle is to be fixed on the basis of
manufacturer’s listed selling price of the brand and model as the
vehicle proposed for insurance at the commencement of insurance /
renewal, and adjusted for depreciation (as per schedule specified
below). The IDV of the side car(s) and / or accessories, if any, fitted to
the vehicle but included in the manufacturer’s listed selling price of the
vehicle is / are also likewise to be fixed. The schedule of age-wise
depreciation as shown below is applicable for the purpose of Total
Loss / Constructive Total Loss (TL/CTL) claims only. A vehicle will be
considered to be a CTL where the aggregate cost of retrieval and / or
repair of the vehicle subject to terms and conditions of the policy
exceeds75% of the IDV
Insurance is the subject matter of solicitation
website.
Cholamandalam MS General Insurance Company Limited
Registered Office: 2nd Floor "DARE HOUSE", 2, N.S.C. Bose Road, Chennai 600 001.
Toll free: 1800 208 5544, T: +91(0) 44 4044 5400, F: +91(0) 44 4044 5550
E mail: customercare@cholams.murugappa.com; website: cholainsurance.com
IRDAI Regn. No.123 | PAN AABCC6633K | CIN: U66030TN2001PLC047977
Motor Private Car Package Policy Schedule cum Certificate of Insurance
[UIN:IRDAN123RP0001V03100001]
Policy Number 3362/60026784/000/00 Certificate Number 3362/60026784/000/00

Name & Communication Address:
Mr Rajesh Kannan,NO 62,MIDDLE ST, AGASAMPATTU ,NELLITHOPPE Registration Address:
S.O,PONDICHERRY,PONDICHERRY,605005 No 62,Middle st, Agasampattu ,NELLITHOPPE
Mobile : 9865693539 | Landline : Mail : S.OPONDICHERRY,PONDICHERRY,605005
rajeshrkg@gmail.com
Aadhar No:
Period of Insurance: From 27/09/2022 00:01 to 26/09/2023 23:59
Preferred Insurance Company: NSDL
Cover Note Number: - Geographical Area : India
Business / Profession :
PARTICULARS OF VEHICLE INSURED

Date of Registration 12/11/2015 Place of Registration PONDICHERRY(OULGARET) Registration Number PY05V3123
Make CHEVROLET Model / Variant
Year of Mfg 2014 Type of Body MPV Fuel used DIESEL
Cubic Capacity 1248 Engine No. 10CL2Z141880198 Chassis No. MA6HBEGAEDH023417
Licensed passenger Carrying Capacity 8 Driver 1 Cleaner -
Total Seating Capacity
Conductor - K.Watt - 8
Including Driver
IDV (Insured's Declared Value)

Value of Chassis (Rs.) 0 Value of Body (Rs.) 0 For Trailer (Rs.) 0
For Vehicle (Rs.) 3,02,836 Non-Electrical Accessories (Rs.) 0 Electrical/Electronic Accessories (Rs.) 57500
Value of CNG/LPG Kit (Rs.) Total Value (Rs.) 3,60,336
website.
Toll free: 1800 208 5544, T: +91 (0) 44 4044 5400, F: +91 (0) 44 4044 5550
[UIN:IRDAN123RP0001V03100001]
Premium
A. OWN DAMAGE B. LIABILITY
Sum Insured No.of Premium
IMT Premium (Rs.) Sum Insured (Rs.) IMT
(Rs.) Person (Rs.)
Basic OD 3,02,836 10149 Basic TP 3,416
Electrical or Electronic
24 2,300 CNG Kit - TP 25 0
Accessories
Non Electronic / Electronic
24 0 Paid Driver Cover 1,00,000 28 50
Accessories
CNG Kit - OD 25 0 TOTAL 3,466
Geographical
TOTAL 12,449 1 0
Extension - TP
Geographical Extension OD 1 0 TOTAL PREMIUM (B) 3,466
Sub Total: (additions) 0 C. PERSONAL ACCIDENT COVERS
Less: PA for owner driver 15,00,000 325
Anti-Theft Device - OD 10 0 Unnamed PA cover 1,00,000 8 16 400
Bonus Discount (50%) 6225
TOTAL PREMIUM(C) 725
Sub Total: (discounts) 0
Total 6,224
TOTAL (A+B+C+D) 5,845
Own Damage Premium
Discount (65%) 4,357 TOTAL
5,845
GST Discount (5 %) 312 CONSIDERATION
TOTAL (A) 1,555
D.ADD ON Option CGST(9%)(Rs.) 0
Benefit No Premium(Rs)
COVERS(BENEFITS) No
Road Side Assistance 99
SGST(9%)(Rs.) 0

KERALA CESS(1%) 0

IGST(18%)(Rs.) 1053

TOTAL ADD-ON-COVERS TOTAL AMOUNT
99 6,898
PREMIUM(D) COLLECTED
website.
Toll free: 1800 208 5544, T: +91 (0) 44 4044 5400, F: +91 (0) 44 4044 5550
[UIN:IRDAN123RP0001V03100001]
LIMITATIONS AS TO USE: The Policy covers use of the vehicle for any purpose other than: a) Hire or Reward b) Carriage of goods (other than samples or personal luggage) c)
Organized racing d) Pace making e) Speed testing f) Reliability Trials g) Any purpose in connection with motor trade.
DRIVER CLAUSE: Any person including insured provided that a person driving holds an effective driving license at the time of the accident and is not disqualified from holding or
obtaining such a license. Provided also that the person holding an effective learner's license may also drive the vehicle and that such a person satisfies the requirements of Rule 3
of the Central Motor Vehicles Rules 1989.
LIMITS OF LIABILITY:Under Section II - 1(i) of the Policy - Death 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 - Rs.7,50,000.00 P.A. Cover for the Owner cum Driver Under Section IV (CSI)- Rs.15,00,000.00
Deduction Under Section 1: Rs. 1000
Additional compulsory deductibles under Section 1 Rs.0
Additional Imposed deductibles under Section 1 Rs.0
Subject to I.M.T. Endt. Nos. and Memorandum : 16,22,28
Benefits under this policy is subject to realisation of premium cheque(s). In case of dishonor of cheque(s), no separate intimation will be given and the policy stands automatically
cancelled ab initio (from inception)”.
Applicable benefits:1,3,15
Please visit our website for Policy terms and conditions
Date and Signature of the proposal 26/09/2022 In witness where of this policy has been signed in lieu of the Cover Note No.:- Date:-
Warranties: It is hereby warranted the coverage under this Policy commences only from the Risk Start time and Date as mentioned in the Policy schedule. No Liability shall attach
under this Policy in respect of any Accident/Loss prior to the time and date of commencement of Period of Insurance. Warranted that NCB under this Policy is based on
representation regarding NCB and absence of claim under the previous Policy. If the information be found incorrect or false in any aspect, this Policy shall be void ab initio and no
benefit shall be payable by the company No Claim Bonus will only be allowed provided the policy is renewed within 90 days of the expiry date of the previous policy. This policy has
been issued upon declaration by the Insured that a valid Pollution Under Control (PUC) Certificate is held on the date of commencement of the Policy. The insured undertakes to
renew and maintain a valid and effective PUC and/or fitness Certificate, as applicable, during the subsistence of the Policy.
As per GR36 A, PA for Owner-driver refers to the Owner of the Insured Vehicle holding an effective driving license
Sl. No. Name of the Nominee Relationship Age of the Nominee %age of share Name of the Guardian Guardian relationship with Nominee
1 Pradeepa Spouse 100%
No Claim Bonus is applicable at the end of the policy period.

NOTE: The Policy Schedule CUM Certificate of Insurance is an important document issued based on your declaration. We request you to verify the details and ensure that
everything is in order. In case of any discrepancies, please contact us within 15 days from the date of issuance of policy.
Financier Name & Address: HDFC BANK LTD,Pondicherry
Intermediary Name: Direct
Code : 200195804475 Contact No.: 044- 43995400
for Cholamandalam MS General Insurance Company Limited

Place: Chennai Date: 26/09/2022
Duly Constituted Attorney(s)

Business Location : Chennai Head Office,
2nd Floor, "Dare House" No.2,NSC Bose Road, Chennai - 600 001
GST Invoice No.: 3362/60026784/000/00 | GSTIN: 33AABCC6633K1ZQ | SAC Code: 997134| SAC Description: Motor Vehicle Insurance Services
Consolidated Stamp Duty Paid Vide G.O. Rt No.426,Commercial Taxes and Registration (j1) Department, Tamil Nadu dated21/12/2020.
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
the Motor Vehicles Act, 1988.
IMPORTANT NOTICE:
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".
For legal interpretation, English Version will hold good.
Whether tax is payable under reverse charge basis : No
Grievance Clause: For resolution of any query or grievance, Insured may contact the respective branch office of the company or may call at(1800-208-5544)or may write an email
at(customercare@cholams.murugappa.com). In case the insured is not satisfied with the response of the office, insured may contact the Grievance Officer of the Company at
(GRO@cholams.murugappa.com) .In the event of unsatisfactory response from the Grievance Office, he/she may, subject to vested jurisdiction, approach the Insurance
Ombudsman for the redressal of grievance. Details of Insurance Ombudsman offices are available at IRDA website:www.irdai.gov.in , or on the website of General Insurance
Council:http://www.cioins.co.in/ombudsman.html or on the company website www.cholainsurance.com. The policy/AddOn wording with detailed terms,conditions and exclusions are
available on our website:www.cholainsurance.com.
Note: UIN for the related add on covers availed under this policy are as mentioned below.
Add on cover Name UIN
Chola Value Added Services -Private Car IRDAN123RP0001V01200203/A0006V01201718
website.
Toll free: 1800 208 5544, T: +91 (0) 44 4044 5400, F: +91 (0) 44 4044 5550
Premium Receipt
Received with thanks from Rajesh Kannan a sum of 6898 towards premium on car insurance policy
TRANSACTION DETAILS
Date of Payment 2022-09-26 16:41:07
Product Description with UIN

Motor Private Car Package Policy Schedule - UIN:IRDAN123RP0001V03100001
Number
Chola MS Proposal Number INSD2C336200072596
Mode of Payment Online
Transaction ID YICI1436299415
Total
Total Premium Amount 5845 CGST 0 SGST 0 IGST 1053 Amount 6898
Collected
Cholamandalam MS General Insurance Company Limited

Registered Office: 2nd Floor, "Dare House" No.2,NSC Bose Road, Chennai - 600 001. India
Address of Issuing Office T: +91 044 4044 5400 | Fax: F: +91 044 4044 5500 |
E: customercare@cholams.murugappa.com Website: www.cholainsurance.com
CIN: U66030TN2001PLC047977 | PAN AABCC6633K | IRDAI Regn. No.123
Place :Chennai CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED
Policy Issued on : 2022-09-26 16:41:07 Authority Sign
DISCLAIMER
(1) This receipt will be null and void ab initio, if the cheque/any valid negotiable instrument as per the Negotiable Instruments Act
1881,as amended from time to time, as receipted by this company via this receipt is dishonoured.
(2) Issuance of the receipt does not tantamount to risk acceptance. Acceptance of risk is dependent on the company's underwriting
practices.
Call Toll Free: 1800 208 5544 | SMS CHOLA to 56677 | Visit www.cholainsurance.com | Email customercare@cholams.murugappa.com
website.

E-Proposal - Policy Schedule Cum Certification of Insurance Motor Private Car Package Policy

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E-Proposal - Policy Schedule Cum Certification of Insurance Motor Private Car Package Policy

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CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

This is only an E Proposal form and not a valid policy certiﬁcate

Chola MS proposal number :INSD2C336200072596

Name of the Proposer Mr Rajesh Kannan

Compulsory Personal Accident cover for Owner-driver

Insurance is the subject matter of solicitation

REACH US THROUGH WHATSAPP

Policy Number 3362/60026784/000/00 Certiﬁcate Number 3362/60026784/000/00

PARTICULARS OF VEHICLE INSURED

IDV (Insured's Declared Value)

No Claim Bonus is applicable at the end of the policy period.

for Cholamandalam MS General Insurance Company Limited

Duly Constituted Attorney(s)

Date of Payment 2022-09-26 16:41:07

Product Description with UIN

Chola MS Proposal Number INSD2C336200072596

Mode of Payment Online

Cholamandalam MS General Insurance Company Limited

Place :Chennai CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

Policy Issued on : 2022-09-26 16:41:07 Authority Sign

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