Onrengty yours Bajaj Allianz General Insurance Company Ltd. Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune ‘Transcript of Proposal for Liability Only Policy for Two Wheeler Dear TARUN KUMAR We wish to inform you that the contract under policy number (OG-22-9906-1806-00059933" bas been finalized based on the in {formation and declaration given by you, the transcript whereof is mentioned below. You are requested to reconfirm the same. Incase of any disagreement or objection or any changes with respect to information mentioned below, we request you to please revert back within a period of 15 days from date of your receipt of this, failing which it will be deemed that you are sat. isfied with the correctness of the details mentioned below. Kindly note that as the contents and declarations contained in this ‘transcript is the basis on which we have issued the policy to you, we advise you to please ensure that you have provided/dis: closed and or not withheld aay material factslinformation and declarations, as Policy becomes Void ab initio if material facts are not providedidisclosed and or withheld and in such ease no claim, if any, will be considered by us apart from forfeiture of the premium, Details provided by you A. Proposer details 1. Proposer Name TARUN KUMAR 2. Proposer Address MET SECTION AIR FORCE STATION , UTARLAL, , BARMER - 344035, 3. Proposer Mobile Number NA 4. Proposer Residential Number NA 5, Proposer e-mail id ‘utu086@gmailcom 6, Proposer Profession NA Month] | Vehicle | Vehicle | Vehicle [Fucl Type | Cubic Ca-] Vear of Man-]Seating Capa Year of | Make | Model | Sub Type pacity’ | ufacture city Regn Kilowatt PHOGLS9IO |UL-2011 | HONDA |CBSHINE| KICK | PETROL | 125 20IT 2 DRUM. SPOKE Tingine Num | Chassis Num] Electrical [Non-Electrical Ac|CNG/LPG Unit] Total IDV Gn Rs) ber er Ga Rs) [IDV Gn Rs) | cessories IDV (in | (Extra fitted) Rs) IDV (in Rs) 209604 | BOIseI6 0 a 0 0 aC.Coverage opted 1. Period of Insurance From 27-May-2021 (Hrs) To 26-May-2022 Midnight 2.18 your vehicle fitted with external LPGICNG kit No. 3. Whether PA cover is opted for owner-driver : No. 4, Whether geographical area extension is opted No. Details of Countries to which geographical area extension cover is given NA. 5.18 LL to person for Paid driver/Operation/Maintenance opted No. 6. Whether PA cover is opted for paid driver other than owner driver No. Number Of Paid Driver(s) NA Sum Insured Per Paid Driver RSNA 7. Whether PA cover is opted for passengers No. ‘Number OF Passengers NA ‘Sum Insured per Passenger RSNA 8. Is TPPD restricted to statutory limit of Rs. 6,000? Yes. 9. Premium for Liability coverage, quoted and agreed upon is s.702.00, 10, Do you have valid PUC certificate ofthe vehicle NA 11, Do you have valid Fitness certificate of the vehiele NA 12, About the last insurance company Previous Insuret - National Insurance Company LimitedPrevious Policy No -36140031206701119498 Expiry On -26-MAY-21 13, To support our Go Green initiative, send policy copy link on registered mobile number / email id lease note Cover Note No. / issued to you basing on the above information, Incase of Disagreement or objection or any changes with respect to information and contents mentioned hereinabove, please ‘contact our toll free number & register your objections/changes/disagreement to the contents of this transcript or you may also ‘send us email or writen correspondence atthe following details within a period of 15 days from date of your receipt ofthis transcript along with Policy UWe hereby unconditionally allow the Company to share all my / our information being collected inthis proposal form or ‘through telephonic / email / web-inputs means or other means, as updated from time to time within group entities, ‘Tollfree Number 1800-102-5858,1800-209-5858 Email address Bagichelp(@bajajallianzco.in Website ‘won: bajajallianz.com ‘Contact our policy servicing branch at: Bajaj Finserv Building, Ist Floor, Behind Weikfielé IT-Park, Viman Nagar, Puno-411014 Phome No :1800-209-0144, INSURANCE ACT, 1938 SECTION 41 - PROHIBITION OF REBATES [No person shall allow or offer o allow either directly o indirectly, as un 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 ofthe ‘commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing a policy accept any rebate, except such rebate as may be allowed in accordance withthe published prospectus or tables of the insurer. ANY PERSON IN BREACH OF COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE WITH FINE WHICH MAY EXTEND TO RUPEES TEN LAKH Bajaj Allianz General Insurance Co LidBajaj Allianz General Insurance Company Lid. 82 Allan House, Alport Road, Yerwads, Pune - 1 006Ina) LIABILITY ONLY POLICY FOR TWO WHEELER CERTIFICATE CUM POLICY SCHEDULE IN : IRDANT13RP0041V01200102 Policy issuing office and Correspondence address for communication by policyholder for claim, sevice request, notice, summons, ‘te, Baja Fisery Bulag, Tot oo, Behind Wee IV Park, vinan Nagar Puneet 1014 Pons No 1000.208 044 Policy Number 0G-22-9906-1806-00059023, Product LUsblty Only Poly For Two Wheeler Period Of insurance From: 27-May-2021 Policyissued on 21-May-2021 To: 26-May-2022 Midnight CoverNoteNo ‘Application No Scrutiny No zreaTa0es Insured Name —TARUN KUMAR Zone B Insured Address MET SECTION AIR FORCE STATION , UTAR CustomerID 210745752 Promium PayorID 218745752 Transaction Id Poliey Status Issued GsTINJUIN NA Place of Supplisate 08 - Ratan Invoice No, zraTen04sit ‘Company GSTNo 27AABCBS730G12x Company PANN AASCBS7S06 Registration | Wake | Subtype] Modal | —CCIKW —] Wig year | Seat Cap | Vehicle! | Engine Number No. "raller chassis PHOSLESTO | HONDA | —KIGK [CR SHINE | Tas] a1 | 2 ase | a loruw.shoxe| Teal Own Damage Premium Basie Thre Party Lay 7o.00 Toa poms Toma ata Uabity Premiums 702.00 Special Daeount g grated GST CO 26.00 Final Premium Re: 28.00 Al Premium Figures aren Rupeos ‘Geographical Area No Claim Bonus : 0% Nominee Details Name : NA Relationship :NA Proviaus insurer - Natoral Insuranes Company LimtedPrevious Pokey No -961400312087011 18488 Expiry Sepembro the ex nancial Sear ’ . Nominee Details Name: Relationship: TS OF UAB: oer etn 1) af ply Death fly ry: uch mea sy mes here equects of be Moor Hag) rguset ving Pace malng Speed eating Reais VdaTAty purest conection wih Misr Tradd n= un sales cessor DRIVER; Ay era cluding te nurd Prove al pee vig laa ete ving ere ee of he acide and ig pt sgl person stent requiremeis of Rule ® of dhe Cenral Motor Veluees Rules, 2 IMPORTANT NOTICE: nur inne ithe yell we riven chet han in ecordance wi thi Sched. Any patent ma by ABE irony Urea inate cy eg hhc Mar Ve Ret TWN sceneries Set ‘Warned that insured named herein a owner of he vehicle nse olds a valid Polstion Under Col (PLC and ot Fines Conf on the dt of commencement th Ply, Ifthe PU and a Fins Cait a oun 0 [Contact No : 0/1800-103-3999 [Email - Paris Caster Gln - Renethelndn Nasr D6-MTSI (2757562800, “TWis create a irae is ued acoroance wth the provision of Chapa X ane Chapter XI of MV. A, 1988, Denese Die ene Na Remarks oat In case of any claim, please contact our 24 Hour Cal centre st 1800-102-S858 (Toll Free)/91-020-20905858 (chargeable, add ‘code before this number incase of mobile call or email us at ‘Bagichelp@bsjaliansco.in : xCrringty yoursBajaj Allianz General Insurance Company Ltd. Bajaj Finserv Building, 1st Floor, Behind Weikfteld IT-Park, Viman Nagar, Pune - 411014 Contact No:Contact No: 180-209-0144 Receipt Number Receipt Date Business Channel Received with thanks from RECEIPT 19906-04875897 2410512021 ws TARUN KUMAR (Customer ID : 216745752 ) a total sum of Rupees Eight Hundred Twenty Eight Only by, Tnstrameni] instrument No,] Instrument Bank Name Branch Name ‘Amount Type Date inline Pay PEPGSa25401 | 21/05/2021 NA NA 328 ment 4 Total Amount Rs. 828.00 Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General In- surance Company Limited. The insurance cover for the risk shall be as per the terms and con- ditions of the Insurance Policy if and when issued. * Cheque/DDIPO receipt is valid subject to realisation of the instrument. For & on behalf of Bajaj Allianz General Insurance Company Ltd Authorised Signatory Regd. Office: Bajaj Allianz House Airport Road, Yerwada, Pune - 411006