LIBERTY GENERAL INSURANCE LIMITED

PRIVATE CAR PACKAGE POLICY

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
IMPORTANT 1)The Validity of this Certificate of Insurance cum Schedule is subject to realization of the premium cheque.
2) No Claim Bonus will only be allowed provided the Policy is renewed within 90 days of the expiry date of the previous policy.
3) In the event of misrepresentation, fraud or non-disclosure of material facts, the company reserves the right to cancel the policy from inception.
Policy issuing office :10TH FLOOR, TOWER A, PENINSULA BUSINESS PARK, GANPATRAO KADAM MARG,LOWER PAREL, MUMBAI, MAHARASHTRA-
400013 Phone:+91 22 6700 1313 Fax: +91 22 06700 1606
Policy Servicing office :CHINTAMANI PLAZA 427/28, ANDHERI KURLA ROAD, Andheri East, ANDHERI,MAHARASHTRA-400099 PH: +91 22 6700
1313 Fax: +91 22 06700 1606
Policy No. 201140040223700804300000 Period of Insurance
Geographical Area India From 00:00 Hrs of 21/09/2023 To Midnight of 20/09/2024
Insured SUMIT SURESHRAO SAMARTH Policy Issued on 20/09/2023
Address WARD NO 10, SOMNATH ROAD Covernote No/Ecovernote No 201140040223700804300000
MUL,SOMNATH
ROAD,,MAHARASHTRA,CHANDRAPUR,DEW
ADA KHURD-441224
Contact Number (M) +9767735852 Covernote Date 20/09/2023
GSTIN No/State NA / MAHARASHTRA
UIN CODES: IRDAN150RP0035V01201213 RTO Location CHANDRAPUR Zone: Zone B
POSP Name
POSP Code
Aadhar/PAN No /
POSP Contact Number 9820797993
Agent Name INVICTUS INSURANCE BROKING SERVICES
Agent Code IMD1007732 Agent Contact No 9820797993
INSURED MOTOR VEHICLE DETAILS AND PREMIUM COMPUTATION
Registration Year of Engine No. Chassis No. Make/Model/Type CC/HP/GVW/ Licensed Carrying Trailer Trailer Chassis No.
Mark & No. Manufacture/ of Body KW capacity including Driver Registration No.
Date of
Registration/In
voice date
TATA
MH-34-BR- 2020/21-10- 46343885407328 MAT631538L
MOTORS/HARRIER 1956 5 NA NA
7234 2020/21-10-2020 8 PJ56584
/XT/Muv
IDV (INSURED DECLARED VALUE)
Year IDV Of Vehicle Trailers Side Car Non Electrical Accessories Electrical & Electronics Accessories Bi-Fuel kit(CNG/LPG) Total Value

1 1,084,482.00 0 0 0.00 0.00 0.00 1,084,482.00

Section I - OWN DAMAGE (A) Section II - LIABILITY (B)

Own Damage Premium on Vehicle and accessories
Third Party Premium
Basic Cover
` Basic Cover
Basic OD 10876.27
Basic TP ` 7,897.00
TOTAL OWN­DAMAGE PREMIUM (A) ` 10,876.27
Section I ­ ADD ON COVERS (C) PA BENEFITS
` Personal Accident Cover Unnamed(No. Of Persons=4, SI=50000) ` 100.00
Passenger Assist
250.00
IRDAN150RP0035V01201213/A0020V01201213 LEGAL LIABILITY
Consumables Cover ` `
1626.72 TOTAL LIABILITY PREMIUM (B) 7,997.00
IRDAN150RP0035V01201213/A0015V02201213
Section III - PA OWNER-DRIVER (D)
Depreciation Cover `
5,422.41 PA Owner-Driver (D) ` 375.00
IRDAN150RP0035V01201213/A0012V01201213
TOTAL ADD­ON COVER PREMIUM (C) ` 7,299.13 Net Premium(A+B+C+D)Taxable Value ` 26,547.00

State Cess ` 0.00

CGST (9%) ` 2,389.00

SGST (9%) ` 2,389.00

TOTAL POLICY PREMIUM ` 31,325.00

Hire Purchase/Lease/Hypothecated with :NA

LIMITATIONS AS TO USE -The Policy covers use of vehicle for any purpose other than: a) Hire or Reward b) Carriage of goods(other than sample of personal luggage)
c) Organized racing d) Pace Making e) Speed Testing f) Reliability Trial g) Use in connection with motor trade.
DRIVERS CLAUSE
Persons or Classes of Person entitled to drive: Any person including the 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 Vehicle Rules, 1989.

LIMITS OF LIABILITY
Deductible under Compulsory Deductible: Under Section II-I(i) Such amount necessary to Under Section II-I(ii) 7,50,000.00 P.A. cover for 15,00,000.00
section - I Rs 2000/- Voluntary of the policy(Death meet the requirements of of the policy(Damage owner-Driver under
Excess: Rs:0 Imposed of or bodily injury): motor vehicle Act,1988. to third party section-III: CSI
Excess : Rs 0/. property)
Additional Excess : Rs
0/.
Subject to I.M.T Endorsement Nos. IMT 16, IMT 22, AD 01, AD 02, AD 04,
Passenger assist cover details:Hospital Cash: Rs 1500 per day for 30 days (per Pax.), Medical Expenses: Rs 10,000 (per Pax.), Ambulance Charges: Rs. 5000

NOMINATION DETAILS
Name of the Nominee Relationship with Insured Name of Appointee (if nominee is minor) Relationship with the Nominee
SURESHRAO SAMARTH FATHER NA NA
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 M.V.
Act,1988.
In witness whereof this Policy has been signed at Mumbai on 20/09/2023
Receipt No:
For Liberty General Insurance Limited
In case of claim ,Please contact us at : Toll Free No -18002665844,
Email id – care@libertyinsurance.in
Insurance is the subject matter of solicitation.

Date of Issue :20/09/2023

Place: ANDHERI
Consolidated Stamp duty has been paid as per letter of Authorization no. LOA/CSD/100/2023/3394
Dated 10/08/2023 issued by Main Stamp Office, Mumbai. ** Not Applicable for the State of
Jammu & Kashmir.
Branch GSTIN :27AABCL9950A1ZL
SAC Code:997134 Description of Service:General Insurance Service
Place of Supply : MAHARASHTRA/27
IRDA Regn. No. 150
CIN No. U66000MH2010PLC209656
Tax is not payable under reverse charge by the recipient.
Authorised Signatory
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 be good.

% DSUnknown
q
1G
1g
0.1 0 0 0.1 9 0 cm
0 J 0 j 4 M []0 d
1i
0g
313 292 m
313 404 325 453 432 529 c
478 561 504 597 504 645 c
504 736 440 760 391 760 c
286 760 271 681 265 626 c
265 625 l
100 625 l
100 828 253 898 381 898 c
451 898 679 878 679 650 c
679 555 628 499 538 435 c
488 399 467 376 467 292 c
313 292 l
h
308 214 170 -164 re
f
0.44 G
1.2 w
1 1 0.4 rg
287 318 m
287 430 299 479 406 555 c
451 587 478 623 478 671 c
478 762 414 786 365 786 c
260 786 245 707 239 652 c
239 651 l
74 651 l
74 854 227 924 355 924 c
425 924 653 904 653 676 c
653 581 602 525 512 461 c
462 425 441 402 441 318 c
287 318 l
h
282 240 170 -164 re
B
Q

Digitally signed by: SACHIN JOSHI

Date: 2023-09-20 16:41:29 IST
Location: Mumbai