Bajaj Allianz General Insurance Company Ltd.

Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune

Transcript of Proposal for Private Car Package Policy

Dear RAFIKUL ALAM,

We wish to inform you that the contract under policy number 'OG-25-9906-1801-00079860' has been finalized based on the
information and declaration given by you, the transcript whereof is mentioned below. You are requested to reconfirm the same.
In case 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
satisfied 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/disclosed and or not withheld any material facts/information and declarations, as Policy becomes Void ab initio if
material facts are not provided/disclosed and or withheld and in such case 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 : RAFIKUL ALAM
2. Proposer Address : Bholanathpur, P.S - Suti,, Kadamtala,Murshidabad-742224
, KADAMTALA, MURSHIDABAD, West Bengal-742224
3. Proposer Mobile Number : 9732421309
4. Proposer Residential Number : NA
5. Proposer e-mail id : [email protected]
6. Proposer Profession : NA

B.Vehicle Details
Registration Month / Year Vehicle Vehicle Vehicle Sub Cubic Capa- Fuel Type Year of Man- Seating Ca-
Number of Regn Make Model Type city/Kilowatt ufacture pacity
WB38AA478 NOV/2012 MAHINDRA XUV500 W8 AWD 2179 Diesel 2012 7
6 AND
MAHINDRA

Engine Number Chassis Number Vehicle IDV (in Electrical Non-Electrical CNG/LPG Unit Total IDV (in
Rs.) Accessories Accessories (Extra fitted) Rs.)
IDV (in Rs.) IDV (in Rs.) IDV (in Rs.)
HJC4L24648 MA1YL2HJUC6 5,58,159.00 0 0 0 5,58,159.00
L10771
 C. Coverage opted

1. Period of Insurance : From 18-SEP-2024 00:00(Hrs)

To 17-SEP-2025 Midnight
2. Is your vehicle fitted with external LPG/CNG kit : No.
3. Electrical Accessories cover Opted (If Applicable) : No.
4. Non - Electrical Accessories cover Opted (If Applicable): : No.
5. Is Voluntary Excess opted : No.
Amount of voluntary excess opted : Rs.NA.
6. Whether PA cover is opted for owner-driver : Yes.
7. compulsory deductible : Rs.2,000.00
8. Is any additional compulsory deductible imposed and agreed upon : Yes.
Amount of additional compulsory deductible imposed : Rs.
9. Whether geographical area extension is opted : No.
Details of Countries to which geographical area extension cover is given : NA.
10. Is LL to person for Paid driver/Operation/Maintenance opted : Yes.
11. Whether PA cover is opted for paid driver other than owner driver : No.
Sum Insured for Paid Driver : Rs.NA.
12. Whether PA cover is opted for passengers : Yes.
Sum Insured per Passenger : Rs.1,00,000
13. Is TPPD restricted to statutory limit of Rs.6,000? : No.
14. Pre Existing damages in the vehicle : NA.
15. 1 Premium for Liability coverage, quoted and agreed upon is :
16. 1 Premium for OD coverage, quoted and agreed upon is :
17. Do you have valid PUC certificate of the vehicle : NA
18. Do you have valid Fitness certificate of the vehicle : NA
19. Total Premium (excluding Goods and Service Tax (GST)) for Liability and OD coverages, quoted and agreed upon is
:
20. NCB (No Claim Bonus) claimed by you and granted by us based on your declaration of no claim during your previous
previous policy : 0 %.
21. About the last insurance company
(i) Insurance Provider : Bajaj Allianz General Insurance Co Ltd..
(ii) Previous Policy No : OG-24-9906-1801-00063707, Previous Policy Expiry Date :17-SEP-24
22. Whether your vehicle is Hypothecated and if so the details of Pledgee whose name is registered by us: No.
Name of Pledgee : NA.
23. Add on Cover(s) optedm3: No.Plan name:NA

24. To support our Go Green initiative, send policy copy link on registered mobile number / email id:

Please note Cover Note No. / issued to you basing on the above information.
In case 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 written correspondence at the following details within a period of 15 days from date of your receipt of this
transcript along with Policy:
I/We hereby unconditionally allow the Company to share all my / our information being collected in this proposal form or
through telephonic / email / web-inputs means or other means, as updated from time to time within group entities.
Toll free Number : 1800-102-5858,1800-209-5858
Email address : [email protected]
Website : www.bajajallianz.com
Contact our policy servicing branch at: Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar,
Pune-411014 PH:1800-209-0144.
INSURANCE ACT, 1938 SECTION 41 - PROHIBITION OF REBATES
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 the policy, nor shall any person taking out or renewing a policy
accept any rebate, except such rebate as may be allowed in accordance with the 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 Ltd
  

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

Regd. Office & Head Office: Bajaj Allianz House, Airport Road, Yerwada,Pune-411006(India)
IRDAI Registration No. 113
Corporate Identity Number: U66010PN2000PLC015329
Certificate of Insurance ( PRIVATE CAR PACKAGE POLICY)

UIN : IRDAN113RP0025V01200102
Policy Number: OG-25-9906-1801-00079860 Customer ID: 282268501
Particulars of Vehicle Insured:
Registration Number Place of Registration Engine Number Chassis Number Make & Model
WB38AA4786 WB38-ASANSOL HJC4L24648 MA1YL2HJUC6L107 MAHINDRA AND
71 MAHINDRA -
XUV500

Sub Type Year of Mfg NCB % CC Seating Capacity

W8 AWD 2012 0 2179 7

Name of Registration Authority : WB38-ASANSOL

Name and Address of Insured : RAFIKUL ALAM
: Bholanathpur, P.S - Suti,,
Kadamtala,Murshidabad-742224, KADAMTALA,
MURSHIDABAD, West Bengal-742224
Geographical Area :
Business or Profession : NA
Effective date of commencement of Insurance for the purpose of act:
Policy Inception Date: From 00:00 O' Clock on 18-SEP-2024
Policy Expiry Date: Midnight on 17-SEP-2025
Persons or Class of Persons entitled to drive:
Any person including the insured:
a) 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.
b) 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.
IMT-Endorsements/Add on Package
22,28, 16,
Beneficier Details:
Beneficier1 Beneficier2 Beneficier3 Beneficier4 Beneficier5

Limitations as to Use:
The Policy covers use 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
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 provi-
sions of Chapter X and Chapter XI of M.V. Act, 1988.
Policy issuing office and correspondence address for communication by holder of Certificate of Insurance for claim,
service request, notice, summons, etc:
Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune-411014 PH:1800-209-0144
Date of issue :01-SEP-2024
For & On Behalf of
For help and more information:
Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at
[email protected] or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 01-Sep-2024 19:49:04 PM- Silent_Printing (Web) (NA)
Bajaj Allianz General Insurance Company Ltd.
Now carry your m-policy on your mobile. Click here to download. https://bagic.page.link/18Avir

Authorized Signatory
  

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of
India [IRDA] vide Reg No.113)
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada,Pune-411006(India)
PRIVATE CAR PACKAGE POLICY SCHEDULE
UIN : IRDAN113RP0025V01200102
Policy issuing office and Correspondence address for communication by policyholder for claim, service request, notice, summons, etc:
Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune-411014 PH:1800-209-0144
INSURED DETAILS POLICY DETAILS
Insured Name RAFIKUL ALAM Policy Number OG-25-9906-1801-00079860
Bholanathpur, P.S - Suti,, Policy Issued on 01-SEP-2024 19:21 PM
Insured Kadamtala,Murshidabad-742224 ,
KADAMTALA, MURSHIDABAD, West From : 18-SEP-2024 00:00 (Hrs)
Address Bengal-742224
Policy Period To : 17-SEP-2025 Midnight
Geographical India
Area Cover Note
/
Customer ID Details
282268501
Previous Policy No OG-24-9906-1801-00063707
Bank Reference
No 1 391893647/3
Invoice No
GSTIN / UIN NA Company GST No 27AABCB5730G1ZX
Place of Supply/ 19 - West Bengal
State Code/Name Company PAN AABCB5730G

Make & Mod-

Registration Number Place of Registration Engine Number Chassis Number SubType
el
MAHINDRA
MA1YL2HJUC6L AND
WB38AA4786 WB38-ASANSOL HJC4L24648 W8 AWD
10771 MAHINDRA -
XUV500
Year Of Manufactur- Trailer Registra-
NCB % CC/KW Seating Capacity Hypothecation Details
ing tion Number
0 2179 7 2012 -,- NOT APPLICABLE
Non electrical Electrical/Elec- Value of CNG/
Vehicle IDV Value For Trailers Total Value
accessories tronic accessories LPG kit
5,58,159.00 0 0 0 0 5,58,159.00
Own Damage Premium(Rs.) Liability Premium(Rs.)
Own Damage Premium 7,146.00 Basic Third Party Liability 7,897.00
Special Discount 0.00 PA Cover for Owner-Driver - SI - Rs.1500000 331.00
Total OD Premium - A 7,146.00 LL to person for Paid driver/Opera- 50.00
Total Premium (Net Premium) (A+B) tion/Maintenance
15,774.00 PA Cover For 7 Passenger Of Rs. 100000 each 350.00
Integrated GST (18%) 2,839.00 Total Act Premium - B 8,628.00
Final Premium ( Rupees Eighteen Thousand Six Hun-
dred Thirteen Only ) 18,613.00
**Note: The above Total OD Premium is inclusive of all applicable Loading /Discounts viz (Automobile association membership, Voluntary Excess,
Anti Theft, Handicap Person, Driver Tuition, Fiber Glass, CNG/LPG Unit, Geographical Extension, Imported Vehicle Etc. wherever Applicable)

As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th September of the next financial year
I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under
sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.

For help and more information:

Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at Ba-
[email protected] or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 01-Sep-2024 19:49:04 PM- Silent_Printing (Web) (NA)
  

Broker Code 43080002 Contact No. 18002585881/18002585970

Broker Name POLICYBAZAAR INSURANCE BROKERS PRIVATE LIMTED
E-Mail ID. [email protected]

Limitation as to Use The Policy covers use of the vehicle for any purpose other than : Hire or reward, Carriage of
goods( other than samples or personal luggage),Organised racing,Pace making, Speed testing,
Reliability trials. Any purpose in connection with Motor Trade.
Driver Any person including the insured provided that a person driving holds an effective driving li-
cense 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
when not used for the transport of goods/passengers at the time of the accident and that such a
person satisfies the requirements of Rule 3 of the Central Motor Vehicle Rules, 1989.
Limits of Liability Under section II-I(i) of the policy -> Death of or bodily injury : Such amount is necessary to meet
there requirements of the Motor Vehicles Act,1988. Under section II-I(ii) of the policy -> Dam-
age to Third Party Property : Rs. 7,50,000.00
Existing Damage Details
Nominee Details Name :NA - Relationship :NA
Subject to Warranties/ 22,28, 16,
IMT-Endorsements/
Add on Package
Additional Details Coinsurance Details: - . Transaction Id: -
Premium Details Receipt No. 9906-10278197, Date 01-SEP-24 ** If Premium paid through Cheque, the Policy is
void ab-initio in case of dishonour of Cheque.
Excess Details Compulsory Excess: Additional Excess: Rs. Voluntary Excess: Rs.
Rs.2,000.00
Theft Excess: Rs.0
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.
It is mandatory to keep your policy with updated contact (Mobile No., Email ID and PAN Card) and bank account details, to process any of
your service requests faster and hassle-free in future.
You can update the same through Caringly yours App {Link}, WhatsApp Service { Say Hi on WhatsApp - +91 75072 45858}, Contact our
24-Hour Call Center at 1800-209-5858, 1800-102-5858, Give a Missed Call on 8080945060, SMS WORRY to 575758, Email ba-
[email protected], website {http://www.bajajallianz.com}, contact your agent or nearest branch.
For & On Behalf of
Bajaj Allianz General Insurance Company Ltd.

Stamp
Duty Rs.
0.25

Authorized Signatory
This document is digitally signed, hence counter signature / stamp is not required.
Consolidated Stamp Duty of Rs. 0.25/- paid for insurance policy stamps vide Order No. CSD/36/2024-25/2886 dated 01-AUG-24 of General Stamp Office, Mumbai, India.

Principal Location : Bajaj Allianz House, Airport Road, Yerwada, Pune - 411006 PH:66026666 | Services Accounting Code : 997134 -
Motor vehicle insurance services. No reverse charge is payable on these services.
 Bajaj Allianz General Insurance Company Ltd.
Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune - 411014
Contact No:Contact No: 1800-209-0144

RECEIPT

Receipt Number 9906-10278197

Receipt Date 01/09/2024
Business Channel WS

Received with thanks from RAFIKUL ALAM

(Customer ID : 282268501 ) a total sum of Rupees Eighteen Thousand Six Hundred Thirteen
Only by,

Instrument Instrument No. Instrument Bank Name Branch Name Amount

Type Date
Online Pay- 105920927 01/09/2024 NA NA 18,613
ment

Total Amount Rs. 18,613.00

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/DD/PO 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

 PRIVATE CAR PACKAGE POLICY: ADD ON COVERS(null): POLICY WORDINGS

S15: ACCIDENTAL MEDICAL EXPENSES COVER

(UIN No. IRDAN113RP0025V01200102/A0005V01201213)

A. Endorsement Wordings
In consideration of payment of additional premium, it is hereby agreed and declared that if You/Your family members
(named in the Schedule) are Hospitalized on advice of a Doctor because of an Accidental Bodily Injury sustained dur-
ing the Policy Period while travelling in the Insured Vehicle, then We will reimburse You, the reasonable and custom-
ary medical expenses incurred up to a maximum Sum Insured as shown in the Schedule for this Cover aggregate in any
one Policy Period. The medical expenses reimbursable would include: i) the reasonable charges that You/Your family
members (named in the Schedule) necessarily incur on the advice of a Doctor for In-patient Care in a Hospital for ac-
commodation; nursing care; the attention of medically qualified staff; undergoing medically necessary procedures and
medical consumables. ii) Ambulance charges for carrying You/Your family members (named in the Schedule) from the
site of accident to the nearest hospital, subject to a limit of Rs. 1,000 per claim.
B. Conditions
(1) Claims made by You against Us under #Accidental Medical Expenses Cover# are subject to the conditions set
forth under the Motor Insurance Policy (2)In case of transfer of ownership of the Insured Vehicle , the cover un-
der #Accidental Medical Expenses Cover# shall expire
C. Exclusions
In addition to the exclusions mentioned under under Motor Insurance Policy, We will not be liable to indemnify You
for the following events:
1. Where the Own Damage Claim made by You against Us under the Motor Insurance Policy is not payable. 2.
Accidental Bodily Injury that You/Your family members (named in the Schedule) meet with: a) Through suicide,
attempted suicide or self inflicted injury or illness b) While under the influence of liquor or drugs c) Arising or
resulting from You/Your family members (named in the Schedule) committing any breach of law with criminal
intent d) Whilst engaging in aviation or ballooning, whilst mounting into, dismounting from or travelling in any
balloon or aircraft other than as a passenger (fare paying or otherwise) in any duly licensed standard type of air-
craft anywhere in the world. e) Whilst participating as the driver, co-driver or passenger of a motor vehicle during
motor racing or trial runs f) As a result of any curative treatments or interventions that You/Your family members
(named in the Schedule) carry out or have carried out on your body g) Arising out of participation in any naval,
military or air force operations whether in the form of military exercises or war games or actual engagement with
the enemy, whether foreign or domestic 3. Consequential losses of any kind, be they by way of loss of profit, loss
of opportunity, loss of gain, business interruption, market loss or otherwise, or any claims arising out of loss of a
pure financial nature such as loss of goodwill or any legal liability of any kind whatsoever 4. Any injury/dis-
ablement/death directly or indirectly arising out of or contributed to any pre-existing condition 5. Venereal or
sexually transmitted diseases 6. HIV (Human Immunodeficiency Virus) and/or any HIV related illness including
AIDS (Acquired Immune Deficiency Syndrome) and/or mutant derivatives or variations thereof however caused
7. Pregnancy, resulting childbirth, miscarriage, abortion, or complications arising out of any of these 8. War
(whether declared or not), civil war, invasion, act of foreign enemies, rebellion, revolution, insurrection, mutiny,
military or usurped power, seizure, capture, arrest, restraint or detainment, confiscation or nationalisation or re-
quisition of or damage by or under the order of any government or public local authority 9. Nuclear energy, radi-
ation If You do not agree whether any of these exclusions apply to Your claim, You agree to accept the burden of
proving that they do not apply.
D. Claims Process
1) Making a Claim If You/Your family members (named in the Schedule) meet with any Accidental Bodily Injury that
may result in a claim, then as a condition precedent to Our liability: a) You or someone claiming on behalf must inform
Us in writing immediately and in any event within 30 days b) You must immediately consult a Doctor and follow the ad-
vice and treatment that he recommends c) You must take reasonable steps to lessen the consequence of Bodily injury d)
You must have Yourself examined by Our medical advisors if We ask for this e) You or some one claiming on behalf
must promptly give Us documentation and other information We ask for to verify the claim or Our obligation to make
payment for it f) In the event of Your/Your family members (named in the Schedule) death, someone claiming on de-
ceased#s behalf must inform Us in writing immediately and send Us a copy of the post- mortem report within 30 days
Note: Waiver of conditions (a) and (f) may be considered in extreme cases of hardship where it is proved to Our satisfac-
tion that under the circumstances in which You/Your family members (named in the Schedule) were placed, it was not
possible for You or any other person to give notice or file claim within the prescribed time limit. 2) Claim Settlement a)
You agree that We need only make payment when You or someone claiming on behalf has provided a claim to Our satis-
faction b) We will make payment to You or to Your Assignee. If there is no Assignee, We will pay to Your legal heir, ex-
ecutor or validly appointed legal representative as per succession certificate and any payment We make in this way will
be a complete and final discharge of Our liability to make payment
E. Definitions
The words and phrases listed have special meanings We have set below whenever they appear in bold type and initial
capitals. Please note that references to the singular or to the masculine also include references to the plural or to the fe-
male the context permits and if appropriate. 1. Accident, Accidental: A sudden, unintended and fortuitous external and
visible event 2. Assignee: The person named in the proposal or Schedule to whom the benefits under the cover are as-
signed by You/Your family members (named in the Schedule) 3. Bodily Injury: Physical bodily harm or injury but not
 PRIVATE CAR PACKAGE POLICY: ADD ON COVERS(null): POLICY WORDINGS

any mental sickness, disease or illness 4. Doctor: A person who holds a recognized qualification in allopathic medicine,
is registered by the medical council of any State of India in which he operates and is practicing within the scope of such
license. 5. Hospital: means any institution in India established for the indoor care and treatment of disease and injury,
which: a) Is registered and licensed as a hospital or nursing home with the appropriate local authorities and is under the
supervision of a registered medical practitioner OR b) Complies with minimum criteria of: i) At least 15 inpatient beds
(10 in Class C towns) ii) Fully equipped OT of its own where surgical operations are carried out iii) Fully qualified nurs-
ing staff under employment round the clock iv) Qualified doctors in charge round the clock but shall not include any es-
tablishment which is a place of rest, a place for the aged, a place for drug-addicts or a place for alcoholics, a hotel or sim-
ilar place 6. Hospitalized/Hospitalization: Your/Your family members (named in the Schedule) required stay of as an in-
patient in a Hospital within India for medically necessary treatment following and due to an insured event 7. In-patient
Care: The treatment for which You/Your family members (named in the Schedule) have to stay in a Hospital for more
than 24 hours for a covered event 8. Insured Vehicle: The vehicle insured by Us under the Motor Insurance Policy 9.
Own Damage Claim: The claims raised by You against Us for loss or damage to the Insured Vehicle due to the perils
mentioned under Section 1 of Motor Insurance Policy 10. Policy/Motor Insurance Policy: Private Car Package Policy is-
sued by Us to which this cover is extended 11. Policy Period: The period between and including the commencement date
and expiry date as shown in the Motor Insurance Policy Schedule 12. Schedule: The Schedule and any Annexure or En-
dorsement to it which sets out Your personal details, the type of insurance cover in force and the Sum Insured 13. Sum
Insured: The amount stated in the Schedule, which is the maximum amount We will pay for claims made by You irre-
spective of the number of claims You make in respect of Yourself/Your family members (named in the Schedule) 14.
You, Your, Yourself: The person or persons We insure as set out in the Schedule 15. We, Our, Us: Bajaj Allianz General
Insurance Company Limited