HDFC ERGO General Insurance Company Limited

Certificate of Insurance cum Policy Schedule 2311100416065800000

Private Car Package Policy

Vehicle Details Policy Details

Make TOYOTA KIRLOSKAR Policy No. 2311 1004 1606 5800 000
Model -ETIOS LIVA G - Period of From 06 Feb, 2019 00:01 hrs
Registration No GJ-01-KS-8653 Insurance To 05 Feb, 2020 Midnight
RTO AHMEDABAD Issuance Date 03 Feb 2019
2311100416065800000
Chassis No. MBJK3ZBT200012929 Invoice No. 100416065800000
MR SIDDHARTH SHARMA Cubic Capacity 1197 Seats 5
QTR 14 TYPE4 BSF OFFICERS COLONY BALSAMAND MANDORE
ROAD Jodhpur Year of Manufacture 2012 Body Type HATCHBACK
RAJASTHAN - 342026 Tel. 9426265479 Engine No. 3NRV046891 PAN No. :
Email ID [email protected]
Insured's Declared Value (IDV) (`)
Vehicle Electrical Accessories Non Electrical Accessories CNG/LPG Kit Trailer Total IDV
172,306 0 0 0 0 172,306
Premium Details (`)
Own Damage Premium(a) (`) Liability Premium(b) (`)
Basic Own Damage: 1968 Basic Third Party Liability: 2863
Total Basic Premium 1968 Net Liability Premium (b) 2863
Less: No Claim Bonus (50%) 984 Total Package Premium (a+b) 3847
Total - Less 984 Integrated Tax 18% 692
Net Own Damage Premium (a) 984 Total Premium 4539
Geographical Area India , Compulsory Deductible (IMT-22) 1,000 Voluntary Deductible (IMT-22A) 0
Payment Details
Cheque / DD / Fund Transfer No. Fund Transfer No. MT1902146883 Dated : 03/02/2019 Drawn on BizDirect
Previous Policy No. OG181402180100003894 Valid 03/02/2018 to 02/02/2019 of BAJAJ ALLIANZ GENERAL INSURANCE CO.LTD NCB 50%
If declaration found incorrect, benefits under the present policy in respect of own damage section will stand forfeited.
Compulsory PA cover for owner-driver has not been provided to the insured basis his/her declaration of not holding an effective driving license.
Nominee for Owner driver Lalita Sharma , Spouse Appointee

Named Persons & Nominee(IMT -15)

List of Endorsements
Endt NO Description Effective Date End Date Primium

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. Persons or Class of Persons 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 Vehicles Rules, 1989. Limits of Liability 1. Under Section II-1 (i) of the policy - Death of or bodily injury - Such amount as is
necessary to meet the requirements of the Motor Vehicles Act, 1988. 2. Under Section II - 1(ii) of the policy -Damage to Third Party Property- ` 750000 3. P. A. Cover under Section III for Owner - Driver(CSI): `
1500000 Terms, Conditions & Exclusions: As per the Indian Motor Tariff. A personal copy of the same is available free of cost on request and the same is also available at our website.

Warranted that the Assured named herein/owner of the vehicle insured holds a valid Pollution Under Control (PUC) Certificate on the date of commencement of the Policy. If the PUC is not found valid on the date
of commencement of the Policy, the Company reserves its right to repudiate the Own Damage claim made under the Policy.
I / We hereby certify that the policy to which the certificate relates as well as the certificate of insurance are issued in accordance with the provision of chapter X, XI of M. V.Act 1988.The stamp duty of 0.50 paid
b y Demand Draft, vide Receipt/Challan no. CSD/230/2018/5009/18 dated 22-11-2018 a s prescribed in Government Notification Revenue and Forest Department No. Mudrank 2004/4125/CR690/M-1,dated
31/12/2004. IMPORTANT NOTICE: The Insured i s 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 i s recoverable from the Insured. See the clause headed "AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY".
Disclaimer: The Policy shall be void from inception if the premium in full is not realised by the company. In the event of misrepresentation, fraud or non-disclosure of material fact, the Company reserves the right
to cancel the Policy. Please note that the insured vehicle was pre-inspected and a report was prepared accordingly. The existing damages to the vehicle as mentioned in the report shall not be paid by the Company.
The policy i s issued basis the information provided b y you, which i s available with the company. In case of discrepancy or non recording of relevant information in the policy, the insured is requested to bring the
same to the notice of the company within 15 days. Goods and Service Tax for this invoice is not payable under reverse charge basis.

Branch :LEELA BUSINESS PARK, 6TH FLR, ANDHERI - KURLA RD, MUMBAI, 400059. Phone No. : +91-22-66383600
Goods and Service Tax Registration No: 27AABCL5045N1Z8 HSN Code 9971
Agent Name : POLICYBAZAAR INSURANCE WEB AGGREGATORS PVT. LTD Agent Code : For HDFC ERGO General Insurance Company Ltd
201714906552

Duly Constituted Attorney

Scan for Instant Policy Info

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HDFC ERGO General Insurance Company Limited.(Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016).CIN: U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District
(Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service no : 022 - 6234 6234 / 0120 - 6234 6234 Te.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | [email protected] | www.hdfcergo.com.
UIN : HDE-MO-P14-40-V02-14-15 IRDAI Reg No.146
HDFC ERGO General Insurance Company Limited
2311100416065800000

Motor Insurance - Proposal Form cum Transcript Letter For Private Car Package
Proposal No. 2311100416065800000

Vehicle Details Policy Details

Make TOYOTA KIRLOSKAR Proposal No. 2311 1004 1606 5800 000
Model -ETIOS LIVA G - Period of From 06 Feb, 2019 00:01 hrs
Registration No GJ-01-KS-8653 Insurance To 05 Feb, 2020 Midnight
RTO AHMEDABAD Issuance Date 03 Feb 2019
2311100416065800000
Chassis No. MBJK3ZBT200012929 Invoice No. 100416065800000
MR SIDDHARTH SHARMA Cubic Capacity 1197 Seats 5
QTR 14 TYPE4 BSF OFFICERS COLONY BALSAMAND MANDORE
ROAD Jodhpur - 342026 Year of Manufacture 2012 Body Type HATCHBACK
RAJASTHAN - Tel. 9426265479 Engine No. 3NRV046891 PAN No. :
Email ID [email protected]
Insured's Declared Value (IDV) (`)
Vehicle Electrical Accessories Non Electrical Accessories CNG/LPG Kit Trailer Total IDV
172306 0 0 0 0 172306
Premium Details (`)
Own Damage Premium(a) (`) Liability Premium(b) (`)
Basic Own Damage: 1968 Basic Third Party Liability: 2863
Total Basic Premium 1968 Net Liability Premium (b) 2863
Less: No Claim Bonus (50%) 984 Total Package Premium (a+b) 3847
Total - Less 984 Integrated Tax 18% 692
Net Own Damage Premium (a) 984 Total Premium 4539
Geographical Area India , Compulsory Deductible (IMT-22) 1,000 Voluntary Deductible (IMT-22A) 0
Payment Details (`)
Cheque / DD / Fund Transfer No. Fund Transfer No. MT1902146883 Dated : 03/02/2019 Drawn on BizDirect
Previous Policy No. OG181402180100003894 Valid 03/02/2018 to 02/02/2019 of BAJAJ ALLIANZ GENERAL INSURANCE CO.LTD NCB 50%
If declaration found incorrect, benefits under the present policy in respect of own damage section will stand forfeited.
Compulsory PA cover for owner-driver has not been provided to the insured basis his/her declaration of not holding an effective driving license.
Nominee for Owner driver Lalita Sharma , Spouse Appointee

Named Persons & Nominee(IMT -15)

Agent Name : POLICYBAZAAR INSURANCE WEB AGGREGATORS PVT. LTD Agent Code : 201714906552
Anti rebate clause
Prohibition of Rebates (Section 41 of Insurance Act, 1938 as amended) : 1. No person shall allow o r 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 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: provided that acceptance by an
insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be acceptance of a rebate of premium within the meaning of this sub-section if
at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed by 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..

Terms and Conditions

I hereby declare that the Insured Person(s) listed in Proposal Form will abide to the following T&C:
1 ) I/We hereby declare that the statements made by me/us 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
HDFC ERGO General Insurance Company Limited.
2) 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 the insurers immediately.
3) I understand that: My premium is derived on the basis of information filled by me, which includes my previous year policy details and No claim Bonus Discount %, if any.
HDFC ERGO General Insurance Company (Company) may verify my previous year policy details and may hold claim settlement process till the time confirmation is received from previous insurer
The Company shall have no liability under this insurance contract if it is found that any of my / our statement on particulars or declaration (other than NCB discount) in this proposal form
or other documents are incorrect and / or untrue / false.
I f any discrepancy found in the information provided for arriving at NCB discount %, Company shall communicated to me via e-mail &/ or letter for payment of the balance premium amount within 20 days from the
date of communication.
I f the balance amount is not paid by me within 20 days from the date of communication, I will be liable to pay three times the balance premium amount at the time of first claim made under the policy which shall be
deducted from the final approved claim amount under the policy
4) I/We also shall endeavor to procure the renewal notice and pass on the same to HDFC ERGO General Insurance immediately upon the receipt of such renewal notice.
5 ) Any person who, knowingly and with intent to defraud the Insurance Company o r other persons, files a proposal for insurance containing any false information, o r conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent act which will render the policy voidable at the Company's sole discretion and result in a denial of insurance benefits.
GSTIN :- Motor(Comprehensive and TP):For policy issued in the name of corporate entity (proprietor, HUF, partnership, private company etc), GSTIN is printed on the policy, basis the details provided during policy
issuance. For any subsequent changes or addition (i.e. if GSTIN not entered at the time of policy issuance ) on policy schedule, changes shall be carried out through fresh policy issuance with prospective effect.
6) I / we declare and confirm having a valid PUC.
7) I understand the Proposal No. 2311100416065800000 is issued to me basis on above information.
Transcript Declaration : In case disagreement or objection or any other changes with respect to information and contents mentioned herein above,please contact our toll free number and register your objections /
changes / disagreement to the content 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
the policy.

HDFC ERGO General Insurance Company Limited.(Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016).CIN: U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District
(Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service no : 022 - 6234 6234 / 0120 - 6234 6234 Te.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | [email protected] | www.hdfcergo.com.
UIN : HDE-MO-P14-40-V02-14-15 IRDAI Reg No.146
HDFC ERGO General Insurance Company Limited

Frequently Asked Question’s (FAQ’s) - Motor Insurance

WHAT ARE THE MAJOR COVERS UNDER THE POLICY? HOW DO I FILE A CLAIM?
Loss or Damage to the Insured Vehicle caused due to: For Accidental Damage to Insured Vehicle (Own Damage Claims):
a. Fire, explosion, self ignition or lightning. ¡ Mobile App: Simply download HDFC ERGO Mobile App - Insurance Portfolio Organizer
b Burglary, housebreaking or theft from Play Store. Link your policy by providing few simple details and register a claim.
c All act of God perils like earthquake, flood, cyclone etc ¡ Call Toll Free 1800 2700 700 (Accessible from India only) and provide your policy
d Accidental external means, terrorism, riot and strike number for reference and register a claim
Liability to Third Parties:
Provides cover for any legal liability arising out of the use of the vehicle for Please keep the following details handy while intimating a claim
a Accidental death / injury to any third party a. Policy Number
b Any damage to property owned by third party b. Registration Details / RC Copy
Personal Accident Cover: c. Drivers details at the time of accident including driving License Number
The policy provides for a mandatory Personal Accident cover for owner driver and optional d. FIR on a case to case basis
cover for passengers covering accidental death and permanent total disability e. Repair estimate

WHAT ARE THE MAJOR EXCLUSIONS OF THE POLICY? WHAT IS THE CLAIM PROCESS?
a. General aging, wear & tear, mechanical or electrical breakdown, failure, depreciation, 1. If your vehicle can be driven, take it to the nearest dealer / garage.
any consequential loss 2. Get a repair estimate, fill up the claim form and attach a copy of the registration
b. Damage by a person driving without a valid license certificate and driving license of the person driving at the time of the accident.
c. Damage by a person driving under the influence of liquor or drugs 3. If the garage is within our network, you could avail of cashless claim facility. Pay for non
d. Loss/damage attributable to war, mutiny, nuclear risks accident related repairs, depreciation and deductible. We would settle the rest.
e. Damage to tyres and tubes, unless damaged during an accident 4. If the garage is outside our network, you would have to get the claim reimbursed
f. Usage on hire & reward (applicable for all classes except public commercial vehicles) subsequently.
g. Loss or damage to bonnet side parts, mudguard, bumpers, lamps, tyres, tubes,
headlights, paint work (applicable for all commercial vehicles; unless opted CLAIMS DOCUMENTS -
additionally) FOR ACCIDENTAL DAMAGE TO INSURED VEHICLE
h. Loss or damage resulting from overturning arising out of operation as a tool (applicable a. Duly filled and signed claim form & satisfaction voucher
for mobile cranes, drilling rigs, mobile plants, navvies, shovels, grabs, rippers unless b. Registration Certificate (RC)
opted for additionally) c. Driving license of the person driving at the time of the accident
i. Loss of or damage to accessories by burglary housebreaking or theft unless the vehicle d. Policy Copy, original repair estimate, repair invoice
is stolen at the same time (applicable to all commercial vehicles & two wheelers) e. Payment receipt for non-cashless claims
f. Original repair invoice for cashless claims
TRANSFER OF INSURANCE (INCASE VEHICLE IS SOLD) g. AML documents for amount more than `1 lakh (PAN card, 2 passport size photo,
To place your request for Transfer of Insurance, visit Customer Support section on our residence proof)
website www.hdfcergo.com. h. Form 35 & original NOC from financer incase of total loss where payment is made to
insured
i. A copy of police FIR/panchnama is required for TP injury / death / property damage
WHAT CHANGES CAN BE DONE IN MY POLICY ENDORSEMENT
j. Sale deed / Delivery note / Form 29 and 30 / transferred RC Copy in 'Used Car' cases
To place your request for any ''Changes in Policy', visit Customer Support section on our
website www.hdfcergo.com. Additional documents required for commercial vehicles:
a. Spot survey b. Load challan c. Fitness certificate d. Route permit
CLAIMS DOCUMENTS: IN CASE OF LOSS DUE TO THEFT
WHAT IS NCB?
a. Duly filled and signed claim form & discharge voucher ( after loss settlement )
b. Original Registration Certificate (RC) NO CLAIM BONUS (NCB):
c. Original Policy Copy NCB is provided for every claim free year basis the slab as provided by Tariff.
d. Copy of FIR lodged at the nearest police station How can I get No Claim Bonus Reserving Letter?
e. All original keys & vehicle invoice copy NCB Reserving letter can be provided only on Sale of vehicle evidenced by transferred RC
f. No trace report confirming that the stolen vehicle is not traceable copy OR Sale Deed and Form 29 & 30. The OD section of the policy needs to be transferred
g. Original NOC from financer incase of hypothecation / HPA to the new owner or cancelled.
h. Intimation to RTO for theft of vehicle HOW DO I RENEW MY POLICY?
i. Duly signed RTO transfer papers (Form 26, 28,29,30,35)
j. RC extract with stolen remark from the concerned RTO after the loss a. Visit www.hdfcergo.com to renew c. Visit our nearest branch / your agent
k. AML documents for amount more than 1 lac (PAN card, 2 passport size photo, residence instantly online
proof) d. Send a copy of the renewal notice along
l. Deed of subrogation cum indemnity on judicial stamp paper b. SMS "RENEW <POLICY NO> " to 9999 with premium cheque to our branch
700700 office /Corporate office
Disclaimer: Where it is brought to the notice of the Company, that vehicle insured
HOW TO CONTACT US?
which is not a new vehicle but shown as a new vehicle with a malafide intention,
claims for total loss of such vehicle would not be admissible, if there is a gap of more Visit Customer Support section on our website www.hdfcergo.com and avail host of
than 10 days from date of invoice of vehicle and the proposal date. services online which is easy, instant & convenient

Convenience at your fingertips

On the Customer Support section of our website, you can:
Ver.Feb18

Get Policy Copy/ Make Changes Track Claim Update Contact

` 80D Tax Certificate on Policy Status Details
This document is a summary of the benefits offered. The information mentioned above is illustrative and not exhaustive. Information must be read in conjunction with the policy wordings.
In case of any conflict between this document and the policy wordings, the terms and conditions mentioned in the policy wordings shall prevail.