ROYAL SUNDARAM GENERAL INSURANCE CO.

LIMITED
Servicing Office of Insurer: No.56/1, 2nd floor, 9th main road, 5th blockJayanagarBangalore, Bangalore,
Karnataka (State Code:29) -560027, PH-- Website: WWW.ROYALSUNDARAM.IN
PAN: AABCR7106G . GSTIN: 29AABCR7106G1ZF Insurer's IRDA Registration Number: 102
Tollfree Helpline 1860 425 0000 Email: [email protected] CIN :
U67200TN2000PLC045611 UIN No: IRDAN102P0004V02201617

BUNDLED PRIVATE CAR LONG TERM POLICY-CERTIFICATE CUM POLICY SCHEDULE

CUM RECEIPT (UIN-IRDAN102RP0005V01201819)
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)
Policy No. FVBL102480 Policy Issued On 22-FEB-2019 (13:00)
Insured Name MS. SHWETHA DM
Own Damage Period 22-FEB-2019(13:00) To 21-FEB-2020(Midnight) Motor Liability Period 22-FEB-2019(13:00) To 21-FEB-2022(Midnight)

Proposal No. & Date PRODFORD1107605, 22-FEB-2019 CPA Cover Period 22-FEB-2019(13:00) To 21-FEB-2022(Midnight)
Insured Add. NO. 37, KODAGANUR, DAVANAGERE DAVANAGERE DIST,, DAVANGERE , KARNATAKA (State Code:29) -577534
Previous Insurer NA Previous Policy No. NA
Broker Details
IRDA Lic. No.: 375, CIN No.: U50300MH1997PLC149349 Broker Category: Composite Broker, Validity: 13-MAY-17 To 12-MAY-20
Name & Add.: TATA MOTORS INSURANCE BROKING & ADVISORY SERVICES
LTD, 1ST FLOOR, AFL HOUSE, LOK BHARATI COMPLEX, MAROL MAROSHI ROAD, ANDHERI (EAST), MUMBAI400 059, INDIA

Make Model Sub Model Cubic Capacity Manufacturing Year Seating capacity

FORD FIGO ASPIRE FORD FIGO ASPIRE 1.5D 1498 2018 5

TREND + MT
Body Type Registration No. RTO Invoice Date Engine No. Chassis No.

SEDAN DAVANGERE 22-FEB-2019 JR31844 MAJZXXMTKZJR31844

Vehicle IDV CNG/LPG Kit Elec. Accessories Non-Elec. Accessories Total IDV

669,428 0 0 0 669,428

Schedule of Premium (Amount in Rs.)

Own Damage Premium (A) Liability Premium (B)
Basic Premium Basic Third Party Liability 9,534

Vehicle 12,818 Third Party Liability For Bi-Fuel Kit 0

Non-Elec. Accessories 0 Third Party Liability For Geographical Area Extension 0

Elec. Accessories (IMT-24) 0 PA Cover For Owner Driver Of Rs. 1500000 (IMT-15) 850

CNG/LPG Kit (IMT-25) 0 PA Cover For 0 Persons of Rs. 200000 Each (IMT-16) 0
Sub Total (Basic Premium) 12,818 PA cover for Paid Driver of Rs 2,00,000 (IMT± 300

Add On Coverages (NIL DEP. 0 TILL 1 YEAR) 3,682 Legal Liability For Paid Driver (IMT-28) 150

Geographical Area Extension (IMT-1) 0 Legal Liability for Employees (for 0 persons) (IMT± 0

IMT 23 Premium 0 Net Liability Premium (B) 10,834

Sub Total-Addition 16,500 Total Premium (A+B) 27,334

CGST (9%) 2461

Deductibles SGST (9%) 2461
Voluntary Deductibles (0) (IMT-22A) 0 Gross Premium Paid 32,256
Note: 1.Warning that in case of dishonour of the premium cheque, this document stands automatically
Anti Theft Device (IMT-10) 0 cancelled 'ab-initio

AA Membership (IMT-8) 0 2.Consolidated stamp duty paid to state exchequer

3.The policy is subject to compulsory deductible of Rs.1000 (IMT-22)
No Claim Bonus (0%) 0

5.Add-on: NIL DEP. 0 TILL 1 YEAR:3682

Sub Total (Deductibles) 0 6.The insurance company will display terms & conditions on its website WWW.ROYALSUNDARAM.IN
which can
be accessed by you online.
Net Own Damage Premium (A) 16,500 *Subject to IMT Endt. Nos.& Memorandum:7,17,22,28
Nominee Details
Name of Nominee Age Relationship with Insured Name of Appointee Relationship with Nominee
KALIBAI 59 MOTHER --N.A-- --N.A--
Payment Details : Cheque No.: 312779, Cheque Date: 22-FEB-2019, Bank Name: VIJAYA BANK, Bank City: BANGALORE
Hypothecation Details: SUNDARAM FINANCE LIMITED - DAVANGERE
MISP Name: VST AUTO ANCILLIARIES PRIVATE LIMITED, MISP PAN No: AAACV4798B, MISP Code: MISP/AAACV4798B
SAC:997134, Description of Service :Motor Vehicle Insurance Services, Place of Supply :KARNATAKA(State Code:29), Receipt No/Invoice No:FVBL102480
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 Motor
Vehicle Act, 1988
For & On Behalf of ROYAL SUNDARAM GENERAL INSURANCE CO. LIMITED

Dealer Code : METRO FORD (BANGALORE) - 3701000

In case of any claim or assistance required please contact our help line at 1800 209 0060 and you may also reach us at [email protected]
 ROYAL SUNDARAM GENERAL INSURANCE CO. LIMITED
Servicing Office of Insurer: No.56/1, 2nd floor, 9th main road, 5th blockJayanagarBangalore, Bangalore,
Karnataka (State Code:29) -560027, PH-- Website: WWW.ROYALSUNDARAM.IN
PAN: AABCR7106G . GSTIN: 29AABCR7106G1ZF Insurer's IRDA Registration Number: 102
Tollfree Helpline 1860 425 0000 Email: [email protected] CIN :
U67200TN2000PLC045611 UIN No: IRDAN102P0004V02201617

BUNDLED PRIVATE CAR LONG TERM POLICY-CERTIFICATE CUM POLICY SCHEDULE

CUM RECEIPT (UIN-IRDAN102RP0005V01201819)
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)
Policy No. FVBL102480 Policy Issued On 22-FEB-2019 (13:00)
Insured Name MS. SHWETHA DM
Own Damage Period 22-FEB-2019(13:00) To 21-FEB-2020(Midnight) Motor Liability Period 22-FEB-2019(13:00) To 21-FEB-2022(Midnight)

Limitations as to use: The policy covers use of the vehicle for any purpose other than (1) Hire or Reward (2) Carriage of
goods (other than samples or personal luggage) (3) Organized racing (4) Pace making (5) Speed testing (6) Reliability trials (7)
Any purpose in connection with motor trade.

Driver¶s Clause: Any person including the insured: Provided that the person driving holds an effective driving license at the
time of the accident and is not disqualified from holding or obtaining such license. Provided also that the person holding an
effective learners license may also drive the vehicle & that such a person satisfies the requirements of Rule 3 of the Central
Motor Vehicle Rules, 1989.

Limits of Liability Clause: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 Vehicle Act 1988.Under Section II-1 (ii) of the policy-Damage to third party property is
Rs.7.5lakhs PA Cover Under Section III for Owner-Driver is Rs. 1500000

Important Notice: The insured is not indemnified if the vehicle is used or driven otherwise than in accordance with the
schedule. Any payment made by the company by reasons 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 ³AVOIDANCE OF CERTAIN TERMS &
RIGHT OF RECOVERY´For legal interpretation English version will hold good.

Note: This Schedule, the attached Policy and Endorsements mentioned herein above shall read together and word or
expression to which a specific meaning has been attached in any part of this policy or of the Schedule shall bear the same
meaning wherever it may appear. Any amendments/modifications/alterations made on this system generated policy document
is not valid and Company shall not be liable for any liability whatsoever arising from such changes. Any changes required to
be made in the policy once issued would be valid and effective, only after written request is made to the Company and
Company accepts the requested amendments/modifications/alterations and records the same through separate endorsement to
be issued by the company.
In Witness whereoff this policy has been signed at BANGALORE on 22-FEB-2019 13:00
 ROYAL SUNDARAM GENERAL INSURANCE CO. LIMITED
Servicing Office of Insurer: No.56/1, 2nd floor, 9th main road, 5th blockJayanagarBangalore, Bangalore,
Karnataka (State Code:29) -560027, PH-- Website: WWW.ROYALSUNDARAM.IN
PAN: AABCR7106G . GSTIN: 29AABCR7106G1ZF Insurer's IRDA Registration Number: 102
Tollfree Helpline 1860 425 0000 Email: [email protected] CIN :
U67200TN2000PLC045611 UIN No: IRDAN102P0004V02201617

BUNDLED PRIVATE CAR LONG TERM POLICY-CERTIFICATE CUM POLICY SCHEDULE

CUM RECEIPT (UIN-IRDAN102RP0005V01201819)
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)
Policy No. FVBL102480 Policy Issued On 22-FEB-2019 (13:00)
Insured Name MS. SHWETHA DM
Own Damage Period 22-FEB-2019(13:00) To 21-FEB-2020(Midnight) Motor Liability Period 22-FEB-2019(13:00) To 21-FEB-2022(Midnight)

PRIVATE CAR PACKAGE POLICY: ADD ON COVERS

MOTOR INSURANCE PRIVATE CAR ADD ON COVER Depreciation Waiver Clause

Clause No. RSMOAC001

What is Covered:

The parts and materials those need to be replaced, following an accident covered under Your policy/admissible claims on
Repair Basis, will normally attract depreciation depending on the age of the vehicle and the material used to produce the
parts. By choosing the Removal of Depreciation Clause, You need not pay this amount towards depreciation. We will pay
the cost of those parts that need replacement, following an accident arising out of an insured peril, in full without any
deduction towards depreciation.

What is not Covered:

1. The amount of total deductible mentioned in the policy schedule

2. Damage caused by an uninsured peril including mechanical breakdown.
3. Damage to uninsured items including electrical, non-electrical accessories and bi-fuel/gas kit.
4. Claims made for theft of parts and/or accessories.
5. Claims made under Self Authorisation Mode.

Deductibles: As per the base Package Policy

Minimum Premium

The cover will be subject to a minimum premium of Rs.100/-

Other Conditions:

1. The Cover will be offered on annual basis and will run concurrently with the Package policy of the vehicle.
2. Mid-term inclusion or removal of this cover shall not be allowed.
3. The Cover is not available for imported vehicles and obsolete models that are no more in production and whose parts
are not available off the shelf

This add-on cover is attached to the base Private Car Package Policy and all the Terms and Conditions of the base policy
shall apply to the addon covers also, unless specifically stated otherwise in the above wordings.