HDFC ERGO General Insurance Company Limited

Certificate of Insurance cum Policy Schedule 2312202516976301000

Motor Insurance - Two Wheeler Comprehensive Policy

2312202516976301000

Vehicle Details Policy Details

MR BIBHUTI BHUSAN PATTANAIK Make HONDA. Policy No. 2312 2025 1697 6301 000
CO- R N PANDA D/133, CO OPERATIVE COLONY KALING VIHAR Model - Variant ACTIVA-5G DLX Period of From 21 Nov, 2023 00:01 hrs
CHHEND, 769015 ROURKELA Insurance
ODISHA - 769009 , Mob. 94XXXXXXX5 Registration No OD-14-Q-5487 To 20 Nov, 2024 Midnight
Engine No. JF50ET8296670 Issuance Date 13/11/2023
Chassis No. ME4JF50BLJT296756 Invoice No. 202516976301000
Cubic Capacity/Watts 110 Seats 2 Customer Id 100496958153
Year of Manufacture 2018 Body Type OPEN PAN No. AXZPP5393H
RTO ROURKELA EIA No. Not provided
Payment Details : 90200015210452 , Bank Name:BizDirect

Insured's Declared Value (IDV) (`)

Policy Year Policy Period For the Vehicle Side Car Non Electrical Acc. Electrical Acc. CNG/LPG Kit Total IDV
Year 1 From 21/11/2023 To 20/11/2024 25348 0 0 0 0 25348
Own Damage Policy Period Liability Policy Period
From Date & Time 21/11/2023 00:01 hrs To Date & Time 20/11/2024 Midnight From Date & Time 21/11/2023 00:01 hrs To Date & Time 20/11/2024 Midnight
Premium Details (`)
Own Damage Premium(a) (`) Liability Premium(b) (`)
Basic Own Damage 568 Basic Third Party Liability 714
Total Basic Premium 568 Sub Total - Addition 714
Net Liability Premium (b) 714
Total Package Premium (a+b) 1282
Integrated Tax 18% 276
Net Own Damage Premium (a) 568 Total Premium 1558
Geographical Area India Compulsory Deductible (IMT-22) 100 Voluntary Deductible (IMT-22A) 0
Previous Policy No. 2312202516976300001 Valid from 21/11/2018 to 20/11/2023 of HDFC ERGO GENERAL INSURANCE CO.LTD. No Claim Bonus 0%
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 Or having Alternate PA / Stand alone CPA
policy with minimum sum insured of Rs 15 Lakhs.

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 when
not used for the transport of passengers at the time of the accident 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- `
100000 3.P.A. Cover under Section III for Owner - Driver(CSI): ` 0 Terms, Conditions & Exclusions: As per the Indian Motor Tariff. A personal copy of the same is available free of cost on request & the
same is also available at our website.

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 by Demand Draft, vide Receipt/Challan no. LOA/CSD/547/2022/5450/22 dated 22/12/2022 as prescribed in Government of Maharashtra Order No. Mudrank-2017/CR.97/M-1, dated the 09th January 2018".
GST Registration No: 27AABCL5045N1Z8. 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." 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 is issued basis the information provided by you, which is 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. GST for this invoice is not payable under reverse charge basis. 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

Branch :leela business park, 6th flr, andheri - kurla rd, mumbai

For Claim/Policy related queries call us at +91- 22 6234 6234/+91- 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim.
GST Registration No: 27AABCL5045N1Z8 HSN Code 997134
HE DIRECT_DBG DIRECT_10137_3 For HDFC ERGO General Insurance Company Ltd
200113740856

Duly Constituted Attorney

Scan the code for Instant Policy Info, Register/Track Claim, Renewal and Modifications in policy.

"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: IRDAN125RP0009V01202122. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
 HDFC ERGO General Insurance Company Limited
2312202516976301000

Motor Insurance - Proposal Form cum Transcript Letter For Two Wheeler Comprehensive Policy

Vehicle Details Proposal Details

Make HONDA. Proposal No. 202311130056904
Model - Variant ACTIVA-5G DLX Period of From 21 Nov, 2023 00:01 hrs
Registration No OD-14-Q-5487 Insurance To 20 Nov, 2024 Midnight
2312202516976301000
Engine No. JF50ET8296670 Issuance Date 13/11/2023
MR BIBHUTI BHUSAN PATTANAIK Chassis No. ME4JF50BLJT296756 Invoice No. 202516976301000
CO- R N PANDA D/133, CO OPERATIVE COLONY KALING
VIHAR CHHEND, 769015 ROURKELA - 769009 Cubic Capacity/Watts 110 Seats 2 Customer Id 100496958153
ODISHA - Tel. 94XXXXXXX5 Year of Manufacture 2018 Body Type OPEN PAN No AXZPP5393H
RTO ROURKELA
Payment Details : 90200015210452 , Bank Name:BizDirect

Policy Year Policy Period For the Vehicle (`) Non Electrical Acc. (`) Electrical Acc. (`) CNG/LPG Kit (`) Total IDV (`)
Year 1 From 21/11/2023 To 20/11/2024 25348 0 0 0 25348
Premium Details (`)
Own Damage Premium(a) (`) Liability Premium(b) (`)
Basic Own Damage 268 Basic Third Party Liability 714
Total Basic Premium 268 Sub Total - Addition 714
Net Liability Premium (b) 714
Total Package Premium (a+b) 982
Integrated Tax 18% 177
Net Own Damage Premium (a) 268 Total Premium 1159
Geographical Area India Compulsory Deductible (IMT-22) 100 Voluntary Deductible (IMT-22A) 0
Previous Policy No. 2312202516976300001 Valid from 21/11/2018 to 20/11/2023 of HDFC ERGO GENERAL INSURANCE CO.LTD. No Claim Bonus 0%
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 Or having Alternate PA / Stand alone CPA
policy with minimum sum insured of Rs 15 Lakhs.
HE DIRECT : HE DIRECT_DBG DIRECT_10137_3
Code : 200113740856
Contact No : 91-22-66383600

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 o r 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/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.
4) Any person who, knowingly and with intent to defraud the Insurance Company or other persons, files a proposal for insurance containing any false information, or 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.
5) I understand the Proposal No. 202311130056904 is issued to me basis on above information.
6) It has been declared by you that you are not a Politically Exposed Person and the source of funds to purchase this policy are from salary/business income.
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.

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: IRDAN125RP0009V01202122. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
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 the insured vehicle (Own Damage Claims):
a. Fire, explosion, self ignition or lightning. ¡ Visit the 'Help' section by clicking https://selfhelp.hdfcergo.com
b Burglary, housebreaking or theft ¡ Send us a "Hi" on our WhatsApp number 8169 500 500
c All act of God perils like earthquake, flood, cyclone etc ¡ Call us on our Customer Service No.: 022-62346234/ 0120-62346234
d Accidental external means, terrorism, riot and strike Please keep the following details handy while intimating a claim:
Liability to Third Parties: a. Policy number
Provides cover for any legal liability arising out of the use of the vehicle for b. Registration details/RC copy
a Accidental death / injury to any third party c. Driver's details at the time of accident including driving license number
b Any damage to property owned by third party d. FIR on a case-to-case basis
Personal Accident Cover: e. Repair estimate
The policy provides for a mandatory Personal Accident cover for owner driver and optional cover for
passengers covering accidental death and permanent total disability
WHAT IS THE CLAIM PROCESS?
WHAT ARE THE MAJOR EXCLUSIONS OF THE POLICY? 1. If your vehicle can be driven, take it to the nearest dealer / garage.
2. Get a repair estimate, fill up the claim form and attach a copy of the registration certificate and
a. General aging, wear & tear, mechanical or electrical breakdown, failure, depreciation, any driving license of the person driving at the time of the accident.
consequential loss 3. If the garage is within our network, you could avail of cashless claim facility. Pay for non accident
b. Damage by a person driving without a valid license related repairs, depreciation and deductible. We would settle the rest.
c. Damage by a person driving under the influence of liquor or drugs 4. If the garage is outside our network, you would have to get the claim reimbursed subsequently.
d. Loss/damage attributable to war, mutiny, nuclear risks 5. The insured should not initiate any repairs or dismantle the vehicle before the survey is completed.
e. Damage to tyres and tubes, unless damaged during an accident CLAIMS DOCUMENTS -
f. Usage on hire & reward (applicable for all classes except public commercial vehicles)
For ACCIDENTAL DAMAGE TO INSURED VEHICLE
g. Loss or damage to bonnet side parts, mudguard, bumpers, lamps, tyres, tubes, headlights, paint
work (applicable for all commercial vehicles; unless opted additionally) a. Duly filled and signed claim form & satisfaction voucher
h. Loss or damage resulting from overturning arising out of operation as a tool (applicable for mobile b. Registration Certificate (RC)
cranes, drilling rigs, mobile plants, navvies, shovels, grabs, rippers unless 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 is stolen at d. Policy copy , original repair estimate, repair invoice
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 lac (PAN card, 2 passport size photo, residence proof)
a. No objection letter from the previous insured h. Form 35 & original NOC from financer incase of total loss where payment is made to insured
b. Form 29/30, Sale Deed OR transferred RC copy. In case of smart card, RTO transfer fee paid i. A copy of police FIR/panchnama is required for TP injury / death / property damage
receipt. Additional documents required for commercial vehicles:
c. Differential Premium if any (NCB recovery, PA to Owner - Driver etc) a. Spot survey b. Load challan c. Fitness certificate d. Route permit
d. NOC from Financier, if applicable.
e. Pre-inspection is must if transfer request date is >14 days from the endorsed RC copy date CLAIMS DOCUMENTS: IN CASE OF LOSS DUE TO THEFT
f. Break-in loading >45 days ( if applicable) a. Duly filled and signed claim form & discharge voucher ( after loss settlement )
b. Original Registration Certificate (RC)
Additional Documents c. Original policy copy
a. Incase of death of Insured - a. Death Certificate b. Legal heir certificate d. Copy of FIR lodged at the nearest police station
b. Incase of Employer to Employee transfer - a. Letter from Employer e. All original keys & vehicle invoice copy
f. No trace report confirming that the stolen vehicle is not traceable
WHAT CHANGES CAN BE DONE IN MY POLICY ENDORSEMENT g. Original NOC from financer incase of hypothecation / HPA
h. Intimation to RTO for theft of vehicle
For Changes related to registration of vehicle or vehicle details like i. Duly signed RTO transfer papers (Form 26, 28,29,30,35)
a. Correction in registration number/ location / address j. RC extract with stolen remark from the concerned RTO after the loss
b. Correction in vehicle make & model/ cubic capacity/ seating capacity/ engine & chassis k. AML documents for amount more than 1 lac (PAN card, 2 passport size photo, residence proof)
number/manufacture year l. Deed of subrogation cum indemnity on judicial stamp paper
Disclaimer: Where it is brought to the notice of the Company, that vehicle insured which is not a new vehicle
To make above changes, you need following documents: but shown as a new vehicle with a malafide intention, claims for total loss of such vehicle would not be
a. Request letter for the change admissible, if there is a gap of more than 10 days from date of invoice of vehicle and the proposal date.
b. Policy copy
c. Registration Certificate copy /Invoice Copy for change in vehicle details WHAT IS NCB?
d. Cheque for additional premium if applicable NO CLAIM BONUS (NCB):
NCB is provided for every claim free year basis the slab as provided by Tariff.
For addition of electrical and non electrical accessories, CNG & LPG Kit: How can I get No Claim Bonus Reserving Letter?
a. Request letter for the change NCB Reserving letter can be provided only on Sale of vehicle evidenced by transferred RC copy OR
b. Policy copy Sale Deed and Form 29 & 30. The OD section of the policy needs to be transferred to the new owner or
c. Invoice copy (mandatory where value of accessory exceeds ` 20,000/-) cancelled.
d. Endorsed Registration Certificate Copy (For CNG/LPG kit) HOW DO I RENEW MY POLICY?
e. Cheque for additional premium You can renew your policy via any of the below options:
E-mail or Call us for additional premium details & send relevant documents copy to our customer service a. RENEW ONLINE: Visit "Instant Renewal" section on our website www.hdfcergo.com
office to renew instantly
b. Call on 022 - 62346234 / 0120 - 62346234 and renew instantly
For Change of financier details (Hypothecation/Lease/Hire-Purchase) c. Courier the Cheque / Demand Draft in favor of "HDFC ERGO General Insurance Company Ltd' to
a. Request letter for the change our Customer service office
b. Policy copy d. Email to [email protected]
c. Endorsed Registration Certificate copy
d. NOC from financier OR form 35 duly signed and stamped by financier HOW TO CONTACT US?
Customer Service No :022 - 6234 6234 / 0120 - 6234 6234
E-Mail :[email protected]
For any endorsments on your policy you can simply place your request on HELP Section of our Write to us at :HDFC ERGO General Insurance Company Limited
website www.hdfcergo.com (Customer service office) D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg,
Bhandup (West). Mumbai - 400078. Maharashtra.

Convenience at your fingertips

On the HELP section of our website, you can:
Ver. APR2023

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.