Digitally signed by

Reliance General
Insurance Company
Limited
SID041 Date: 2023.04.12

0 2312 Reliance Two Wheeler Package Policy - Schedule

2312
Policy Number: 110522323120058675 Proposal/Covernote No: R12042306042

https://rgi
Insured Name :MR.SYED FIRDOUS ALAM Period of Insurance: From 00:00 Hrs on 15-Apr-2023 to Midnight of 14-Apr-
2024

Communication Address & Place of Supply :5/3 AYYAM PERUMAL KOVIL Policy Issuing Branch : 4TH FLOOR, CHINTAMANI AVENUE, NEXT TO
STREET, ROYAPETTAH,CHENNAI,,,TAMIL NADU,,INDIA,600118 VIRVANI INDUSTRIAL ESTATE, W.EXP. HIGHWAY, GOREGAON EAST ,
MUMBAI,,MAHARASHTRA,
400063

Mobile No :9363438308 Tax Invoice No. & Date :R12042306042 & 12 Apr 2023 10:18

Email-ID : [email protected] GSTIN/UIN & Place of Supply:

Insured's Blood group :
Insured Vehicle Details
Registration No. TN06T9113 Mfg. Month & Year JAN-2017
Make / Model & Variant Honda / Dio / Std CC / HP / Watt 102
Seating Capacity Including
Engine No./Chassis No. JF39E72048287 / ME4JF39EGH7010585 2
Driver
Type of Body NA Total Premium ` 961.00
RTO Location TAMIL NADU - Chennai (Mandaveli) IDV ` 21434.00
Hypothecation/Lease NA
Insured Declared Value (IDV)
Vehicle IDV ` 21434 Non Electrical Accessories ` 0.0

Electrical / Electronic Accessories ` 0.0 Total IDV `

21434.00

Premium Summary

Own Damage - Section I Amount (`) Liability - Section II Amount (`)

Basic OD 115.29 Basic Liability 714.00
Total Basic Own Damage Premium 115.29 Total Basic Liability Premium 714.00
Less PA Benefits - Section III
Deduct 50 % for NCB -57.65 TOTAL0LIABILITY PREMIUM 714.00
Sub Total of Deductions -57.65 TOTAL1PACKAGE PREMIUM (Sec I + II + III) 814.00
TOTAL OWN DAMAGE PREMIUM 100.00 1
IGST (@18.00 %) 147.00
TOTAL PREMIUM PAYABLE (`) 1 961.00
Subject to I.M.T.Endt.Nos. IMT 22
1
GSTIN :27AABCR6747B1ZG,HSN :997134,
0
Description of services :Motor vehicle Insurance Service
"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"
Add-on for Total Cover : Provides cover for registration charges, road tax and insurance premium (Total Cover Sum Insured - ` 0.0 )

Limits of liability : (a) Under Section II (1)(i) of the Policy-Death of or bodily injury to any person so far as it is necessary to meet the
requirements of the Motor Vehicle Act, 1988. (iii) PA cover for owner driver under section III CSI `0.0/-
Consolidated Stamp duty Paid vide Letter of Authorisation "NO.LOA/CSD/562/2023/(Validity Period Dt.10/01/2023 to Dt.01/12/2023)/117 DT.9 JAN 2023" at
General Stamp Office, Mumbai.** Not Applicable for the State of Jammu & Kashmir
21BRG642 / Policybazaar
18002585970 [email protected]
Insurance Brokers Pvt. Ltd.

Intermediary Code/Name Intermediary Contact No. Intermediary E-mail ID POS UID Aadhaar No. / PAN No.
Limitations as to use : The Policy covers use for any purpose other than: (a) Hire or Reward other than for the purpose of driving tuition, (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/Classes of persons : Any person including insured:
entitled to drive Provided that a person driving holds a valid driving license at the time of the accident and is not disqualified from holding or
obtaining such a license. Provided that the person holding a valid learner’s license may drive the vehicle when not used for
the transport of goods at the time of the accident and that such a person satisfies the requirements of Rule 3 of the Central
Motor Vehicles Rules, 1989.
Deductible under Section-I : (i) Compulsory deductible `100.0 /- (ii) Additional compulsory deductible `0 /- (iii) Voluntary deductible `0.0 /-

Reliance General Insurance Company Limited. IRDAI Registration No. 103. An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai - 400 063.
Corporate Identity No. U66603MH2000PLC128300. UIN: IRDAN103RP0011V02100001. Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
Page 1 of 6
 Compulsory PA cover for owner driver :
Insured is not eligible for compulsory PA cover for owner driver in the policy as the same has not been opted for the reasons allowed as per motor tariff and/or basis
insured's declaration given below:"
"I/ we hereby declare that I/ we hold an effective personal accident insurance policy covering death and permanent disability (total & partial) and/ or compulsory
personal accident (CPA) for owner driver in other vehicles; whereby the Sum Insured limit is of Rs 1,500,000 or more in all such above mentioned conditions.
"In case you have missed it, please opt for compulsory PA cover by payment of additional premium as applicable .Liability of insurance company shall commence
from the date of receipt of such additional premium .
0.0
*No Claim Bonus is subject to no claim on the previous policy. Benefits under the policy stands forfeited if claim is/was made in previous policy.
"It is hereby declared and agreed that any damages pre-existing, any losses occurred & any Liability having been incurred, prior to the commencement of cover
under this policy are excluded from the scope of this policy."
The policy wording with detailed terms, conditions and exclusions are available on our website www.reliancegeneral.co.in. 0.0
Statutory Provisions:
"As per Section 146 of the Motor Vehicle Act, 1988 it is Mandatory to have your vehicle insured against third party risk.
As per Section 196 of the Motor Vehicle Act, 1988 driving an uninsured vehicle is punishable with fine or Rs. 2000 and/or imprisonment up to 3 months for the first
offence and fine of Rs. 4000 and/or imprisonment up to 3 months for the second offence."
I/We hereby certify that the Policy to which the certificate relates as well as this certificate of insurance are issued in accordance with the provision of Chapter X and
Chapter XI of M.V. Act, 1988.
Note: In the event of dishonor of cheque, this policy document automatically stands cancelled from inception irrespective of whether a separate communication is
sent or not.
The policy has been issued based on the information provided by you and the policy is not valid if any of the information provided is incorrect. Subject otherwise to
the terms, conditions and exclusions of the Reliance Miscellaneous and Special Types of Vehicles Package Policy Certificate Cum Policy Schedule. In witness
whereof this Policy has been signed at Mumbai on policy tax invoice date in lieu of Proposal/Covernote No. as mentioned in the policy.
Safeguard your transaction by paying your premium via crossed cheque/DD in favour of Reliance General Insurance Co. Ltd.
Updating Registration Number of vehicles within 15 days of policy inception is MANDATORY as per IRDA. Kindly provide the same to your Agent/Our Call
centre/Policy issuing Branch (Applicable for policies booked without Registration No of vehicles).
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 hold good.
In case of a renewal, the benefits provided under the policy and/or terms and conditions of the policy including premium rate may be subject to change.
As per National Highways Authority of India, kindly ensure to affixed FASTag on your vehicle.
Grievance Clause :- For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 1800 3009 or may
write an email at [email protected]. In case the insured is not satisfied with the response of the office, insured may contact
the Nodal Grievance Officer of the Company at [email protected]. In the event of unsatisfactory response from the Nodal
Grievance Officer, insured may email to Head Grievance Officer at [email protected]. In the event of unsatisfactory
response from the Head Grievance Officer, he/she may, subject to vested jurisdiction, approach the Insurance Ombudsman for the
redressal of grievance. Details of the offices of the Insurance Ombudsman are available at IRDAI website www.irda.gov.in or on company
website www.reliancegeneral.co.in or on www.gbic.co.in. The insured may also contact the following office of the Insurance Ombudsman
within whose territorial jurisdiction the branch or office of the Company is located.Office of the Insurance Ombudsman,3rd Floor,Jeevan
Seva Annexe,S. V. Road,Santacruz (W), Mumbai - 400 054. Tel.: 022 - 26106552 / 26106960 Fax: 022 - 26106052 Email:
[email protected] | Shri. A. K. Sahoo Office of the Insurance Ombudsman,Jeevan Darshan Bldg.,3rd Floor,C.T.S. No.s. 195
to 198,N.C. Kelkar Road,Narayan Peth, Pune – 411 030. Tel.: 020-41312555 Email: [email protected]
Note: Kindly acknowledge the receipt of this policy. In case you find any variations against your proposal or any discrepancy in the policy, kindly contact us
immediately.
This document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services Tax Rules 2017.

In the unfortunate event of a claim, please call quoting your Policy No. 022 48903009(Paid) on and register your claim immediately within 7days from the
date of loss.
In the absence of any communication from you within a period of 15 days of receipt of this letter, we will consider that the issued policy is in order and as per your
proposal.
Special Conditions : NA
Policy has been issued with reference to vehicle inspection report, reference lead no.InspectionID_HIDE & special conditions.The
inspection report remarks can be viewed on company's website by the lead no.
For Reliance General Insurance Co. Ltd.

Authorised Signatory

Reliance General Insurance Company Limited. IRDAI Registration No. 103. An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai - 400 063.
Corporate Identity No. U66603MH2000PLC128300. UIN: IRDAN103RP0011V02100001. Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
Page 2 of 6
 Proposal Form For Reliance Two Wheeler Package Policy
Is the vehicle made in India? Yes No Type of vehicle: Two Wheeler Three Wheeler Four Wheeler

For Office Use Only

Policy Number 110522323120058675 Date

Savvion Reference No Inspection Lead No.

Intermediary Details (To be filled in BLOCK LETTERS)

Intermediary Name POLICYBAZAAR Code 21BRG642

Branch Name Andheri Code 1105
Sales Manager Name Hrishi Das Code 70785718

Details (To be filled in BLOCK LETTERS)

1. This Proposal is for A new Policy Renewal of Policy Endorsement Others (Please specify) __________
2a. Proposer's Full Name Mr. Mrs. Ms. SYED FIRDOUS ALAM
2b. Address Address for Communication Address where Vehicle is Normally Kept and Used
Flat/Building/Door/Block No. 5/3 Ayyam Perumal Kovil Street, Royapettah,
Chennai
Road/Street/Sector
Nearest Landmark
Area Mr.
City
Pin Code 600118 RollOver
State TAMIL NADU,
RollOver
Country India
Mr.
Phone 09363438308 Mobile 9363438308
Emergency Contact No. Blood Group
Email [email protected] Fax

3. Period of Insurance: From: 15/04/2023 To: Mid Night of 14/04/2024

4. Source of Funds Business Profession Salary Agricultural Income Savings Others

5. Monthly Income Upto ` 20,000 ` 20,001 to ` 50,000 ` 50,001 to ` 1,00,000 ` 1,00,001 and above
6. UID Aadhaar No. 7. PAN
8. Do you have a GST Registration Number Yes No
If Yes, please specify
9. Related Party Yes No

Details of the vehicle

10. Registration Number: TN06T9113 11. Date of registration: 01-Aug-2017
12. Registeration Authority & Location: TAMIL NADU - Chennai
14. Cubic Capacity 102
13. Year & Month of Manufacture: JAN-2017
15. Engine Number: JF39E72048287 19. Seating Capacity including Driver 2
16. Chasis Number: ME4JF39EGH7010585
17. Make of Vehicle: HONDA
18. Type of Body/Model NA

Reliance General Insurance Company Limited. IRDAI Registration No. 103. An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai - 400 063.
Corporate Identity No. U66603MH2000PLC128300. UIN: IRDAN103RP0011V02100001. Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
Page 3 of 6
 Details of the Vehicle Type and Use
20. a. Whether the Vehicle is driven by Non-conventional source of power? Yes No If yes Bi Fuel CNG LPG
Non-electrical Electrical & Electronics
Insured declared value Side Car(Two_wheeler)
(IDV) of the Vehicle
Accessories fited to the Accessories fited to the
Trailer(Pvt.Cars)
Value of CNG/ LPG Kit Total Value
Vehicle Vehicle
Petrol
21434 0.0 0.0 0.0 0.0 21434.00
b. Do you have a valid PUC? Yes No
(Note-Warranted that the insured named herein/owner of the vehicle holds a valid Pollution Under Control (PUC) Certificate and/or valid fitness
certificate, as applicable, on the date of commencement of the Policy and undertakes to renew and maintain a valid and effective PUC and/or fitness
Certificate, as applicable, during the subsistence of the Policy. Further, the Company reserves the right to take appropriate action in case of any
discrepancy in the PUC or fitness certificate.)
21. Age of Owner Driver 22. D.O.B
23. Add On Covers (Subject to availability and eligibility)
a. Nil Depreciation Cover NO

NCB Retention Cover (Applicable only for Annual

b. NO
Policy)
c. Easy Monthly Instalment (EMI) Protection Cover: Yes No
If Yes, please choose any one option;
Plan I -1 EMI,EMI Amount : ` Plan II -2 EMI,EMI Amount: `
Plan III -3 EMI,EMI Amount: `
d. Total Cover NO

e. Daily allowance benefits NO

Per Day Allowance: `0.0 Coverage Days: 0

NO f. Helmet cover: ` Number of Helmet Cover:
g. Daily Allowance Benefit Plus NO

Per day allowance amount opted: `0.0

Coverage Days opted : 0
h. Voluntary Deductible
Voluntary Deductible amount opted
`_____________________
i. Hospital Cash Cover (Applicable only for Annual Policy) NO

(Sum Insured: `0.0)

(No of Days: 0)
(Convalescence Benefit
SI:`_____________________________)
j. Emergency Hotel Accommodation NO

Benefit Amount: `0.0

k. Tyre Protector( Applicable only for annual Policy) NO
Specifications of Tyres and Tubes:
l. Rim Protector(Applicable only for annual Policy) NO
Specification of Rims:
m. Consumable Expenses NO
n. Engine Protector: NO
o. Key Protect Cover: (Sun Insured: Rs. 0.0) NO
p. Return to Invoice (Applicable only for Annual Policy) NO
Loss of Personal belongings (Applicable only for annual
q.
Policy)
NO
0.0
(Sum Insured: Rs. 0.0)
r. Enhanced PA to owner Driver
Any other Details
s.
_____________________________________
24. Is the vehicle fitted with any Anti-theft device approved by the ARAI ? Yes No
If Yes,please attach certificate of installation in the vehicle,issued by automobile Association of India.
25. Are you a member of Automobile Association of India ? If Yes,please submit membership copy. Yes No
26. Will the Vehicle be used exclusively for
a. Private,social,domestic,pleasure and professional purposed ? Yes No
b. Carriage of goods other than samples or personal luggage? Yes No
27. Whether the Vehicle is used for Driving Tuitions ? Yes No
28. Whether use of Vehicle is limited to Own Premises ? Yes No

Previous Policy Claim (Only for

Previous
Reliance Insurer
General Name Company Limited. IRDAI Registration No. 103.
Insurance An ISO 9001:2015 Certified Company
Previous Policy No. Period of Insurance SAOD)
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai - 400 063.
Corporate Identity No. U66603MH2000PLC128300. UIN: IRDAN103RP0011V02100001. Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
Page 4 of 6
 29. Whether the Vehicle is fitted with Fibre Glass Tank ? Yes No
Whether the Vehicle belongs to the Embassy/Consulate of a Foreign Country ?
30. Yes No
If so,is the duty element included in the IDV ?
31. Whether the Vehicle is design for the use of Blind/Handicapped/Mentally Challenged Person ? Yes No
32. Date of purchase of the Vehicle by the Proposer 01-Aug-2017
33. Whether the Vehicle at the time of purchase was New Second Hand

Risk Inclusions
34. Please select the higher deductible if you wish to opt for over and above the compulsory deductible
Two wheeler

35. Personal Accident Cover for Owner Driver. Please give details of nomination
Name of Appointee (if Nominee
Name Name of Nominee Age of Nominee Relationship Address
is Minor)

(Note: 1. Personal Accident cover for owner driver is compulsory for Sum Insured of `15,00,000/- for Two Wheeler, Private Car, GCV, PCV and Misc-D
2. Compulsory PA cover for owner driver cannot be granted where a vehicle is owned by a company, a partnership firm or a similar body corporate or
where the owner-driver does not hold an effective driving license)
36. Extension of Geographical Area:
INDIA Whether extension of Geographical Area to the following countries required?
1. Bangladesh 2. Bhutan 3. Maldives 4. Nepal 5. Pakistan 6. Sri Lanka

Details of Hire Purchase / Hypothecation / Lease

37. Please state if the vehicle is under Hire purchase Lease Agreement Hypothecation Agreement
FINANCE_
HIDE If so, give name and address of concerned parties.
38. Full Name M/s
39. Address
Details of Previous Insurance
40. Full Name of previous insurer KERALA STATE INSURANCE
41. Address
42. Policy Number DBCR00467062363/00 Previous policy Expiry 08-Apr-2023
43. Type of cover: Package Policy Liability Only Other (To be describe)

44. Claims taken in previous policy Yes No

If yes, No. of Claims Claims Amount `
45. Are you entitled to No Claim Bonus Yes No
If yes, please submit/attached proof thereof
46. No Claim Bonus allowed under previous Policy (%)
I/ We hereby declare that the rate of NCB claimed by me/ us is correct and that No claim has arisen in the expiring policy period (copy of policy enclosed). I/
We undertake that if this declaration id found incorrect, all benefits under this policy in respect of Section 1 of the policy will stand `forfeited.
Signature of the Proposer

Payment Details
Cheque / DD Cheque / DD No.
Cheque/DD Date Cash Credit Card Others
Proposer's Bank Details
47. Name of the Bank Account Holder
48. Bank Account No.: 49. Account: Saving Current
50. Name of the Bank
51. Branch
52. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank)
53. IFSC Code (11 character code appearing on your cheque leaf)
I understand that any refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank Account.*
*As per IRDAI, its mandatory that all payments made to the insured are only through electronic mode.

AML Guidelines
"I/ We herby confirm that all premiums have been/ will be paid from bonafide sources and no premium have been/ will be paid out of the proceeds of crime related
to any of the offence listed in Prevention of Money Laundering Act 2002. I understand that the company has the right to call for the documents to establish source of
funds. The insurance company has the right to cancel the insurance contract in case I am/ have been found guilty by any competent court of law under any of the
statues, directly/ indirectly governing the prevention of Money Laundering in India.

Reliance General Insurance Company Limited. IRDAI Registration No. 103. An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai - 400 063.
Corporate Identity No. U66603MH2000PLC128300. UIN: IRDAN103RP0011V02100001. Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
Page 5 of 6
 Nationality: Indian Non- Indian, If Non Indian please specify the country
Type of
Corporations Government Non Government Organizations Society Trust
Organization :
Partnership International Organization Cooperatives Section 25 companies

Declaration by Proposer
I/We hereby declare that the statements made by me/us in this Proposal Form 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 RELIANCE General Insurance Company Limited. 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. I/We hereby declare that the
contents of the form and documents have been fully explained to me/us and that I/We have fully understood the significance of the proposed contract. I/We agree to
accept a policy subject to the condition prescribed by the company. • I have read and understood the brochure, prospectus, sales literature & Policy wordings and
confirm to abide by the same. • I/We declare that the rate of NCB stated above by me/us is correct and that no claim has arisen in the expiring policy (copy of the
policy enclosed). • I/We further undertake that, if this declaration is found to be incorrect, all benefits under the policy in respect of section I of the policy will stand
forfeited. • I/We further understand and agree that RELIANCE General Insurance will seek confirmation of above stated details from my/our previous insurers.
Pending receipt of necessary confirmation, I/We agree that, though coverage under the policy will be available to me/us, RELIANCE General Insurance will be liable
to release the payment towards any claims under section I of the policy only after a confirmation in this regard is received. In the event this declaration is found to be
incorrect, any and all coverage available under section I of the policy from the date of commencement of the policy shall stand automatically forfeited. Further, any
survey arranged/allowed by RELIANCE General Insurance of the motor vehicle, pending confirmation of the declaration from my/our previous insurers, shall be
without prejudice to any of the rights and remedies available to RELIANCE General Insurance as contained herein and under the relevant laws and regulations. •
I/We acknowledge and agree that, Pending receipt of confirmation of the declaration from my/our previous insurers, the "cash-less repair facility" provided by
RELIANCE General Insurance shall stand suspended. • I/We also shall endeavour to procure the renewal notice and pass on the same to RELIANCE General
Insurance immediately upon the receipt of such renewal notice. Mode of Payment: Secure your payment by cheque/DD favouring Reliance General Insurance
CO.Ltd. This policy shall be voidable at the option of the Company in the event of mis-representation, mis-description of nondisclosure of any material particulars by
the Proposer. Any person who, knowingly and with intent to defraud the Insurance Company or other persons, files a proposal fo insurance containing any false
information, or conceals for the purpose of misleading, information, 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.• I/We here by state that the above mentioned address shall be taken as
address on record for the purpose of GST. • I/We hereby confirm that the contents of the proposal form and connected documents have been fully explained to
me/us and I/We have fully understood the significance of the proposed contract.
This proposal form was completed by
Name Place :
Date :12 Apr 2023 10:18 Date :12 Apr 2023 10:18

Signature Signature of Proposer & Company Seal

Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015.
1. 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 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.
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.
Supporting Confirmation of Agent/Broker/SM/CSO
I confirm the above signature to be of the registered owner of the vehicle proposed for insurance
Place :
Date :
(In case of Direct Business, Name & Signature of CSO / SM to be taken) Signature of IRDAI Agent/Broker

Reliance General Insurance Company Limited. IRDAI Registration No. 103. An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai - 400 063.
Corporate Identity No. U66603MH2000PLC128300. UIN: IRDAN103RP0011V02100001. Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
Page 6 of 6