Mr. Suklal Hansda 188/175 Nun Nun Geria Near Satpathi Marbles Jhargram WEST BENGAL India - 721507 7679770268

Trejhara
Mr. SUKLAL HANSDA

188/175
NUN NUN GERIA
Near Satpathi Marbles
JHARGRAM
WEST BENGAL India - 721507
7679770268
Welcome on board.
Your Reliance Two Wheeler Package Policy -
Schedule Number 920222023121382878 is now
live to access your policy anytime, anywhere
download our Reliance Selfi App and enjoy a
host of special features.
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 Identification 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 8
Digitally signed by Reliance
General Insurance
Company Limited
Date: 2024.07.22 19:57:56
Trejhara IST
Reliance Two Wheeler Package Policy - Schedule
Policy Number : 920222023121382878 Proposal/Covernote No: R14062002162

Insured Name : Mr. SUKLAL HANSDA Period of Insurance : From 00:01 Hrs on 15-Jun-2020 to Midnight of
14-Jun-2021
Communication Address & Place of Supply : Policy Issuing Branch :
188/175 6th Floor, Oberoi Commerz, Oberoi Garden City, Off. Western Express Highway,
NUN NUN GERIA Near Satpathi Marbles JHARGRAM, WEST MIDNAPORE, Goregaon (East), MUMBAI, MAHARASHTRA, 400063.
Mobile No : 7679770268 Tax Invoice No. & Date: R14062002162 & 2020-06-14 09:54:22.0
Email-ID : [email protected] GSTIN/UIN & Place of Supply: WEST BENGAL
Insured's Blood Group :
Insured Vehicle Details

Registration No. WB34N5825 Mfg. Month & Year JAN-2006
Make / Model & Variant HERO HONDA SPLENDOR SUPER CC / HP / Watt 125
Engine No. / Chassis No. 05KAAE09935 / 05LAAF00271 Seating Capacity Including Driver 2
Type of Body NA Total Premium ` 1005
RTO Location WEST BENGAL - Midnapur IDV ` 13,874.00
Hypothecation/Lease NA
Insured Declared Value (IDV)

Vehicle IDV ` 13874 Non Electrical Accessories ` 0
Electrical / Electronic Accessories ` 0 Total IDV ` 13874
Premium Summary
Own Damage - Section I Amount (`) Liability - Section II Amount (`)
Basic OD including Add-on 125.00 Basic Liability (TPPD 1) 752.00
Total Basic Own Damage Premium 125.00 Total Basic Liability Premium 752.00
Less PA Benefits - Section III
Deduct 20 % for NCB -25.00 TOTAL LIABILITY PREMIUM 752.00
Sub Total of Deductions -25.00 TOTAL PACKAGE PREMIUM (Sec I + II + III) 852.00
IGST (18.00%) 153.00
TOTAL OWN DAMAGE PREMIUM 100.00
TOTAL PREMIUM PAYABLE (`) 1,005.00
Subject to I.M.T.Endt.Nos. IMT 22

GSTIN : 27AABCR6747B1ZG HSN : 997134,
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)
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. (b) Under Section II (1)(ii) of the Policy-Damage to property other than
property belonging to the insured or held in trust or in the custody of control of the insured up to the limits specified-
(TPPD 1 Sum Insured - ` 1,00,000 /- ,TPPD 2 Sum Insured - ` 6,000 /-) (iii) PA cover for owner driver under section III
CSI ` 1500000.0/-
Consolidated Stamp duty Paid vide Letter of Authorisation No. CSD/337/2020/864/2020 dated 27th Feb 2020** Not Applicable for the State of J&K
Direct / Direct
Intermediary Code/Name Intermediary Contact No. Intermediary E-mail ID POS UID Aadhaar No. / PAN No.
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
Private Limited and used by Reliance General Insurance Company Limited under. License RGI/MCOM/CO/2312/PS/VER. 1.0/310118
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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/- (ii) Additional compulsory deductible ` 00/- (iii) Voluntary deductible ` 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 02248903009 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]
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.
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 subrule
(4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule
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. & 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
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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 920222023121382878 Date
Savvion Reference No. Inspection Lead No.
Intermediary Details (To be filled in BLOCK LETTERS)

Intermediary Name Direct Code Direct
Branch Name Corporate Office(Servicing) Code 9202
Sales Manager Name Web Sales Code D9202162
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. SUKLAL HANSDA
2b. Address Address for Communication Address where vehicle is normally kept and Used
Flat/Building/Door/Block No. 188/175
Road /Street/Sector NUN NUN GERIA
Nearest Landmark
Area
City JHARGRAM
Pin Code 721507
State WEST BENGAL
Country India
Phone Mobile 7679770268
Emergency Contact No. Blood Group
Email [email protected] Fax
3. Period of Insurance From 15/06/2020 To: Midnight of 14/06/2021

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 `1,00,001and above
6. UID Aadhaar No. 7. PAN No.
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 WB34N5825 11. Date of Registration 01/06/2006
12. Registering Authority & Location WEST BENGAL - Midnapur
13. Year & Month of Manufacture JAN-2006 14. Cubic Capacity 125
15. Engine Number 05KAAE09935
16. Chassis Number 05LAAF00271
17. Make of Vehicle HERO HONDA
18. Type of Body/Model NA/SPLENDOR 19. Seating Capacity including Driver 2
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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
Insured declared
Non-electrical Accessories Electrical & Electronics Side Car(Two_wheeler)
value (IDV) of Value of CNG/ LPG Kit Total Value
fited to the Vehicle Accessories fited to the Vehicle Trailer(Pvt.Cars)
the Vehicle
13874 0 0 0 0 13874
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. Assistance Covers No
b. Nil Depreciation Cover No
c. NCB Retention Cover (Applicable only for Annual No
Policy)
d. Easy Monthly Instalment (EMI) Protection Cover:
If Yes, please choose any one option;
Plan I - 1 EMI, EMI Amount : ₹
Plan II - 2 EMIs, EMI Amount : ₹
Plan III - 3 EMIs, EMI Amount : ₹
e. Total Cover No
f. Daily allowance benefits No
Per Day Allowance: ₹
Coverage Days :
g. Helmet cover: Sum Insured ₹ No
Number of Helmet Covered
h. Daily allowance benefits Plus No
Per Day Allowance: ₹
Coverage Days :
i. Voluntary Deductible
Voluntary Deductible amount opted: ₹ ______________________
j. Hospital Cash Cover (Applicable only for Annual Policy) No
Sum Insured: ₹
No of Days:
(Convalescence Benefit
SI: ₹_____________________________)
k. Emergency Hotel Accommodation No
Benefit Amount: ₹
l. Additional limit of TPPD No
Additional amount opted: ₹
m. Tyre Protector( Applicable only for annual Policy) No
Specifications of Tyres and Tubes:
n. Rim Protector(Applicable only for annual Policy) No
Specification of Rims:
o. Consumable Expenses No
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p. Engine Protector No
q. Key Protect Cover: No
Sun Insured: ₹
r. Return to Invoice (Applicable only for Annual Policy) No
s. Loss of Personal belongings (Applicable only for annual No
Policy)
Sum Insured: ₹
t. Enhanced PA to owner Driver No
u. Any other Details
___________________________________
v. Battery Protection Cover No
w. Electric Motor Protection Cover No
x. EV Charger Cover No
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
29. Whether the Vehicle is fitted with Fibre Glass Tank? Yes No
30. Whether the Vehicle belongs to the Embassy/Consulate of a Foreign Country? Yes No
If so, is the duty element included in the IDV?
31. Whether the Vehicle is design for use of Blind/Handicapped/Mentally Challenged Person? Yes No
32. Date of purchase of the Vehicle by the Proposer 01/Jun/2006
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. Liability to third parties : The policy provides Third Party Property Damage(TPPD) of ` 1 lakh (Two wheelers) and ` 7.5 lakhs (Private car) (Private car))
Do you wish to restrict the above limits to the statutory TPPD Liability limit of ₹ 6000/- only? Yes No
Legal Liability No of Person
Driver:
36. Personal Accident Cover for Owner Driver. Please give details of nomination
Name of the Appointee (if
Name Name of the Nominee Age of Nominee Relationship Address
Nominee 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)
37. Extension of Geographical Area

Whether extension of Geographical Area to the following Countries required ?
1. Bangladesh
2. Bhutan
3. Maldives
4. Nepal
5. Pakistan
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6. Sri Lanka
Details of Hire Purchase / Hypothecation / Lease

38. Please state if the vehicle is under Hire Purchase Lease Agreement Hypothecation Agreement
If so, give name and address of concerned parties.
39. Full Name
40. Address
Details of Previous Insurance

41. Full Name of previous insurer The Oriental Insurance Company Limited
42. Address
43. Policy Number 311901/31/2014/7633 Previous Policy Expiry 14/06/2020
44. Type of Cover Package Policy Liability only others (to be describe)
45. Claims taken in previous policy Yes No
If yes, No. of Claims Claims Amount `
46. Are you entitled to No Claim Bonus Yes No
If yes, please submit/attached proof thereof
47. NO CLAIM BONUS allowed under previous policy (%) 0
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

48. Name of the Bank Account Holder
49. Bank Account No.: 50. Account: Saving Current
51. Name of the Bank
52. Branch
53. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque
issued by the bank)
54. 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 mandetory 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.
Nationality Indian Non-Indian, If Non Indian Please specify the

Type of organization Corporation Goverment Non Goverment Society Trust Partenership
International Organization Corporatives Section 25 Companies
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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 : 14 Jun 2020 09:54 Date : 14 Jun 2020 09:54
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 tobe 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
Page 8 of 8

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Trejhara

Mr. SUKLAL HANSDA

Reliance Two Wheeler Package Policy - Schedule

Policy Number : 920222023121382878 Proposal/Covernote No: R14062002162

Insured Vehicle Details

Insured Declared Value (IDV)

TOTAL PREMIUM PAYABLE (`) 1,005.00

Subject to I.M.T.Endt.Nos. IMT 22

For Reliance General Insurance Co. Ltd.

Proposal Form For Reliance Two Wheeler Package Policy

For Office Use Only

Intermediary Details (To be filled in BLOCK LETTERS)

Details (To be filled in BLOCK LETTERS)

3. Period of Insurance From 15/06/2020 To: Midnight of 14/06/2021

Details of the Vehicle

Details of the Vehicle Type and Use

b. Do you have a valid PUC? Yes No

21. Age of Owner Driver _________________ 22. D.O.B. _________________

23. Add On Covers (Subject to availability and eligibility)

37. Extension of Geographical Area

Details of Hire Purchase / Hypothecation / Lease

Details of Previous Insurance

Signature of the Proposer _______________________________________________________

Proposer's Bank Details

Nationality Indian Non-Indian, If Non Indian Please specify the

This proposal form was completed by

Name ____________________________ Place : ____________________________

Signature Signature of Proposer & Company Seal

Supporting Confirmation of Agent/Broker/SM/CSO

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21. Age of Owner Driver _ 22. D.O.B. _

Name Place :