Bajaj Allianz General Insurance Company Ltd.

Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune

Transcript of Proposal for Two-Wheeler Package Policy

Dear LALAN PRASAD SHARMA,

We wish to inform you that the contract under policy number 'OG-25-9906-1802-00161919' has been finalized based on the
information and declaration given by you, the transcript whereof is mentioned below. You are requested to reconfirm the same.
In case of any disagreement or objection or any changes with respect to information mentioned below, we request you to
please revert back within a period of 15 days from date of your receipt of this, failing which it will be deemed that you are
satisfied with the correctness of the details mentioned below. Kindly note that as the contents and declarations contained in this
transcript is the basis on which we have issued the policy to you, we advise you to please ensure that you have
provided/disclosed and or not withheld any material facts/information and declarations, as Policy becomes Void ab initio if
material facts are not provided/disclosed and or withheld and in such case no claim, if any, will be considered by us apart from
forfeiture of the premium.
Details provided by you:

A. Proposer details
1. Proposer Name : LALAN PRASAD SHARMA
2. Proposer Address : JYOTI NAGAR,UPPER BAGDOGRA,BAG, DOGRA,DARJEELING,WEST
BENGAL,
, , DARJEELING, WEST BENGAL-734014
3. Proposer Mobile Number : 7031341811
4. Proposer Residential Number : 7031341811
5. Proposer e-mail id : [email protected]
6. Proposer Profession : NA

B.Vehicle Details
Registration Month / Year Vehicle Vehicle Vehicle Sub Cubic Capa- Fuel Type Year of Man- Seating Ca-
Number of Regn Make Model Type city/Kilowatt ufacture pacity
WB74AS579 DEC/2017 HERO MO- SUPER IBS SELF 125 Petrol 2017 2
0 TOCORP SPLENDOR START
DRUM
BREAK
CAST
WHEEL

Engine Number Chassis Number Vehicle IDV (in Electrical Non-Electrical CNG/LPG Unit Total IDV (in
Rs.) Accessories Accessories (Extra fitted) Rs.)
IDV (in Rs.) IDV (in Rs.) IDV (in Rs.)
JA05EGH9G368 MBLJAR035H9 23,957.00 0 0 0 23,957.00
80 G32731
 C. Coverage opted

1. Period of Insurance : From 25-JUL-2024 00:00(Hrs)

To 24-JUL-2025 Midnight
2. Is your vehicle fitted with external LPG/CNG kit : No.
3. Electrical Accessories cover Opted (If Applicable) : No.
4. Non - Electrical Accessories cover Opted (If Applicable): : No.
5. Is Voluntary Excess opted : No.
Amount of voluntary excess opted : Rs.NA.
6. Whether PA cover is opted for owner-driver : No.
PA cover is exempted for owner-driver with Reason :Owner does not have Valid Driving
License
7. compulsory deductible : Rs.100.00
8. Is any additional compulsory deductible imposed and agreed upon : No.
Amount of additional compulsory deductible imposed : NA.
9. Whether geographical area extension is opted : No.
Details of Countries to which geographical area extension cover is given : NA.
10. Is LL to person for Paid driver/Operation/Maintenance opted : No.
11. Whether PA cover is opted for paid driver other than owner driver : No.
Sum Insured for Paid Driver : Rs.NA.
13. Is TPPD restricted to statutory limit of Rs.6,000? : No.
14. Pre Existing damages in the vehicle : NA.
15. 1 Premium for Liability coverage, quoted and agreed upon is :
16. 1 Premium for OD coverage, quoted and agreed upon is :
17. Do you have valid PUC certificate of the vehicle : NA
18. Do you have valid Fitness certificate of the vehicle : NA
19. Total Premium (excluding Goods and Service Tax (GST)) for Liability and OD coverages, quoted and agreed upon is
:
20. NCB (No Claim Bonus) claimed by you and granted by us based on your declaration of no claim during your previous
previous policy : 0 %.
21. About the last insurance company
(i) Insurance Provider : .
(ii) Previous Policy No : NA , Previous Policy Expiry Date : NA
22. Whether your vehicle is Hypothecated and if so the details of Pledgee whose name is registered by us: No.
Name of Pledgee : NA.
23. Add on Cover(s) optedm3: No.Plan name:NA

24. To support our Go Green initiative, send policy copy link on registered mobile number / email id:

Please note Cover Note No. / issued to you basing on the above information.
In case of Disagreement or objection or any changes with respect to information and contents mentioned hereinabove, please
contact our toll free number & register your objections/changes/disagreement to the contents 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 with Policy:
I/We hereby unconditionally allow the Company to share all my / our information being collected in this proposal form or
through telephonic / email / web-inputs means or other means, as updated from time to time within group entities.
Toll free Number : 1800-102-5858,1800-209-5858
Email address : [email protected]
Website : www.bajajallianz.com
Contact our policy servicing branch at: Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar,
Pune-411014 PH:1800-209-0144.
INSURANCE ACT, 1938 SECTION 41 - PROHIBITION OF REBATES
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 a policy
accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.
ANY PERSON IN BREACH OF COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE
WITH FINE WHICH MAY EXTEND TO RUPEES TEN LAKH.Bajaj Allianz General Insurance Co Ltd
   

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

Regd. Office & Head Office: GE Plaza, Airport Road, Yerwada,Pune-411006(India)
IRDAI Registration No. 113
Corporate Identity Number: U66010PN2000PLC015329
Certificate of Insurance (TWO-WHEELER PACKAGE POLICY)
UIN : IRDAN113RP0026V01200102
Policy Number: OG-25-9906-1802-00161919 Customer ID: 442278560
Particulars of Vehicle Insured:
Registration Number Place of Registration Engine Number Chassis Number Make & Model
WB74AS5790 WB74-SILIGURI JA05EGH9G36880 MBLJAR035H9G327 HERO MOTOCORP -
31 SUPER SPLENDOR

Sub Type Year of Mfg NCB % CC Seating Capacity

IBS SELF START DRUM BREAK CAST 2017 0 125 2
WHEEL

Name of Registration Authority : WB74-SILIGURI

Name and Address of Insured : LALAN PRASAD SHARMA
: JYOTI NAGAR,UPPER BAGDOGRA,BAG,
DOGRA,DARJEELING,WEST BENGAL,, ,
DARJEELING, WEST BENGAL-734014
Geographical Area : .00
Business or Profession : NA
Effective date of commencement of Insurance for the purpose of act:
Policy Inception Date: From 00:00 O' Clock on 25-JUL-2024
Policy Expiry Date: Midnight on 24-JUL-2025
Persons or Class of Persons entitled to drive:
Any person including the insured:
a) 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.
b) 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.
IMT-Endorsements/Add on Package
22
Beneficier Details:
Beneficier1 Beneficier2 Beneficier3 Beneficier4 Beneficier5

Limitations as to Use:
The Policy covers use 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
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 provi-
sions of Chapter X and Chapter XI of M.V. Act, 1988.
Policy issuing office and correspondence address for communication by holder of Certificate of Insurance for claim,
service request, notice, summons, etc:
Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune-411014 PH:1800-209-0144
Date of issue :22-JUL-2024
For & On Behalf of
Bajaj Allianz General Insurance Company Ltd.
For help and more information:
Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at
[email protected] or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 22-Jul-2024 20:09:33 PM- Silent_Printing (Web) (99060001)
Now carry your m-policy on your mobile. Click here to download. https://bagic.page.link/A8zgRi

Authorized Signatory
   

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of
India [IRDA] vide Reg No.113)
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada,Pune-411006(India))
TWO-WHEELER PACKAGE POLICY SCHEDULE
UIN : IRDAN113RP0026V01200102
Policy issuing office and Correspondence address for communication by policyholder for claim, service request, notice, summons, etc:
Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune-411014 PH:1800-209-0144
INSURED DETAILS POLICY DETAILS
Insured Name LALAN PRASAD SHARMA Policy Number OG-25-9906-1802-00161919
JYOTI NAGAR,UPPER BAGDO- Policy Issued on 22-JUL-2024 20:09 PM
GRA,BAG,
Insured DOGRA,DARJEELING,WEST From : 25-JUL-2024 00:00 (Hrs)
Address BENGAL, , , DARJEELING, WEST
BENGAL-734014 Policy Period To : 24-JUL-2025 Midnight
Geographical India Cover Note
Area /
Details
Customer ID
442278560
Previous Policy No 0
Bank Reference
No 1 Invoice No 429398649/1

GSTIN / UIN NA Company GST No 27AABCB5730G1ZX

Place of Supply/ 19 - West Bengal Company PAN AABCB5730G
State Code/Name
Make & Mod-
Registration Number Place of Registration Engine Number Chassis Number SubType
el
IBS SELF
HERO MOTO- START
MBLJAR035H9G3 CORP - SU- DRUM
WB74AS5790 WB74-SILIGURI JA05EGH9G36880
2731 PER BREAK
SPLENDOR CAST
WHEEL
NCB % CC/KW Seating Capacity Year Of Manufacturing Hypothecation Details
0 125 2 2017
Non electrical Electrical/Elec- Value of CNG/
Vehicle IDV Value For Side Car Total Value
accessories tronic accessories LPG kit
23,957.00 0 0 0 0 23,957.00
Own Damage Premium(Rs.) Liability Premium(Rs.)
Own Damage Premium 34.00 Basic Third Party Liability 714.00
Special Discount 0.00 Total Act Premium - B 714.00
Total OD Premium - A 34.00
Total Premium (Net Premium) (A+B) 748.00
Integrated GST (18%) 135.00
Final Premium ( Rupees Eight Hundred Eighty Three 883.00
Only )
**Note: The above Total OD Premium is inclusive of all applicable Loading /Discounts viz (Automobile association membership, Voluntary Excess,
Anti Theft, Handicap Person, Driver Tuition, Fiber Glass, CNG/LPG Unit, Geographical Extension, Imported Vehicle Etc. wherever Applicable)

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
I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover noti-
fied 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.

For help and more information:

Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at Ba-
[email protected] or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 22-Jul-2024 20:09:33 PM- Silent_Printing (Web) (99060001)
   

Broker Code 10043080 Contact No. 0/1800-103-3999

Broker Name POLICYBAZAAR INSURANCE BROKERS PRIVATE LIMTED
E-Mail ID.

Limitation as to Use The Policy covers use of the vehicle for any purpose other than : Hire or reward, Carriage of
goods( other than samples or personal luggage),Organised racing,Pace making, Speed testing,
Reliability trials. Any purpose in connection with Motor Trade.
Driver Any person including the insured provided that a person driving holds an effective driving li-
cense 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 goods/passengers at the time of the accident and that such a
person satisfies the requirements of Rule 3 of the Central Motor Vehicle Rules, 1989.
Limits of Liability Under section II-I(i) of the policy -> Death of or bodily injury : Such amount is necessary to meet
there requirements of the Motor Vehicles Act,1988. Under section II-I(ii) of the policy -> Dam-
age to Third Party Property : Rs. 1,00,000.00
No Claim Bonus The insured is entitled for a No Claim Bonus (NCB) on the Own Damage section of the policy, if
no claim is made or pending during the preceding year (s), as per the following: 1. The preceding
year: 20% , 2. Preceding Two consecutive years: 25% , 3. Preceding Three consecutive years:
35%, 4. Preceding Four consecutive years: 45% , 5. Preceding Five consecutive years: 50% No
Claim Bonus will only be allowed provided the policy is renewed within 90 days of the expiry
date of the previous policy.
Existing Damage Details NA
Nominee Details Name :NA - Relationship :NA
Subject to Warranties/ 22
IMT-Endorsements/
Add on Package
Additional Details Coinsurance Details: - . Transaction Id: -
Premium Details Receipt No. 9906-10117806, Date 22-JUL-24 ** If Premium paid through Cheque, the Policy is
void ab-initio in case of dishonour of Cheque.
Excess Details Compulsory Excess: Rs.100.00 Additional Excess: Rs.0 Voluntary Excess: Rs..00
Theft Excess: Rs.0
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.
Warranted that insured named herein or owner of the vehicle insured holds a valid Pollution Under Control (PUC) and / or Fitness Certificate on the date of
commencement of the Policy. If the PUC and/or Fitness Certificate is not found to be valid on the date of commencement of the Policy, the Company reserves
its right to consider the policy void ab initio.
For & On Behalf of
Bajaj Allianz General Insurance Company Ltd.

Authorized Signatory
This document is digitally signed, hence counter signature / stamp is not required.Consolidated Stamp Duty paid towards Insurance Policy Stamps vide
Order No. ADJ/CS/42/07/7383/07 Dated 18th April2007 of General Stamp Office, Mumbai.
   

Principal Location : Bajaj Allianz House, Airport Road, Yerwada, Pune - 411006 PH:66026666 | Services Accounting Code :
997134 - Motor vehicle insurance services. No reverse charge is payable on these services.

For help and more information:

Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at Ba-
[email protected] or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 22-Jul-2024 20:09:33 PM- Silent_Printing (Web) (99060001)
 Bajaj Allianz General Insurance Company Ltd.
Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune - 411014
Contact No:Contact No: 1800-209-0144

RECEIPT

Receipt Number 9906-10117806

Receipt Date 22/07/2024
Business Channel WS

Received with thanks from LALAN PRASAD SHARMA

(Customer ID : 442278560 ) a total sum of Rupees Eight Hundred Eighty Two Only by,

Instrument Instrument No. Instrument Bank Name Branch Name Amount

Type Date
Online Pay- PBPB9947906 22/07/2024 NA NA 882
ment 3

Total Amount Rs. 882.00

Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General In-
surance Company Limited. The insurance cover for the risk shall be as per the terms and con-
ditions of the Insurance Policy if and when issued.
* Cheque/DD/PO receipt is valid subject to realisation of the instrument.

For & on behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory

Regd.Office: Bajaj Allianz House,Airport Road, Yerwada, Pune - 411006