140122423090179417 (1)

Trejhara
Mr. HANAMANTHRAO MOHARE

S/O BHIMARAO WARD NO 1 H NO 551
KILLAGALLI BAGALKOT
BAGALKOT
KARNATAKA India - 587101
9481******
Welcome on board.
Your Reliance Private Car Policy-Stand-alone
Own Damage Policy, with Policy
Number 140122423090179417 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 Identity No. U66603MH2000PLC128300UIN: IRDAN103RPMT0004V03202425. 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/2311/PS/Ver. 1.3/010218.
Page 1 of 14
Digitally signed by Reliance
General Insurance
Company Limited
Date: 2024.12.08 07:59:58
Trejhara IST
Reliance Private Car Policy-Stand-alone Own Damage Policy Schedule

Important
1) The validity of this certificate of Insurance cum policy is subject to realization by the company of the premium cheque paid by the Insured.
2) Except as provided in GR 27 Rule (g) of Erstwhile Indian Motor Tariff (i.e. Sale of Vehicle), No NCB will be allowed when a policy is not renewed within 90 days of
its expiry.
Policy Number : 140122423090179417 Proposal/Covernote No: R30112493578

Insured Name : Mr. HANAMANTHRAO MOHARE Period of Insurance : From 18:51 Hrs on 30-Nov-2024 to Midnight of
29-Nov-2025
Communication Address & Place of Supply : Policy Issuing Branch :
S/O BHIMARAO WARD NO 1 H NO 551 KILLAGALLI BAGALKOT BAGALKOT, UNNATI ARCADE, 5/111 & 6/112, 1st Floor, 1st Block, Dr.Rajkumar Road,
KARNATAKA, India, 587101. (1st main road), Rajajinagar,, BANGALORE, KARNATAKA, 560010.
Mobile No : 9481****** Tax Invoice No. & Date: R30112493578 & 03 Dec 2024 10:39
Email-ID : h****************@gmail.com GSTIN/UIN & Place of Supply : NA
Insured's Blood group :
Insured Vehicle Details

Registration No. KA29P1909 Mfg. Month & Year NOV-2023
Make / Model & Variant RENAULT TRIBER RXE BSVI Date of Registration 2023-11-11 00:00:00
Engine No. / Chassis No. B4DF424E036299 / MEERBC003P6185347 Seating Capacity Including Driver 7
Type of Body CC / HP / Watt 999
RTO Location KARNATAKA - Bagalkot LCC Excluding Driver 6.00
Hypothecation/Lease KARNATAKA GRAMEENA BANK , BAGALKOT
Opening Odometer Reading /
Kilometer Limit Opted
Coverage Upto
Carry Forward Limit (applicable for
Top Up Limit (If Opted)
Limit sure - Pay as you Drive Add On)
Available
Kilometers(applicable for Grace Limit(applicable for Limit sure -
Limit Sure - Pay as you Drive Pay as you Drive Add On)
Add On)
Insured Declared Value (IDV)

Year 1
Vehicle IDV ` 510,000.00
Electrical / Electronic Accessories ` 0.00
Non Electrical Accessories ` 0.00
Bi Fuel kit ` 0.00
Total IDV ` 510,000.00
Premium Summary
Own Damage - Section I Amount (`) Liability - Section II Amount (`)
Basic OD including Add-on 4,074.73 TOTAL PACKAGE PREMIUM (Sec I) 3,300.00
Total Basic Own Damage Premium 4,074.73
Less
Deduct 20 % for NCB -774.95
Sub Total of Deductions -774.95
Add on Cover/s Opted
Emergency Medical Assistance CGST (@9%) 297.00
Assistance cover- PC SGST (@9%) 297.00
TOTAL OWN DAMAGE PREMIUM 3,300.00
TOTAL PREMIUM PAYABLE (`) 3,894.00
Subject to I.M.T.Endt.Nos. IMT 22,7
GSTIN :29AABCR6747B1ZC HSN : 997134,
Description of services : Motor vehicle Insurance Service As per the
"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."
PA-Nominee Details Name Age Relation

Consolidated Stamp duty Paid vide Letter of Authorisation “NO LOA/ENF-1/CSD/70/2024-25/(Validity Period Dt.01/11/2024 to Dt.01/12/2025)/5162 Date 30-10-2024” at
General Stamp Office, Mumbai. ** Not Applicable for the State of Jammu & Kashmir.
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: IRDAN103RPMT0004V03202425. 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/2311/PS/Ver. 1.3/010218.
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23P62209 / GEETHA P 9886523069 [email protected] *****624C
Intermediary Code/Name Intermediary Contact No. Intermediary E-mail ID POS UID Aadhaar No. / PAN No.
Existing TP Policy Details
Existing TP Policy No Existing TP Policy Company Name Existing TP Policy Period :
3311/01152554/000/00 Cholamandalam MS General Insurance Company Ltd. From 11-11-2023 to 10-11-2026
The Customer Information Sheet (CIS) for this product is available on our website
https://www.reliancegeneral.co.in/insurance/about-us/downloads.aspx
Special Conditions : NA
Assistance Cover Annexure : https://www.reliancegeneral.co.in/downloads/reliance-pvt-car-assistance-cover-annexure.pdf
Policy has been issued with reference to vehicle inspection report, reference lead no.24297367& special conditions.The
inspection report remarks can be viewed on company's website by the lead no.
Limits of liability : Under Section III of the policy - PA cover for owner driver CSI ` 0 (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 - ` 7,50,000/-, TPPD 2 Sum
Insured - ` 6,000/-).
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
of such a license. Provided that the person holding a valid learner’s license may drive the vehicle 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 ` 1000/- (ii) Additional compulsory deductible ` 0/- (iii) Voluntary deductible ` 0/-
Grace Limit(applicable for Limit Sure : 5% Available Kilometre limit or Grace Limit, whichever is lower.
Pay as you Drive Add On Cover if Claims occurring during Grace Limit is payable(subject to all other terms and condition), if and only if the Insured opts for
opted) a suitable Top Up Limit before the expiry of the Grace Limit.
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 the compulsory PA cover by payment of an additional premium as applicable.Liability of insurance company shall commence
from the date of issuance of endorsement.
"It is hereby declared and agreed that all pre-existing damages to the vehicle having occured prior to the commencement of cover are excluded from the scope of the
policy"
Except as provided in GR 27 Rule (g) of Erstwhile Indian Motor Tariff (i.e. Sale of Vehicle), No NCB will be allowed when a policy is not renewed within 90 days of its
expiry.
*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."
% of Discount on Own Damage Premium
Period of Insurance % of NCB on OD Premium
The Preceding Year 20%
Preceding Two Consecutive Years 25%
Preceding Three Consecutive Years 35%
Preceding Four Consecutive Years 45%
Preceding Five Consecutive Years 50%
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Payment of premium under Liability Section (Section II) of bundled policy to other insurer is sole responsibility of policy holder.
The policy wording with detailed terms, conditions and exclusions are available on our website www.reliancegeneral.co.in.
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. No Claim Bonus will be allowed, provided the policy is renewed within 90 days of the expiry of the previous policy.
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,Jeevan Soudha Building,PID No. 57-27-N-19 Ground Floor,19/19,24th Main Road,JP Nagar,Ist Phase,
Bengaluru – 560 078. Tel.: 080 - 26652048 / 26652049 Email: [email protected]
Note: This 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. In case you find any
variations against your proposal or any discrepancy in the policy, kindly contact us immediately. Subject otherwise to the terms, conditions and exclusions of the
Reliance Motor Private Car Package Policy. 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. This document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services Tax Rules 2017.
Fast Tag ID -
The policy does not cover liability for death, bodily injury or damage as excluded under Section 150 (2) (ii) and (iii): b and C of the Motor Vehicles Act 1988 (Inserted
Vide GSR no 164 (f) dated 25.02.2022 w. e. f 01.4.2022)
In the unfortunate event of a claim, please call quoting your Policy No. on 022 48903009(Paid) and register your claim immediately within 7days from the date of
loss.You can also reach us at [email protected].
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.
To check the nearest available Preferred Network Garage for repairs please click here below link
https://www.reliancegeneral.co.in/SiteAssets/RgiclAssets/Reliance_Preferred_Network_Garages.pdf
For Reliance General Insurance Co. Ltd.
Authorised Signatory
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0 0 0 Risk Assumption Letter

Dear Mr. HANAMANTHRAO MOHARE
Thank you for choosing Reliance General Insurance.
Please find enclosed policy no.: 140122423090179417 which has been issued based on the details declared by the applicant.
Insured Vehicle Details

Registration No. KA29P1909 Mfg. Month & Year NOV-2023
Make / Model & Variant RENAULT TRIBER RXE BSVI Date of Registration 11-Nov-2023
Engine No. / Chassis No. B4DF424E036299 / MEERBC003P6185347 Seating Capacity Including Drive 7
Type of Body NA CC / HP / Wat 999
RTO Location KARNATAKA - Bagalkot LCC Excluding Driver 6.00
Insured's Declared Value (IDV)

Vehicle IDV ` 510,000.00 CNG / LPG Kit ` 0.00
Electrical / Electronic Accessories ` 0.00 Trailer / Side Car ` 0.00
Non Electrical Accessories ` 0 Total IDV ` 510,000.00
Previous Policy Details

Previous Year Policy No. Period of Insurance Previous Policy-Claim Status
3311/01152554/000/00 From: 11/11/2023 To: 10/11/2024 midnight Yes No
YOU HAVE OPTED FOR THE FOLLOWING COVERS
Standard Vehicle Own Damage + Third Party Coverage
Cover Electrical/electronic accessories
Non-electrical accessories
Bi-fuel kits comprising LPG/CNG systems
Add-on Covers
Limit Sure - Pay as you DriveThe own damage insurance for the motor vehicle including theft shall be covered upto the Available Kilometres mentioned in the
Policy Schedule. The Available Kilometres includes sum of Kilometre Limit,Top Up Limit and Carry Forward Limit.
Nil Depreciation Cover No deduction for depreciation on vehicle parts other than tyres and tubes and covers the loss of key, loss of personal belongings
in respect to approved partial loss claims.
NCB Retention Cover No-Claim Bonus % is retained even after a claim, which would have become 0% without this cover.
Total Cover Provides cover for registration charges, road tax and insurance premium (Total Cover Sum Insured - ` 0.0/-)
EMI Protect Pays for car EMIs for the time period during which the car is in one of our network garages for repair.
Daily Allowance Benefit Provides allowance as per plan opted, if vehicle is in garage for more than minimum days & for initial two eligible own damage
claim., and in case of theft where vehicle is not found for more than 90 days.
Daily Allowance Benefit Plus Provides allowance as per plan opted, if vehicle is in garage for more than minimum days & for eligible own damage claim., and
in case of theft where vehicle is not found for more than 90 days.
Consumable Expenses Covers expenses incurred towards consumable items due to damage to vehicle caused by perils covered. For e.g. nut & bolt,
screw, washers, grease etc
Emergency Hotel Provide allowance towards the Hotel accommodation insured vehicle met with accident/ stolen 200 kms away from the location
Accomodation provided in policy copy.
Engine Protector Provides coverage to internal parts of engine, gear box, transmission assembly & differential assembly due to ingress of water or
leakage of lubricating oil.
Key Protect Cover Provides replacement cost of keys in the event the keys are lost. It also covers replacement cost of locks if the vehicle is broken
into.
Return to Invoice Covers difference between IDV & purchase price of the vehicle in the event of theft, total loss/ CTL including first time registration
charges, road tax & applicable insurance cost.
Tyre Protector Covers repair or replacement expenses arising out of accidental loss or damage to tyre & tubes.
Rim Protector Covers repair or replacement expenses arising out of accidental loss or damage to Rims.
Loss of Personal Belongings Covers loss of personal belongings of insured or his family while such items are in vehicle at the time loss or damage to the
vehicle
Hospital Cash Cover Provides hospital confinement allowance for accident or injuries sustained while driving insured vehicle.
Additional towing Charges Provides cover for towing charges over and above the standard policy guideline as per the cover opted by customer (Sum
Insured - ` 0.0/-).
Assistance cover- PC Provides help or support in various emergency situation to the insured and Insured Vehicle due to accident or breakdown.
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(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.)
Please take a moment to carefully check your policy details mentioned above and in the policy schedule. Kindly confirm that the same are in order. In case of
discrepancies, please let us know immediately. You can write to us at [email protected] or call us 022 48903009(Paid) for necessary
changes/rectification. 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. Non disclosure and/or misrepresentation of claims in the previous policy period can lead to cancellation of your policy or rejection of your
claims.
For Reliance General Insurance Co. Ltd.
Authorised Signatory
Page 6 of 14
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Know your policy

Remember to carefully go through the Risk Assumption Letter and confirm your personal as well as your vehicle details.
In case of any discrepancy in the policy details, kindly revert within 15 days from the policy start date on 022 48903009 (Paid No) or visit any of our branches.
Kindly refer to the Key Feature Document and Policy Wording at www.reliancegeneral.co.in to understand your policy better and learn more about the policy coverages,
add-on covers and Policy Exclusion. This document is a statement of the specific provisions that form the Terms and Conditions of this Policy.
What documents do you require for making any change to your policy
1. Changes in vehicle make & model/cubic capacity/seating capacity/engine & chassis no./year of manufacture/registration no./ location/address
Documents required :Letter for change, policy copy and registration certificate copy along with additional premium cheque, if applicable.
2. Changes in electrical and non electrical accessories/CNG/LPG kit
Documents required :Letter for addition, policy copy, invoice copy of accessories, endorsed registration certificate copy (for CNG/LPG kit) and cheque for additional
premium.
3. Changes in financier details (Hypothecation/Lease/Hire purchase)
Documents required :Letter for change, policy copy, endorsed registration certificate copy and no objection certificate from financier (not mandatory for deletion, if
registration certificate copy is endorsed).
How to register a Claim - Cashless
How to register a Claim - Reimbursement
What documents do you require to register a Claim

1. Claim form duly filled and signed (company stamp in case of company registered vehicles)
2. Registration copy
3. Driving License of the driver at the time of loss
4. Policy copy
Note: 1. As soon as a claim occurs, please intimate immediately at our call centre 022 48903009 (Paid). Delay in intimation would result in the violation of policy
condition.
2. Any additional document, if required, will be informed.
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Live Smart
Name : HANAMANTHRAO MOHARE
Policy no. : 140122423090179417
Policy Period : 30-Nov-2024 to 29-Nov-2025
Chasis No. : MEERBC003P6185347
Vehicle No. : KA29P1909
Emergency Contact no.
Blood Group.
Scan QR code for more
details
For breakdown and claims Call 022 48903009
-All insurance contracts are based on the information provided by the insured in the
proposal form.
-Intimate claim immediately at our Paid No. 022 48903009 and provide:
1.Policy No. as mentioned on the card.
2.Place,Date & Time of Loss.
3.Name of the Driver Driving the vehicle at the time of Loss.
4.The damages suffered by the vehicle.
5.Injuries to passengers/driver/third parties if any.
6.Place when the vehicle is currently available for inspection.
IRDAI Registration No. 103

Reliance General Insurance Company Limited.
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
RGI/MCOM/MOT-02/MOTOR CARD/Ver. 1.0/200115.
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and
used by Reliance General Insurance Company Limited under License.
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Proposal Form For Reliance Private Car Policy-Stand-alone Own Damage

Is the Vehicla Made in India? Yes No Type of Vehicle : Two wheeler Four wheeler Three Wheeler
For Office Use Only

Policy Number 140122423090179417 Date
Savvion Reference No Inspection Lead No.
Intermediary Details (To be filled in BLOCK LETTERS)

Intermediary Name GEETHA P Code 23P62209
Branch Name Bangalore I Code 1401
Sales Manager Name Ravishankar Vh Code 70700676
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. HANAMANTHRAO MOHARE
2b. Address Address for Communication Address where vehicle is normally kept and Used
Flat/Building/Door/Block No.
Road /Street/Sector S/O BHIMARAO WARD NO 1 H NO 551
KILLAGALLI BAGALKOT
Nearest Landmark
Area
City BAGALKOT
Pin Code 587101
State KARNATAKA
Country India
Phone Mobile 9481******
Emergency Contact No. Blood Group
Email h****************@gmail.com Fax
3. Period of Insurance From 30/11/2024 Hrs of To: Mid Night of To 29/11/2025
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. *****624C
Fast Tag ID
8. Do you have a GST Registration Number Yes No
If Yes, please specify
9. Where do you park your vehicle? Road Side Parking Open Garage Parking Pay And Park Open with Residential Compound
Stilt Parking
10. Are you an existing Reliance General Yes No

Insurance Customer
If Yes, please Provide the Policy No.:
11. Related Party Yes No
Details of the Vehicle

12. Registration Number KA29P1909 13. Date of Registration 11-Nov-2023
14. Registering Authority & Location KARNATAKA - Bagalkot
15. Year & Month of Manufacture NOV-2023 16. Cubic Capacity 999
17. Engine Number B4DF424E036299
18. Chassis Number MEERBC003P6185347
19. Make of Vehicle RENAULT
20. Type of Body NA/TRIBER 21. Seating capacity including Driver 7
Details of the Vehicle Type and Use

22. a. Whether the Vehicle is driven by Non-conventional source of power? Yes No If yes Bi Fuel CNG LPG
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Side car
Non - electrical accessories Electronic accessories fitted Value of CNG/ LPG
Insured's Declared Value (IDV) (twowheeler)Trailer Total Value
fitted to the vehicle to the vehicle Kit Bi Fuel
of vehicle Chassis Bod (Pvt. Cars)
(₹) (₹) (₹) (₹) (₹)
510,000.00 0.00 0.00 0 0.00 510,000.00
b. Do you have a valid PUC? Yes No
(Note-Warranted that the Assured named herein/owner of the vehicle insured holds a valid Pollution Under Control (PUC) Certificate on the date of commencement of the
Policy and renews and maintains valid and effective PUC Certificate during the duration of the Policy period. If the PUC is not found valid on the date of loss, the company
shall repudiate the OD claim made under the Policy)
23. Age of Owner Driver Age of Owner Driver 24. D.O.B
25. Add On Covers (Subject to availability and eligibility)
a. Limit Sure- Pay as you drive Yes No
ai. if Yes Select Kilometer

Limit
aii. Odometer Reading (since first registration of Kms The customer has to resubmit the actual Odometer
Vehicle) reading (in KM) at the Policy Inception date, in case the
Policy Inception Date is later than the Proposal form.
Date : Where the Insured fails to declare , the latest Odometer
reading (in KM) declared to the Us shall be considered
as the Odometer reading (in KM) of the Vehicle at the
Policy inception date.
b. Nil Depreciation Cover No

c. NCB Retention Cover (Applicable only for Annual Policy) No
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. Return to Invoice (Applicable only for Annual Policy) No
h. Tyre Protector( Applicable only for annual Policy) No
Specifications of Tyres and Tubes:
i. Rim Protector(Applicable only for annual Policy) No
Specification of Rims:
j. Hospital Cash Cover (Applicable only for Annual Policy) No
Sum Insured: ₹
No of Days:
(Convalescence Benefit SI: ₹_____________________________)
k. Consumable Expenses No
l. Engine Protector No
m. Key Protect Cover: No
Sun Insured: ₹
n. Daily allowance benefits Plus No
Per Day Allowance: ₹
Coverage Days :
o. Loss of Personal belongings (Applicable only for annual Policy) No
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Sum Insured: ₹
p. Emergency Hotel Accommodation No
Benefit Amount: ₹
q. Voluntary Deductible
Voluntary Deductible amount opted: ₹ ______________________
r. Additional limit of TPPD No
Additional amount opted: ₹
s. Battery Protection Cover No
t. Electric Motor Protection Cover No
u. EV Charger Cover No
v. Any other Details
___________________________________
w. Preferred Network Garage Benefit No
To view the complete list of Reliance Preferred Network Garages, please refer to the following link
https://www.reliancegeneral.co.in/SiteAssets/RgiclAssets/Reliance_Preferred_Network_Garages.pdf
x. Assistance Cover No
y. Assistance cover- PC Yes
26. 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.
27. Are you a member of Automobile Association of India ? If Yes,please submit membership copy. Yes No
28. Will the Vehicle be used exclusively for
a. Private,social,domestic,pleasure and professional purposes ? Yes No
b. Carriage of goods other than samples or personal luggage? Yes No
29. Whether the Vehicle is used for Driving Tuitions? Yes No
30. Whether use of Vehicle is limited to Own Premises? Yes No
31. Whether the Vehicle is fitted with Fibre Glass Tank? Yes No
32. Whether the Vehicle belongs to the Embassy/Consulate of a Foreign Country? Yes No
If so, is the duty element included in the IDV?
33. Whether the Vehicle is design for use of Blind/Handicapped/Mentally Challenged Person? (Attach RC Copy) Yes No
34. Date of purchase of the Vehicle by the Proposer 11-Nov-2023
35. Whether the vehicle at the time of purchase was New Second Hand
Risk Inclusions
36. Please select the higher deductible if you wish to opt for over and above the compulsory deductible Yes No
Private Car : ₹ 2500 ₹ 5000 ₹ 7500 ₹ 15000
37. Liability to third parties: The policy provides Third Party Property Damage (TPPD) of ₹ 1 lakh (Two wheelers) and ₹ 7.5 lakhs ((Private car)
Do you wish to restrict the above limits to the statutory TPPD Liability limit of
Yes No
₹ 6000/- only?
Legal Laibility No of Persons
Driver.
38. Personal Accident Cover for Owner Driver. Please give details of nomination
Name of 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)
Page 11 of 14
Trejhara
39. Extension of Geographical Area

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

40. Please state if the vehicle is under Hire Purchase Lease Agreement Hypothecation Agreement
If so, give name and address of concerned parties.
41. Full Name M/s. KARNATAKA GRAMEENA BANK
42. Address BAGALKOT
Details of Previous Insurance

43. Full Name of previous insurer Cholamandalam MS General Insurance Company Ltd.
44. Address
45. Policy Number 3311/01152554/000/00 Previous Policy Expiry 10-Nov-24
46. Type of Cover Package Policy Liability only others (to be describe)
47. Claims taken in previous policy Yes No
If yes, No. of Claims Claims Amount `
48. Are you entitled to No Claim Bonus Yes No
If yes, please submit/attached proof thereof
49. 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 _________________________________
Existing TP Policy Details

Existing TP Policy Details:
Existing TP Policy Company Name
Existing TP Policy Period :
Payment Details
Cheque/ DD Cheque/ DD No.
Cheque/ DD Date Cash Credit Card Others
Proposer's Bank Details

50. Name of the Bank Account Holder
51. Bank Account No.: 52. Account: Saving Current
53. Name of the Bank
54. Branch
55. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque
issued by the bank)
56. 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.
GENERAL DECLARATION:
I understand that as per the new AML/CFT Guidelines issued Reliance General Insurance Co. Ltd will be verifying my details pertaining to KYC and PAN provided at
the time of proposal.
I further, do hereby agree and consent that in the case of the event of a mismatch of information provided by me in the proposal form, identification proof, and address
proof at the time of issuance of the policy. I request Reliance General Insurance Company Limited to issue the policy with the details appearing as per my proposal
form. I will be solely responsible for any consequences arising out of the difference in detail given by me during the verification of supporting documents provided by
me at the time of issuance of the policy or otherwise.
Page 12 of 14
Trejhara
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 country

Type of organization Corporation Goverment Non Goverment Society Trust Partenership
Organization
International Organization Corporatives Section 25 Companies
PEP Declaration:
Are you a Politically Exposed Person (PEP)? Yes No
If yes, please mention the position held
Is any of your close relation or family member a PEP? Yes No
If yes, please mention the name and relation and the position held
by such close relative/family member.
I hereby declare that in future if me, any of my close relatives or any of my family member attains a position of PEP then I shall confirm the same to Reliance General
Insurance Co. Ltd as a mandate. I understand that this is a crucial information under the PMLA Rules and AML/ CFT Guidelines and shall confirm that the answers
given by me is true. In case the company comes to know that this is a misrepresentation and concealment of information then the policy shall be put on hold for
scrutiny by the company and I shall be solely responsible for the same.
Note :
“Politically Exposed Persons” (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign country, e.g., Heads of
States/Governments, senior politicians, senior government/judicial/military officers, senior executives of state-owned corporations, important political party officials,
etc (As per sub clause (xii) of 3(b) of Chapter I of Master Direction – Know Your Customer (KYC) Direction, 2016 issued by Reserve Bank of India (RBI).
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

You can support our Go Green Initiative by saying “No” to Policy kit, Renewal Notice and Other Communications hard copy. We will be sending you a
digitally signed soft copy on your registered Email ID & Mobile number.
Hard copy required Yes No
Name Place :
Date : 03 Dec 2024 10:39 Date : 03 Dec 2024 10:39
Signature Signature of Proposer & Company Seal
Page 13 of 14
Trejhara
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
Name of IRDAI Agent/ Broker Mr. Mrs. GEETHA P
Place
Date : 03 Dec 2024 10:39
(In case of Direct Business, Name & Signature of CSO /SM to be taken) Signature of IRDAI Agent/ Broker
* Mandatory details to be filled
The policy does not cover liability for death, bodily injury or damage as excluded under Section 150 (2) (ii) and (iii): b and C of the Motor Vehicles Act 1988 (Inserted
Vide GSR no 164 (f) dated 25.02.2022 w. e. f 01.4.2022)
IRDAN103RP0001V01201920/A0003V01201920 IRDAN103RP0001V01201920/A0004V01201920 IRDAN103RP0001V01201920/A0007V01201920

IRDAN103RP0001V01201920/A0043V01202223 IRDAN103RP0001V01201920/A0048V01202223 IRDAN103RP0002V02202425/A0010V01201920
IRDAN103RPMT0004V03202425/A0006V02202425 IRDAN103RPMT0004V03202425/A0007V02202425 IRDAN103RPMT0004V03202425/A0008V02202425
IRDAN103RPMT0004V03202425/A0050V01202425
Page 14 of 14

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Trejhara

Mr. HANAMANTHRAO MOHARE

Reliance Private Car Policy-Stand-alone Own Damage Policy Schedule

Policy Number : 140122423090179417 Proposal/Covernote No: R30112493578

Insured Vehicle Details

Insured Declared Value (IDV)

PA-Nominee Details Name Age Relation

23P62209 / GEETHA P 9886523069 [email protected] *****624C

0 0 0 Risk Assumption Letter

Insured Vehicle Details

Insured's Declared Value (IDV)

Previous Policy Details

For Reliance General Insurance Co. Ltd.

Know your policy

How to register a Claim - Cashless

How to register a Claim - Reimbursement

What documents do you require to register a Claim

For breakdown and claims Call 022 48903009

IRDAI Registration No. 103

Proposal Form For Reliance Private Car Policy-Stand-alone Own Damage

For Office Use Only

Intermediary Details (To be filled in BLOCK LETTERS)

Details (To be filled in BLOCK LETTERS)

10. Are you an existing Reliance General Yes No

11. Related Party Yes No

Details of the Vehicle

Details of the Vehicle Type and Use

23. Age of Owner Driver Age of Owner Driver 24. D.O.B

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

a. Limit Sure- Pay as you drive Yes No

ai. if Yes Select Kilometer

b. Nil Depreciation Cover No

39. Extension of Geographical Area

Details of Hire Purchase / Hypothecation / Lease

Details of Previous Insurance

Existing TP Policy Details

Proposer's Bank Details

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

Are you a Politically Exposed Person (PEP)? Yes No

If yes, please mention the position held

Is any of your close relation or family member a PEP? Yes No

This proposal form was completed by

Signature Signature of Proposer & Company Seal

Supporting Confirmation of Agent/Broker/SM/CSO

IRDAN103RP0001V01201920/A0003V01201920 IRDAN103RP0001V01201920/A0004V01201920 IRDAN103RP0001V01201920/A0007V01201920

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