Servicing Office Address
Dindigul Business Office,First floor, 5-A,Kalaignar MaligaiSub Collector's
Office Road, Opposite : Dist CourtY MR patty, Dindigul, Tamil NaduDindigul
GSTIN No: 33AAACN9967E1ZA
PROPOSAL CUM QUOTATION
(THIS IS A QUOTATION CUM PROPOSAL FORM, RISK WILL BE COVERED ONLY AFTER REALISATION OF PAYMENT AND POLICY GENERATION.)
PROPOSER'S DETAILS
Name MR RAVICHANDRAN A
Address S/0,ARUMUGAM,OLD NO 368/92 NEW NO 368,VADAMADURAI VEDASANDUR,DINDIGUL,
Pin Code 624802 email id xxxxxxxxxx09@gmail.com
PAN No GSTIN No
Mobile No xxxxxxxx80 Aadhar No
Nominee's Name G.JEYALAKSHMI Relation WIFE Nominee's Age 45 years
AGENT DETAILS
Agent Name N VIVEKANANDAN
Mobile 9042928005 email id vivekam89@gmail.com
PAN No xxxxxx585G GSTIN No
Agent Code 9000170498 Aadhar No
VEHICLE DETAILS
Model HERO MOTOCORP LIMITED HERO PASSION PRO DRUM SELF CAST(100) Year of Make 2016
Reg No TN-57-AQ-5168 Engine No HA10EVGHK27185 Chassis No MBLHA10BSGHK26007
Reg. Date 03/11/2016 Fuel PETROL Colour BLACK
Antitheft Device NO Automobile Association Membership NO
Finacier FastTag ID 0
IDV Rs. NIL
Accessories Electrical Rs. NIL Non-Electrical Rs. NIL Bi-fuel Kit Rs. NIL
POLICY/COVERAGE OPTION DETAILS
Type of Policy/Cover Required 2W 1 Year LIABILITY Policy
Policy Required (period) From 30/10/2024 to 29/10/2025
Do you hold Dr. License for this vehicle class YES
Want WC Cover for Driver NO
Legal Liability to Employees NO
Legal Liability to Unnamed Passenger NO
Retrict to Statutory TPPD cover YES Nil Depreciation NO NCB Protect NO
Nil Depreciation Plus NO Engine protect NO Invoice Protect NO
Registration Charges Rs. NIL Road Tax Rs. NIL
Voluntary Excess Rs. NIL
Loss of Driving Licence
Geographical Area INDIA.
Wheather Nil Depriciation was covered in Previous Policy NO. Road Side Assistance NO
EMI Protect NO EMI Amount Rs. NIL EMI SI Rs. NIL
Total Installment NIL
PREMIUM DETAILS
Total OD Premium Rs. 0.00 Total TP Premium Rs. 959.00 GST Rs. 172.00 Premium Payable Rs. 1,131.00
PREVIOUS POLICY DETAILS *
Previous Policy Type THIRD PARTY Previous Policy Expiring on 29/10/2024
Previous Policy No 64080031236760005646 issued by NATIONAL INSURANCE COMPANY LIMITED
Previous NCB % 0% Claims reported in Previous Policy NO
* Copy of Previous Policy/Renewal Notice to be attached
Declaration by the Insured
a. 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 National Insurance Company Ltd. 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 National Insurance Company immediately.
b. I/We hereby declare that the vehicle proposed for insurance has not met with an accident during the period of break in insurance. Any liability arising during
this period of break will not be admissible under the policy. The vehicle proposed for insurance is in existence and is roadworthy at the time of taking the policy.
c. I/We hereby declare that the vehicle proposed for insurance has a valid Pollution Under Control Certificate & Fitness Certificate (in case of transport
vehicles) on the date of fresh issuance / renewal of the policy.
d. I/We hereby declare that the statements made by me/us in this Proposal 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 National Insurance Co. Ltd.
e. I/We hereby declare that if any additions or alterations are carried out to the vehicle after the submission of this proposal then the same would be conveyed
to the insurers immediately.
Place :
Date : Signature of the Proposer/s.
nic/ubportal/proposal no. 64080060000011 Dt. 29/10/2024
