HDFC ERGO General Insurance Company Limited

Certificate of Insurance cum Policy Schedule 2302205917819200000

PRIVATE CAR COMPREHENSIVE POLICY

2302205917819200000

Vehicle Details Policy Details

MR T SRINIVASAN Make VOLKSWAGEN Policy No. 2302 2059 1781 9200 000
FLAT C-306 PLOT-9/38-1 MYTHRI¿S THE TOWN SHAILI Model POLO-1.2L HIGHLINE (P) Period of From 02 Dec, 2023 00:01 hrs
GARDEN YAPRAL HYDERABAD HYDERABAD Registration No TS-08-EE-8090 Insurance To 01 Dec, 2024 23:59
TELANGANA - 500087 Tel. 99XXXXXXX1
RTO HYDERABAD Issuance Date 01/12/2023
Chassis No. WVWL14604FT044759 Invoice No. 205917819200000
Cubic Capacity /Watts 1198 Seats 5 Customer Id 100173097300
Year of Manufacture 2014 Body Type HATCHBACK PAN No. AFFPT5763B
Engine No. CJL086822 EIA No. Not provided
Odometer reading: 0
Payment Details : PMT1661898711110 , Bank Name:BIZDIRECT
Email ID : tsxxxxxxxxn4@gxxxx.com
Policy Year Policy Period For the Vehicle (`) Trailer (`) Non Electrical Acc. (`) Electrical Acc. (`) CNG/LPG Kit (`) Total IDV (`)
Year 1 From 02/12/2023 To 01/12/2024 238280 0 0 0 0 238280
Own Damage Policy Period Liability Policy Period
From Date & Time 02/12/2023 00:01 hrs To Date & Time 01/12/2024 Midnight From Date & Time 02/12/2023 00:01 hrs To Date & Time 01/12/2024 Midnight
Premium Details (`)
Own Damage Premium(a) (`) Liability Premium(b) (`)
Basic Own Damage 1739 Basic Third Party Liability 3416
Total Basic Premium 1739 PA Cover for Owner Driver of 1500000 325
Less: No Claim Bonus (20%) 348 PA Cover for Paid Driver of 100000 (IMT-17) 50
Total - Less 348 Net Liability Premium (b) 3791
Add on Coverages Total Package Premium (a+b) 6879
Emergency Assistance (IRDAN125A0016V01201314) 499 GST 18% : Central Tax 9% ( `619 ) + State Tax 9% ( `619) 1238
Emergency Assistance Wider (IRDAN125A0016V01201314) 999
Loss of Personal Belonging - IRDAN125RP0001V02201415/A0023V01202122 199
Pay as You Drive ¿ Kilometre Benefit - 0
IRDAN125RP0001V02201415/A0033V01202223
Total - Add on 1697
Net Own Damage Premium (a) 3088 Total Premium 8117
Geographical Area India Compulsory Deductible (IMT-22) 1,000 Voluntary Deductible 0
Previous Policy No. VPC1700371000100 Valid 02/12/2022 to 01/12/2023 of ROYAL SUNDARAM GENERAL INSURANCE NCB 0%
Policy Holder declare that no claim has been made in the previous year policy. If declaration found incorrect, benefits under the present policy in respect of own damage section will stand forfeited.
Nominee for
Compulsory Owner
PA cover for driver
owner driver has not been providedChitra
to the M Bhatt,
insured Spouse
basis his/her declaration of not holding an effectiveAppointee
driving license Or having Alternate PA / Stand alone CPA policy with minimum sum
Leased
SpecialAgreement
Conditions (IMT-6)/Hypothecated
: (IMT-7) with

Pay as You Drive – Kilometre benefit Table

Mileage Band % of Basic Own Damage premium
0-2,500 Kms 25.0%
2,501-5,000 Kms 17.5%
5,001-7,500 Kms 10.0%
7,501-10,000 Kms 5.0%
> Above 10,000 Kms 0.0%

LIMITATIONS AS TO USE: The Policy covers use of the vehicle 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. Persons or Class of Persons entitled to drive: Any person including the insured, 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. 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. Limits of Liability 1. Under Section II-1 (i) of the policy - Death of or bodily injury - Such amount as is
necessary to meet the requirements of the Motor Vehicles Act, 1988. 2. Under Section II - 1(ii) of the policy -Damage to Third Party Property- ` 750000 3. P. A. Cover under Section III for Owner - Driver(CSI): `
1500000 Terms, Conditions & Exclusions: As per the Indian Motor Tariff. A personal copy of the same is available free of cost on request and the same is also available at our website.

I / We hereby certify that the policy to which the certificate relates as well as the certificate of insurance are issued in accordance with the provision of chapter X, XI of M. V.Act 1988.The stamp duty of Rs. 0.50
paid b y Demand Draft, vide Receipt/Challan no. LOA/CSD/547/2022/5450/22 dated 22/12/2022 as prescribed in Government of Maharashtra Order No. Mudrank No. 2017/CR.97/M-1, dated the 09th January 2018. I
/ 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 sub-rule (4) of rule 48, we are not required to prepare
an invoice in terms of the provisions of the said sub-rule. IMPORTANT NOTICE: The Insured is not indemnified if the vehicle is used or driven otherwise than in accordance with this Schedule. Any payment made
b y the Company b y 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". Disclaimer: The Policy shall be void from inception if the premium in full i s not realised by the company. In the event of misrepresentation, fraud or non-disclosure of
material fact, the Company reserves the right to cancel the Policy. Please note that the insured vehicle was pre-inspected and a report was prepared accordingly. The existing damages to the vehicle as mentioned
in the report shall not be paid by the Company. The policy is issued basis the information provided by you, which is available with the company. In case of discrepancy or non recording of relevant information in the
policy, the insured is requested to bring the same to the notice of the company within 15 days. GST for this invoice is not payable under reverse charge basis.

Branch :4th floor,office no.401 & 402,kuchkulla house,himayatnagar hyderabad - hyderabad

For Claim/Policy related queries call us at +91- 22 6234 6234/+91- 120 6234 6234 or Visit Help Section on www.hdfcergo.com for policy copy/tax certificate/make changes/register & track claim.
Goods & Services Tax Registration No: 36AABCL5045N1Z9 HSN Code 997134

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN :IRDAN125RP0001V02201415. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
Certificate of Insurance cum Policy Schedule 2302205917819200000

PRIVATE CAR COMPREHENSIVE POLICY

2302205917819200000

Broker Name : LANDMARK INSURANCE BROKERS PVT LTD For HDFC ERGO General Insurance Company Ltd
Broker Code : 200075064435 Tel No. : 91-8850766009 POSP PAN No.: ACWPP1760C

Duly Constituted Attorney

Scan the code for Instant Policy Info, Register/Track Claim, Renewal and Modifications in policy.
"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings."

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN :IRDAN125RP0001V02201415. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited
2302205917819200000

Motor Insurance - Proposal Form cum Transcript Letter For Private Car Package

Vehicle Details Proposal Details

Make VOLKSWAGEN Proposal No. 202312010015896
Model POLO-1.2L HIGHLINE (P) Period of From 02 Dec, 2023 00:01 hrs
Registration No TS-08-EE-8090 Insurance To 01 Dec, 2024 23:59
RTO HYDERABAD Issuance Date 01 Dec 2023
2302205917819200000
Chassis No. WVWL14604FT044759 Invoice No. 205917819200000
MR T SRINIVASAN Cubic Capacity Customer Id 100173097300
1198 Seats 5
FLAT C-306 PLOT-9/38-1 MYTHRI¿S THE TOWN SHAILI GARDEN
YAPRAL HYDERABAD HYDERABAD - 500087 Year of Manufacture 2014 Body Type HATCHBACK PAN No. AFFPT5763B
TELANGANA - Tel. 99XXXXXXX1 Engine No. CJL086822
Odometer reading: 0
Payment Details : PMT1661898711110 , Bank Name:BIZDIRECT
Email ID : tsxxxxxxxxn4@gxxxx.com
Policy Year Policy Period For the Vehicle (`) Trailer (`) Non Electrical Acc. (`) Electrical Acc. (`) CNG/LPG Kit (`) Total IDV (`)
Year 1 From 02/12/2023 To 01/12/2024 238280 0 0 0 0 238280
Own Damage Policy Period Liability Policy Period
From Date & Time 02/12/2023 00:01 hrs To Date & Time 01/12/2024 Midnight From Date & Time 02/12/2023 00:01 hrs To Date & Time 01/12/2024 Midnight
Premium Details (`)
Own Damage Premium(a) (`) Liability Premium(b) (`)
Basic Own Damage 1739 Basic Third Party Liability 3416
Total Basic Premium 1739 PA Cover for Owner Driver of 1500000 325
Less: No Claim Bonus (20%) 348 PA Cover for Paid Driver of 100000 (IMT-17) 50
Total - Less 348 Net Liability Premium (b) 3791
Add on Coverages Total Package Premium (a+b) 6879
Emergency Assistance (IRDAN125A0016V01201314) 499 GST 18% : Central Tax 9% ( `619 ) + State Tax 9% ( `619) 1238
Emergency Assistance Wider (IRDAN125A0016V01201314) 999
Loss of Personal Belonging - IRDAN125RP0001V02201415/A0023V01202122 199
Pay as You Drive ¿ Kilometre Benefit - 0
IRDAN125RP0001V02201415/A0033V01202223
Total - Add on 1697
Net Own Damage Premium (a) 3088 Total Premium 8117
Geographical Area India Compulsory Deductible (IMT-22) 1,000 Voluntary Deductible (IMT-22A) 0
Previous Policy No. VPC1700371000100 Valid 02/12/2022 to 01/12/2023 of ROYAL SUNDARAM GENERAL INSURANCE NCB 0%
Policy Holder declare that no claim has been made in the previous year policy. If declaration found incorrect, benefits under the present policy in respect of own damage section will stand forfeited.
Nominee for
Compulsory Owner
PA cover for driver
owner driver has not been providedChitra
to the M Bhatt,
insured Spouse
basis Appointee
his/her declaration of not holding an effective driving license Or having Alternate PA / Stand alone CPA policy with minimum sum
Leased
SpecialAgreement
Conditions (IMT-6)/Hypothecated
: (IMT-7) with
Pay as You Drive – Kilometre benefit Table
Mileage Band % of Basic Own Damage premium
0-2,500 Kms 25.0%
2,501-5,000 Kms 17.5%
5,001-7,500 Kms 10.0%
7,501-10,000 Kms 5.0%
> Above 10,000 Kms 0.0%

Broker Name : LANDMARK INSURANCE BROKERS PVT LTD Broker Code : 200075064435 Tel No. : 91-8850766009 POSP PAN No.: ACWPP1760C
Anti rebate clause
Prohibition of Rebates (Section 41 of Insurance Act, 1938 as amended) : 1. No person shall allow o r 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: provided that acceptance by an
insurance agent of commission in connection with a policy of life insurance taken out by himself on his own life shall not be deemed to be acceptance of a rebate of premium within the meaning of this sub-section if
at the time of such acceptance the insurance agent satisfies the prescribed conditions establishing that he is a bona fide insurance agent employed by 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..

Terms and Conditions

I hereby declare that the Insured Person(s) listed in Proposal Form will abide to the following T&C:
1 ) I/We hereby declare that the statements made by me/us 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
HDFC ERGO General Insurance Company Limited.
2) 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.
3) I/We also shall endeavor to procure the renewal notice and pass on the same to HDFC ERGO General Insurance immediately upon the receipt of such renewal notice.
4 ) Any person who, knowingly and with intent to defraud the Insurance Company o r other persons, files a proposal for insurance containing any false information, o r conceals for the purpose of misleading,
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.
GSTIN :- Motor(Comprehensive and TP):For policy issued in the name of corporate entity (proprietor, HUF, partnership, private company etc), GSTIN is printed on the policy, basis the details provided during policy
issuance. For any subsequent changes or addition (i.e. if GSTIN not entered at the time of policy issuance ) on policy schedule, changes shall be carried out through fresh policy issuance with prospective effect.
5) I understand the Proposal No. 202312010015896 is issued to me basis on above information.
6) It has been declared by you that you are not a Politically Exposed Person and the source of funds to purchase this policy are from salary/business income.
Transcript Declaration : In case disagreement or objection or any other changes with respect to information and contents mentioned herein above,please contact our toll free number and register your objections /
changes / disagreement to the conte nt 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.

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN :IRDAN125RP0001V02201415. Customer Service Address: D 301, 3rd Floor,
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com