Policy Number : P0025200001/4111/505084

DEVELOPMENT HOUSE, 24 Park Street , Kolkata -700016

(www.magmahdi.com)
IRDA REG NO. 149 DATED 22nd MAY,2012
CIN: U66000WB2009PLC136327
In case of any query, assistance or claims, please contact us at 1800 266 3202
UIN: IRDAN149RP0003V01201819
Private Car Policy -Bundled - 3 year Act Only and 1 year Own Damage
Date : 01/05/2024

To,
NILESH DHANJIBHAI BORICHA
363/1 VAIKUNTH 2 NEW VIP ROAD NEAR KHODIYAR NAGAR
VADODARA
GUJARAT 390022
Mobile:8401662421

Agent/ Intermediary Name and Code:MARUTI SUZUKI INSURANCE BROKING PRIVATE LIMITED BRC0000397
Sub: Risk Assumption Letter
Dear Sir /Madam,

Thank you for choosing Magma-HDI General Insurance Company Limited as your preferred General Insurance Company. Please find enclosed Policy
No. P0025200001/4111/505084, which has been issued based on the details furnished to us as below:

Insured & Vehicle Details

Name of Insured NILESH DHANJIBHAI BORICHA

Period of Insurance(Own Damage) 00:00 Hrs of 30/04/2024 To 23:59 Hrs of 29/04/2025

Period of Insurance(Third Party Liability) 00:00 Hrs of 30/04/2024 To 23:59 Hrs of 29/04/2027
Period of CPA Cover 00:00 Hrs of 30/04/2024 To 23:59 Hrs of 29/04/2027
Vehicle Make/Model MARUTI / BALENO ZETA 1.2
RTO VADODRA
Vehicle Registration No. NEW
Vehicle Registration Date 30/04/2024
Engine No. K12NP7423710
Chassis No. MBHHWB13SRA652644

The information received from you is reproduced in the proposal attached with this Risk Assumption Letter and your proposal has been processed
accordingly. Coverage of risk is subject to realisation of the full premium post which, insurance coverage under the policy would commence. In case the
premium is not received by us due to cheque dishonour or any other reason, the insurance cover shall be void ab-initio.
If you require any changes in the certificate of insurance cum policy schedule, you are requested to inform us by either writing to us at
customercare@magma-hdi.co.in or calling our toll free helpline on 1800 266 3202. Absence of any communication from you in this regard within a period of
20 days of date of this letter, would mean that the issued policy is in order and as per your proposal.The Risk Assumption Letter is to be read in conjunction
with the policy and shall be considered as null and void without the same.

Dear Customer , Magma HDI general Insurance Company may be storing your AML/KYC details and might require you to update the information submitted
from time-to-time, in accordance with and requirements under the Master Guidelines on Anti-Money Laundering/ Counter Financing of Terrorism (AML/CFT),
2022 issued by the Insurance Regulatory Development Authority of India.

Thanking You,
Regards

For Magma HDI General Insurance Co Ltd.

Authorised Signatory
 Policy Number : P0025200001/4111/505084

DEVELOPMENT HOUSE, 24 Park Street , Kolkata -700016

In case of any query, assistance or claims, please contact us at 1800 266 3202
UIN: IRDAN149RP0003V01201819

Private Car Policy -Bundled - 3 year Act Only and 1 year Own Damage
CERTIFICATE OF INSURANCE CUM SCHEDULE /TAX INVOICE
Policy Servicing Office UNIT NO. 201/B, 2ND FLOOR, NEPTUNE PRIME, NEXT TO ABS TOWER, OLD PADRA ROAD, ,VADODARA -390020 ,GUJARAT , PH: (1800) 2663202
Policy No P0025200001/4111/505084
E Policy no. P0025200001/4111/505084
Insured NILESH DHANJIBHAI BORICHA Period of Insurance(Own Damage) 00:00 Hrs of 30/04/2024 To 23:59 Hrs of 29/04/2025
Address 363/1 VAIKUNTH 2 NEW VIP ROAD NEAR KHODIYAR NAGAR Period of Insurance(Third Party Liability) 00:00 Hrs of 30/04/2024 To 23:59 Hrs of 29/04/2027
VADODARA Period of CPA Cover 00:00 Hrs of 30/04/2024 To 23:59 Hrs of 29/04/2027
GUJARAT 390022 Agent No.: BRC0000397
Mobile:8401662421
Contact Number 8401662421 Hypothecation with BAJAJ FINANCE LIMITED
Email ID:
GST Number Unregistered
INSURED MOTOR VEHICLE DETAILS AND PREMIUM COMPUTATION
SEATING
Registration No. & RTA Location Year of Manufacture Engine No. Chassis No. Make/Model/Type of Body CUBIC CAPACITY
CAPACITY
NEW / VADODRA 2024 K12NP7423710 MBHHWB13SRA652644 MARUTI BALENO ZETA 1.2/SALOON 1197 5
IDV (INSURED'S DECLARED VALUE)
IDV of Vehicle Non Electrical Accessories Electrical/electronic Accessories Bi-Fuel kit(LPG/CNG) Other accessories Total Value
800850 0 0 0/0 0 800850
OWN DAMAGE(A) LIABILITY(B)
Basic - OD 10,222.05 Basic - TP 10,640.00
Engine Protector 1,201.28 PA Paid Drivers, Cleaners and Conductors 750.00
Key Replacement (Sum Insured - 50000) 250.00 PA Owner Driver -SI Rs.1500000 Tenure 3 Year(s) 975.00
Basic Roadside Assistance 51.00 Sub Total 12,365.00
Zero Depreciation 4,004.25
Return to Invoice 800.85
Consumables 800.85
Sub Total 17,330.28
Less:
Anti-Theft Device - OD 255.55
Sub-Total Deductions 255.55
Total Own Damage Premium(A) 17,074.00
Total Liability Premium(B) 12,365.00
Premium Computation
Total Package Premium(A+B) 29,439.00
CGST @ 9% 2,649.51
SGST @ 9% 2,649.51
TOTAL 34,738.00
Disclaimer:The Exclusions in this policy are as specified in the pre inspection report ID :
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)Use in connection with Motor Trade
Driver 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
Clause : 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
Under Excess in respect of each and every claim under Sec I of motor Under In respect of any one Under Damage to Third Party Property Rs. 750000/- Under PA Owner – Driver as per
Section I policy Section II-I accident -- As per Motor Section II-I in respect of any one claim or series of claims Section III: premium computation table
Compulsory : Rs. 1000/- Voluntary : Rs. 0/- Imposed : Rs. 0/- (i) Vehicle Act (ii) arising out of one event.
Total : Rs. 1000/-
Subject to I.M.T Endorsement Nos. IMT 7,IMT 10,IMT 15,IMT 17,IMT 22
NOMINATION DETAILS
Name Of the Nominee Date of Birth of Nominee Age of Nominee Relationship With Insured Percentage
MANISHA 01/01/1996 28 Wife 100
Date of Signature of proposal 30/04/2024
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 provisions of chapter X and chapter XI of M.V. Act, 1988.
Premium Collection Details :- [Collection No - ReceiptDate - Amount] : P/200025/25/100108591- 30/04/2024 , 34738
Premium Amount in Word's ( ) :- Thirty-Four Thousand Seven Hundred Thirty-Eight Only
In case of Claims, please contact us at 1800 266 3202 For Magma HDI General Insurance Co. Ltd.

Date of Issue : 01/05/2024

Place : Kolkata

Consolidated Stamp Duty on the issue of General Insurance Policies Paid vide G.O No. 2250, dated 20.12.2023 Authorised Signatory
GST Number of MHDI - 24AAGCM1685C1ZP
GST Invoice Number - MP16042500765
Accounting Code for Service - 997134, Motor vehicle insurance services

Place of Supply:GUJARAT ( 24 )

Whether Tax is payable on Reverse Charge - No

UIN : IRDAN149RP0003V01201819
This is a valid Tax invoice in terms of Sub-rule 2 of Rule 54 of CGST Rule 2017. Further, being an Insurance Company, issuing of e-invoice and QR Code
are not applicable on us in terms of Notification No 13 and 14 of 2020 dated 21st March 2020 issued from Central Board of Indirect Taxes and Customs.
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 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 be good. Please note that any
misrepresentation, non disclosure or withholding of material facts will lead to cancellation of policy ab initio with forfeiture of premium and non consideration of claim, if any.

As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 31st October of the next financial year.
For Complete details of coverage , terms, conditions & exclusion please refer the standard policy wording attached with this schedule

IMPORTANT - 1) The Validity of this Certificate of Insurance cum Schedule is subject to realisation of the premium cheque.
2) No Claim Bonus will only be allowed provided the Policy is renewed within 90 days of the expiry date of the previous policy.
3) This document is digitally signed, hence counter signature / stamp is not required.
4) For detailed terms & conditions please refer our website www.magmahdi.com
 Policy Number : P0025200001/4111/505084
We at MAGMA HDI prefer receiving premium amount through cheque
No. Pvt./202405010278359

Call Us : 1800 266 3202

(Information for fields marked with asterisk [*] is mandatory)

Proposal Form for Private Car Policy -Bundled - 3 year Act Only and 1 year Own Damage
Customer ID 20016866023
*Proposal For: New Policy Roll- Over Renewal Endorsement
*Type of Vehicle : Two Wheeler Private Car Three Wheeler *Vehicle Insured is: New Used
*Coverage Comprehensive Package Cover Third Party Liability only Cover Third Party, fire & theft only Cover
1 Year Comprehensive Package Cover and 3 Year Third Party
Required: Third Party and Fire only Cover Third Party and Theft only Cover
Liability only Cover

Intermediary Code: BRC0000397 Intermediary Name: MARUTI SUZUKI INSURANCE BROKING PRIVATE LIMITED

* Period of Insurance (own damage): 30/04/2024 Time: 00:00 ,To Midnight of 29/04/2025 * Period of Insurance (Third Party Liability): 30/04/2024 Time: 00:00 ,To Midnight of 29/04/2027
(Note: Cover shall not commence earlier than the date and time of acceptance of risk and/or issuance of cover note and subsequent to payment of premium)

1. *Proposer Details:
1. Name (Registered Owner of the Vehicle): NILESH DHANJIBHAI BORICHA

PAN No: *DOB: 02/06/1996 *Gender: M F *Occupation: *Marital Status:

Bank Name Branch Name A/c Type- Saving Current
Account No. MICR IFSC
2. *Address where Vehicle Registered and Based
363/1 VAIKUNTH 2 NEW VIP ROAD NEAR KHODIYAR NAGAR, VADODARA, GUJARAT 390022, 8401662421 ,Mobile:8401662421
GST Number Unregistered
3. *Communication Address (For policy dispatch)
363/1 VAIKUNTH 2 NEW VIP ROAD NEAR KHODIYAR NAGAR, VADODARA, GUJARAT 390022
GST Number Unregistered
4. City where the vehicle will primarily be used: VADODARA
5. Have you been previously insured in respect of this vehicle? Yes No Policy No.

If so, are you entitled to No Claim Bonus from your previous Insurer? Yes No
If Yes, Kindly indicate the percentage: 20% 25% 35% 45% 50% 55% 65%

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 further undertake that if this declaration is found incorrect, all
benefits under the Policy in respectof Section1 of the Policy will stand forfeited.

Signature of Proposer
6. About the Motor Vehicle to be Insured
*Make MARUTI *Chassis No MBHHWB13SRA652644 Speedometer reading as on date
*Model BALENO ZETA 1.2 RTO where vehicle will be registered VADODRA *Vehicle IDV 800850
*Year of Manufacture APRIL - 2024 Date of Registration /Purchase 30/04/2024 Trailer(s) Identification No. 1_________
*CC/GVW 1197 Licensed Carrying Capacity 5 2_________
(No of Passengers Including driver)
*Registration No. NEW 3_________
Type of Body SALOON Colour of the vehicle 4_________
*Engine No. K12NP7423710 Vehicle Make (Indigenous or Imported) BALENO ZETA 1.2
Note: Either Registration no or Engine and Chassis Number is mandatory
*Vehicle Rate Under: Zone -A Zone -B
*Fuel Used: Petrol Diesel Bi Fuel LPG/CNG Electric Hybrid Others (please specify)
*Type of Permit: Express Way National/State Highways City/Town Road District Roads Private Road
* Average Monthly usage : Less Than 50 Kms Between 50 and 100 Kms Between 101 and 250 Above 251 Kms
Whether any modification or conversion has been done in the vehicle from the maker’s standard specification? Yes No
If Yes, please give details of such modifications/conversions...........
Is the vehicle in good state of repair? Yes No If No, please furnish details ................
Where will the vehicle be generally parked?

Roadside Public Parking Road Outside Parking lot open or covered Within compound of residence open

Within compound of residence covered

7. Financier Details: Hypothecation Hire Purchase Lease Financier Name : BAJAJ FINANCE LIMITED

8. Nominee Details : Nominee Name: MANISHA DOB 01/01/1996 Relationship Wife

Appointee Name & age *If Nominee is minor (below 18 yrs) Appointee Name is mandatory.
9. Insured Declared value of the Vehicle:
The IDV of the vehicle will be deemed to be the Sum-Insured for the purpose of the Policy and will be fixed on the basis of the manufacturer’s listed selling price of the brand and model as the vehicle proposed for insurance at the
time of commencement of insurance / renewal and adjusted for depreciation as per the schedule specified below.
Age of the Vehicle % of Depreciation *Vehicle Chassis Value 800850
Not exceeding 6 months 5% Vehicle Body Value
Exceeding 6 months but not exceeding 1 year 15% Non- Electrical Accessories (Other than factory fitted): Details
Exceeding 1 year but not exceeding 2 years 20% Electrical Accessories (Other than factory fitted) Details
Exceeding 2 years but not exceeding 3 years 30% Bi- Fuel/ CNG/LPG Kit
Exceeding 3 years but not exceeding 4 years 40% Trailer(s)/ Side Car Value (only for 2 wheelers):
Exceeding 4 years but not exceeding 5 years 50% Total IDV:
Note - For vehicles more than 5 years old, please contact the Company for fixing the IDV
 Policy Number : P0025200001/4111/505084
We at MAGMA HDI prefer receiving premium amount through cheque
10. Extended Covers/ Extra Benefits at Additional Premium:
Extension of Geographical Area: Vehicle is fitted with Fibre Glass Fuel Tank Yes No

Bangladesh Bhutan Nepal Vehicle will be used for Driving Tuitions Yes No

Maldives Pakistan Sri Lanka Imported vehicle without payment of customs duty Yes No

Compulsory Personal Accident (If owner has a valid Yes No Is the vehicle Company Yes No
driving license) Maintained?

Will the vehicle be let out on occasional Hire? Yes No

Whether the vehicle is certified as Vintage Car by Yes No

Vintage and Classic Car Club of India ?
Vehicle used for commercial purposes: Yes No

Yes No Do you wish to include Personal Accident cover for unnamed occupants of the vehicle in excess of the compulsory
Do you want to opt for wider legal liability to Paid Driver Personal Accident cover for the Owner/Driver?

Yes No

Other employees Yes No Sum Insured per person to be Rs 0

(If Yes, No. of persons tobe covered.........) Nominee Details : Name _________________

Do you want to cover loss of accessories Age _______________ Relationship _______________

due to burglary, If yes, please indicate the Sum-Insured per person (In multiples of Rs.10000/- for a maximum of Rs.1 lakh per
Yes No person for Two Wheelers and Rs. 2 lakhs per person for Private Cars. The number of persons to be covered for the
housebreaking or theft?
purpose of this Add-on will be equivalent to the registered carrying capacity of the vehicle)
(Applicable only for Two-Wheelers)

Do you wish to have an enhanced Personal Do you wish to cover Hospital Cash for hospitalisation arising out of accident for Yourself/Your Driver/Unnamed
accident cover for Yourself/ occupants of the vehicle?
Your Driver/Unnamed occupants of the
Yes No Yes No
vehicle?

If Yes, please provide the Sum Insured per

person............

Do you wish to include Personal Accident cover for named persons? Yes No

If YES, give name and Capital Sum Insured (CSI) opted for :

Name CSI Opted (Rs.) Nominee Nominee Age/DOB Relationship

1)
2)
3)

(Note : The maximum CSI available per person is Rs. 2 lakhs in case of Private Cars and Rs.1 Lakh in the case of motorized Two wheeler)
11. Add On Coverage at additional :

Extra Coverage: Return to Invoice , Key Replacement (Sum Insured - 50000) , Consumables , Engine Protector , Zero Depreciation , Basic Roadside Assistance
12. Restrictions of Cover/ Discounts:
Is the vehicle designed for use of Blind / Handicapped/Mentally challenged persons and duly endorsed as such by
RTA ?
Vehicle fitted with Anti-theft device approved by ARAI : Yes No
Yes No
Vehicle will be used within own premises : Yes No
Are you a member of Automobile Association of India? Yes No
Third Party Property Damage cover restricted to 6000 Yes No
If yes, please state
(Third Party Property Damage cover of Rs 1 lakh for 2 wheelers and Rs 7.5 lakhs for Private cars)
a. Name of Association
b. Membership No. c. Date of expiry
*Voluntary Deductible :
Private Car : None 2,500/- 5,000/- 7,500/- 15,000/-

I hold a valid and effective PUC and/or fitness certificate, as applicable, for the vehicle mentioned herein above and undertake to renew the same during the policy period.

Signature of Proposer
13. Previous Insurance Details:
Previous Insurer Name: Type of cover:
Policy/ Cover note number: Period of Insurance: From To
Has any Insurance Company ever: Claims reported in last 5 years
1) Declined the proposal Year 1 2 3 4 5
2) Cancelled & Refused to renew
3) Required an increase in Premium Type of Claims
4) Imposed special conditions or excess (OD/TP)
No. of Claims
Amount
14. Driver Details:
a. Age & Date of Birth of the Owner : Age:_______ Yrs DOB:_____/_____/_____
b. Age & Date of Birth of the Driver : Age:_______ Yrs DOB:_____/_____/_____
c. Does the driver suffer from defective
vision or hearing or any physical infirmity? Yes No
lf YES, please give details of such infirmity :
d. Has the driver ever been involved/convicted
for causing any-accident of loss? Yes No

lf YES, give details as under including the pending prosecutions:

-Driver's Name :
-Date of Accident:
-Loss / Cost ( Rs.)
-Circumstances of Accident / Loss
15. Premium Details
Total Premium (Including GST): 34,738.00 Payment Mode : Cash Cheque DD
Cheque/DD, Cheque No Bank/Branch Date.
16. Electronic Insurance Details
• Do you wish to have this Policy credited to an eIA? (Please select any one)
• No, I do not have an eIA and do not wish to open one Yes, Credit this Policy to my e-Insurance account
• If yes, Please share existing e-Insurance Account No :
• Please select Insurance Repository Name (you have opened your account with)
• M/s NSDL Database Management Limited M/s Karvy Insurance Repository Limited
• M/s Central Insurance Repository Limited M/s CAMS Repository Services Limited (Please select any one) Or
• I do not have existing e-Insurance account and I am interested in creating a new e-Insurance account (Please submit electronic insurance account opening form (eIA form) along with relevant documents)
• My CKYC No. (Central Know Your Customer registry number) is (if available): 40075488671225
• Representative Details (only if eIA is to be opened for any other person other than Proposer and primary Insured)
First Name :
Middle Name :
Last Name :
Gender :
DOB :
PAN :
Address Line 1 :
Address Line 2 :
Address Line 3 :
Pin Code :
Telephone Number :
Mobile Number :
Relationship :
Other Relationship :
Email Id :
UID :
LandMark :
State :
 Policy Number : P0025200001/4111/505084
City :
Country :

Declaration: 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 thebasis of the contract
between me/us and the Magma HDI General Insurance Co. Ltd.
I/We also declare that any additions or alterations carried out after the submission of this Proposal Form would be conveyed to Magma HDI General Insurance Co. Ltd immediately.
I/We hereby agree to receive a One Page Motor Insurance Policy in Physical Form, to be read along with the detailed Terms and Conditions available on the website www.magmahdi.com
Yes No
I/We further confirm that the existing damages as per the pre inspection report, if any, have duly been shared with me & my consent has been obtained for the same.
I/We hereby declare and undertake that the amount paid by me/us as premium for the aforementioned vehicle is out of my/our lawful and declared source of Income.

I wish to get all policy related communications on My Whatsapp Number:_____________________ and allow to make welcome calls, Services calls or any other communication(electronic or otherwise),subject to the provision of
applicable law. The salient features of the policy,terms and conditions of this proposal have been explained to me/us in___________________ language, and I/we agree to the same.

__________________________________
Place: Kolkata Date: 30/04/2024 Signature of Proposer
SECTION 41 INSURANCE LAWS (AMENDMENT) ACT, 2015 - PROHIBITION OF REBATES
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 or 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 prospectus or tables of the Insurer.
2.If any person fails to comply with sub-regulation (1) above, he shall be liable to payment of a fine which may extend to Ten Lakh Rupees.