Liberty General Insurance

Servicing Office: PLOT NO 5 1ST FLOOR MEERA COMPLEX SARDARPURA , UDAIPUR, RAJASTHAN -313001
Proposal Form
PAN: AABCL9950A, GSTIN: 08AABCL9950A1ZL, CIN: U66000MH2010PLC209656, IRDAI Reg. No.: 150

Proposal No: HIIB4572840 Proposal Date: 14-Sep-2023 (13:11)

Proposer Name: MRS. POOJA DAVE Previous Policy No: HFI04652
Vehicle Class: PRIVATE Previous Insurer: Future Generali India Insurance Company Limited.
Period of Own Damage: 21-SEP-2023 (00:00) To 20-SEP-2024 (1 YEAR)
W/O LT PIYUSH VYAS 41 HANUMAN NAGAR NEAR
Proposer Address: VAISHNAV SEC SCHOOL OPP PAL BALAJI, JODHPUR, Period of Liability Cover: 21-SEP-2023 (00:00) TO 20-SEP-2024 (1 YEAR)
RAJASTHAN-342001 Period of Compulsory
Personal Accident Cover: 21-SEP-2023 (00:00) To 20-SEP-2024 (1 YEAR)
Proposer Type PAN GSTIN Name Age Relation
Proposer Details: Nominee Details
INDIVIDUAL NA NA VIVAN VYAS 7 SON
Vehicle Details
Make Model Sub Model Cubic Capacity Manufacturing Year Seating Capacity
HYUNDAI NEW I20 (IB) I20 SPORTZ CRDI 1396 2017 5
Invoice Date Registration No. RTO Hypothecation/Lease* Engine No. VIN / Chassis No.
21-SEP-2017 RJ-19-CG-9051 JODHPUR YES D4FCHM329154 MALBM51RLHM387450
Invoice Value Vehicle IDV Elec. Accessories Non-Elec. Accessories BI Fuel Kit Total IDV
666667 300000 0 0 0 300000
Schedule of Premium (Amount in Rs.)
Own Damage Premium (A) Amount Liability Premium (B) Amount
Basic Own Damage Premium Basic Third Party Liability 3416
Vehicle 6032 Bi-Fuel Kit 0
Non-Elec. Accessories (IMT-24) 0 Geographical Area Extension (IMT-1) 0
Elec. Accessories (IMT-24) 0 Sub Total (Third Party Liability Premium) 3416
Bi-Fuel Kit (IMT-25) 0 Personal Accident (PA) Cover
Sub Total (Basic Premium) 6032 Compulsory PA Cover for Owner Driver Rs.1500000 (IMT-15) 375
Geographical Area Extension (IMT-1) 0 PA Cover for (0) Unnamed Passengers Rs.0 Each (IMT-16) 0
IMT 58 Premium 0 PA Cover for Paid Driver Rs. 2 Lac (IMT-17) 0
Sub Total 6032 Sub Total PA Cover 375
Discounts/Deductibles Legal Liability
Voluntary Deductible (IMT-22A) (0) 0 Paid Driver (IMT-28) 50
Anti-Theft Device (IMT-10) 151 Employees (for- 0 Persons) (IMT-29) (for 0 persons) 0
AA Membership (IMT-8) 0 Sub Total (Legal Liability) 50
No Claim Bonus – (25%) 1471 Net liability Premium (B) 3841
Handicapped Discount (IMT-12) 0 Total Premium (A+B) 12749
Sub Total (Discounts/Deductibles) 1622 CGST (9%) 1148
Add-on Coverage (ZD, KP, PB) 4498 SGST (9%) 1148
Net Own Damage Premium (A) 8908 Gross Premium Paid 15045
Add-on Cover Opted in the Policy: NIL DEPRECIATION, KEY REPLACEMENTS, PERSONAL BELONGING.
SAC: 997134, Description of Service: Motor Vehicle Insurance Services, Place of Supply: RAJASTHAN (State Code: 08)
*Hypothecation Details: SBI - jodhpur - JODHPUR Payment Mode:ONLINE
Break in Insurance Declaration “I/We hereby Declare and Undertake

That, the vehicle proposed to be insured had, during the period in which it was not covered by valid and effective insurance policy issued by any insurer/s, had NOT met with any accident (*Select the appropriate
check box and provide relevant information against selected entry)

That, the vehicle proposed to be insured had, during the period in which it was not covered by valid and effective insurance policy issued by any insurer/s, met with an accident on DD/MM/YYYY at DD/MM/YYYY
Add more date/s with time if vehicle had met with an accident more than once)
I/we understand that all and/or any kind of liabilities arising out of accident/s which had occurred prior to risk inception date and time as mentioned in the Policy Document issued by Liberty General Insurance Ltd. in
consideration of these presents will be completely out of ambit of said Policy and said Company will not be in any manner liable or held responsible, therefore.
I/we further undertake that if this declaration and/or any of its part is found to be incorrect in any manner, all the benefits under the Policy will then stand forfeited and the contract of insurance will be treated as void
ab-initio”.
NCB Declaration I / We 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 the policy enclosed) I/We further undertake that if this declaration is
found to be incorrect, all benefits under policy respect of Section I of the policy will be forfeited.
Declaration “I am/we are aware that the complete terms and conditions of this insurance policy are available at the official website of the insurer http://www.libertyinsurance.in. I/We hereby consent to receive only the
certificate and schedule of insurance upon undertaking of the insurer that the complete policy terms & conditions will be made available free of cost upon my/our request”. I hereby declare and confirm that the PUC
certificate of the vehicle proposed for insurance is valid as on date. I hereby declare and confirm that the Fastage of the vehicle proposed for insurance is affix as on date.
Any other Material Information Declaration and Consent I/We hereby declare that the statements, answers given by me /us in this proposal form are true to the best of my knowledge and belief and I/We hereby
agree that this declaration shall form the basis of the contract between me/us and the It is hereby understood and agreed that all statements, details and particulars provided herein above are the basis on which this
Insurance is being granted and that if, after the insurance is affected, it is found that any of the statements, answers or particulars are incorrect or untrue in any respect, the company shall have no liability under this
Insurance. I/We agree and undertake to convey to any change / alterations carried out in the risk proposed for insurance after submission of this proposal form. “I/We have insurable interest in the subject matter of
this insurance, and we hereby declare that the Cost of the same and the premium for this insurance is paid from legal sources of funds. I, the undersigned proposer hereby declares and confirm that I have understood
the features, terms and conditions of the policy and details asked contained in the proposal form. I also understand that the reply to the details asked in the proposal form, forms the basis of the contract of insurance.
If any information/statement given in proposal is found to be untrue, the policy shall be treated as void ab initio and the premium paid shall be forfeited to the Company. Please give details if you are politically exposed
person or relative of politically exposed person. ------------------------------------------------------------ Please give details if you are no profit organization. ----------------------------------------------

I hereby agree to receive a one pager policy document I hereby confirm having a valid personal accident policy for sum Insured of minimum Rs.15 lakhs.
I hereby confirm that I have mandated Hyundai India Insurance Broking Pvt.Ltd. to place my insurance risk and have read and agreed on the terms and conditions.

Insurance Broker Name: Hyundai India Insurance Broking Pvt. Ltd. Proposer Signature & Date:
Corporate Office: 16th Floor, Building No. 9A, DLF Cybercity, Phase III, Gurugram, Haryana 122001
Broker Code: 822 (Valid UPTO:30/05/2025) MISP NAME: DHOOT SERVICES PRIVATE LIMITED Proposal Form Created by:
CIN: U67200HR2021PTC098982 MISP CODE: HIIB-MHY-0358
GST: 06AAGCH0310P1ZP Designated Person NAME : SHUBHAM DHOOT MISP Authorised Signatory
INSURANCE ACT 1938, SECTION 41- 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 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
Disclaimer: This Proposal is valid for today only. Price may vary subject to Terms & Conditions of Insurance Company at the time of policy issuance.