Proposal Preview
IFFCO Tokio General Insurance Company Limited.
Servicing Office : GROUND FLOOR, SCO 19-20, C/O HAFED DISTRICT OFFICE, SECTOR 12 132001
PAN :AAACI7573H GSTIN : 06AAACI7573H1ZG CIN :U74899DL2000PLC107621 IRDAI Reg. No.:106
Proposal No: HIIB17524128 Proposal Date: 21-Aug-2025 (17:27)
Proposer Name MR. PARVEEN KUMAR Vehicle Class PRIVATE
Period of Own Damage : 21-OCT-2025 (00:00) ) To 20-OCT-2026 (1 YEAR)
S/O DAYAL DASS, H NO:-59, WARD NO-9, PANIPAT MC, Period of Liability Cover: NA
Proposer Address:
KALANDER CHOWK, CHADAW MOHLLA,
Period of Compulsory NA To NA
Personal Accident Cover:
Proposer Type PAN GSTIN Name Age (Yr.) Relation
Proposer Details Nominee Details
INDIVIDUAL ******831K NA NA 0 NA
Previous TP Details
TP Insurance Company Name: Universal Sompo General Insurance Company TP Policy No: USGI/WEBAG/1014822/00/000
Limited.
TP Risk Inception Date: 21-Oct-2023 TP Risk Expiry Date: 20-Oct-2026
Vehicle Details
Make Model Variant Cubic Capacity Manufacturing Year Seating capacity
HYUNDAI ALL NEW I20 I20 SPORTZ 1.2 KAPPA MT 1197 2023 5
Registration Date Registration No. RTO Hypothecation/Lease* Engine No. VIN / Chassis No.
17-Nov-2023 HR-06-BE-8296 PANIPAT Yes G4LFPV292247 MALBH512LPM253522
Invoice Value Vehicle IDV Elec. Accessories Non-Elec. Accessories BI Fuel Kit Total IDV
807,600 646,080 0 0 0 646080
Schedule of Premium (Amount in Rs.)
Own Damage Premium (A) Amount(INR) Liability Premium (B) Amount(INR)
Basic Own Damage Premium Basic Third Party Liability Premium 0
Vehicle 10,309 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) 0
Bi-Fuel Kit (IMT-25) 0 Personal Accident (PA) Cover
Sub Total (Basic Premium) 10,309 Compulsory PA Cover for Owner Driver Rs 0 (IMT-15) 0
Geographical Area Extension (IMT-1) 0 PA Cover for 0 Unnamed Passengers Rs 0 Each (IMT-16) 0
IMT 23 Premium 0 PA cover for Paid Driver of Rs 2 Lac (IMT-17) 0
Sub Total 10,309 Sub Total PA Cover 0
Discount/Deductibles Legal Liability
Voluntary Deductible (IMT-22A) ( 0 ) 0 Paid Driver (IMT-28) 0
Anti-Theft Device (IMT-10) 258 Employees (for 0 persons) (IMT-29) 0
AA Membership (IMT-8) 0 Sub Total (Legal Liability) 0
No Claim Bonus(25%) 2,513 Net Liability Premium (B) 0
Handicapped Discount (IMT-12) (50) 0 Total Premium (A+B) 14,425
Sub Total (Discounts/Deductibles) 2,771 CGST(9%) 1,299
Add-on Coverage (CM, EP, KP, RTI, TYR, ZD) 6,887 SGST(9%) 1299
Net Own Damage Premium (A) 14,425 Gross Premium Paid 17,023
Add-on Cover Opted in the Policy: Consumables, Engine Protect, Key Protect, Return to Invoice, Tyre & Rim Protect, Zero Depreciation
SAC: , Description of Service: Motor Vehicle Insurance Services, Place of Supply: HARYANA (State Code: 06)
*Hypothecation Details: AXIS BANK LTD - PANIPAT - PANIPAT Payment Mode: ONLINE
Break in Insurance Declaration ³I/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 IFFCO Tokio General
Insurance Company Limited. 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 ³I 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.iffcotokio.co.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. ³I/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:30/05/2028) MISP NAME-SAWAN K MOTORS PRIVATE LIMITED Proposal Form Created by:
CIN No.: U67200HR2021PTC098982 MISP CODE-HIIB-MHY-0276
GST: 06AAGCH0310P1ZP DP NAME- MISP Authorised Signatory
SECTION 41 INSURANCE LAWS(AMENDMENT) ACT, 2015-PROHIBITON 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.
