Trejhara

Mr. GUNIMEDA VAMSEE KRISHNA

PLOT NO 129 3RD FLOOR ROAD NO 7, HIGH
TENSION ROAD PANCHASHEEL
ENCLAVE PET BASHEERABAD QUTUBULAPUR,
MEDCHAL DIST
HYDERABAD
TELANGANA India 500055
9346******

Welcome on board.
Your Reliance Two Wheeler Policy Bundled -
Policy Schedule, with Policy
Number 180122423750044981 is now live to
access your policy anytime, anywhere download
our Reliance Selfi App and enjoy a host of
special features.

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off Western
Express Highway, Goregaon (East), Mumbai – 400 063
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0003V04202425 Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under. License RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
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 Digitally signed by Reliance
General Insurance
Company Limited
Date: 2024.10.08 13:18:20
Trejhara IST

Reliance Two Wheeler Policy Bundled - Policy Schedule

Important
1) The validity of this certificate of Insurance cum policy is subject to realization by the company of the premium cheque paid by the Insured.
2) Except as provided in GR 27 Rule (g) of Erstwhile Indian Motor Tariff (i.e. Sale of Vehicle), No NCB will be allowed when a policy is not renewed within 90 days of
its expiry.

Policy Number : 180122423750044981 Proposal/Covernote No : R08102443654

Insured Name : Mr. GUNIMEDA VAMSEE KRISHNA Period of Insurance :
Section-I Period : From13:18 Hrs on 08-Oct-2024 to Midnight of 07-Oct-2025
Section-II Period : From13:18 Hrs on 08-Oct-2024 to Midnight of 07-Oct-2029
Communication Address & Place of Supply : PLOT NO 129 3RD FLOOR Policy Issuing Branch : SAGAR PLAZA, 4-1-327 TO 337, IV FLOOR, ABIDS
ROAD NO 7, HIGH TENSION ROAD PANCHASHEEL ENCLAVE PET ROAD, , HYDERABAD, TELANGANA, 500001.
BASHEERABAD QUTUBULAPUR, MEDCHAL DIST HYDERABAD,
TELANGANA, India, 500055.
Mobile No : 9346****** Tax Invoice No. & Date : R08102443654 & 2024-10-08 13:18:16.0
Email-ID : R************@GMAIL.COM GSTIN/UIN & Place of Supply: TELANGANA
Insured's Blood Group :

Insured Vehicle Details

Registration No. NEW Mfg. Month & Year SEP-2024
Make / Model & Variant HONDA ACTIVA 125 DRUM ALLOY OBD2 CC / HP / Watt 125
Engine No. / Chassis No. JK13EW7288240 / ME4JK13DJRW088070 Seating Capacity Including Driver 2
Type of Body NA Total Premium ` 7053
RTO Location TELANGANA - Medchal-Malkajgiri IDV ` 82,980.00
Hypothecation/Lease Kotak Mahindra Prime Ltd / SOMAJIGUDA

Insured Declared Value (IDV)

Vehicle IDV ` 82980 Non Electrical Accessories ` 0
Electrical / Electronic Accessories ` 0 Total IDV ` 82980

Premium Summary
Own Damage - Section I Amount (`) Liability - Section II Amount (`)
Basic OD including Add-on where Applicable 1,750.74 Basic Liability (TPPD 1) 3,851.00
Total Basic Own Damage Premium 1,750.74 Total Basic Liability Premium 3,851.00
Add on Cover/s Opted PA Benefits - Section III
Nil Depreciation Compulsory PA cover to Owner Driver 375.00
Helmet Cover(No.of Helmets: 1 & SumInsured: ` 1000) Total PA Premium 375.00
TOTAL LIABILITY PREMIUM 4,226.00
TOTAL PACKAGE PREMIUM (Sec I + II + III) 5,977.00
CGST (9.00%) 538.00
TOTAL OWN DAMAGE PREMIUM 1750.74 SGST (9.00%) 538.00
TOTAL PREMIUM PAYABLE (`) 7,053.00

Subject to I.M.T.Endt.Nos. IMT 15,22,7

GSTIN : 36AABCR6747B1ZH HSN : 997134,
Description of services : Motor vehicle Insurance Service
As per the GS
"As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th September of the next financial year."

PA-Nominee Details Name Age Relation

1 SUNITHA 37 Spouse

The Customer Information Sheet (CIS) for this product is available on our website
https://www.reliancegeneral.co.in/insurance/about-us/downloads.aspx

Add-on for Total Cover : Provides cover for registration charges, road tax and insurance premium (Total Cover Sum Insured - ₹0)

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0003V04202425 Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under. License RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
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Limits of liability : (a) Under Section II (1)(i) of the Policy-Death of or bodily injury to any person so far as it is necessary to meet the
requirements of the Motor Vehicle Act, 1988. (b) Under Section II (1)(ii) of the Policy-Damage to property other than
property belonging to the insured or held in trust or in the custody of control of the insured up to the limits specified-
(TPPD 1 Sum Insured - ₹100000 /- ,TPPD 2 Sum Insured - ₹6,000 /-) (iii) PA cover for owner driver under section III CSI
₹1500000/-
Consolidated Stamp duty Paid vide Letter of Authorisation “NO LOA/ENF-1/CSD/50/2024-25/(Validity Period Dt.01/09/2024 to Dt.01/12/2025)/4240 Date 20-08-2024” at
General Stamp Office, Mumbai. ** Not Applicable for the State of Jammu & Kashmir.

18M90202 / Raam Two Wheelers India Pvt

8886645021
Ltd
Intermediary Code/Name Intermediary Contact No. Intermediary E-mail ID POS UID Aadhaar No. / PAN No.

Limitations as to use : The Policy covers use for any purpose other than: (a) Hire or Reward other than for the purpose of driving tuition, (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/Classes of persons : Any person including insured:
entitled to drive: Provided that a person driving holds a valid driving license at the time of the accident and is not disqualified from holding
or obtaining such a license. Provided that the person holding a valid learner’s license may drive the vehicle when not used
for the transport of goods at the time of the accident and that such a person satisfies the requirements of Rule 3 of the
Central Motor Vehicles Rules, 1989.
Deductible under Section-I : : (i) Compulsory deductible ₹100 /- (ii) Additional compulsory deductible ₹0 /- (iii) Voluntary deductible ₹0 /-

*No Claim Bonus is subject to no claim on the previous policy. Benefits under the policy stands forfeited if claim is/was made in previous policy.
"It is hereby declared and agreed that any damages pre-existing, any losses occurred & any Liability having been incurred, prior to the commencement of cover under
this policy are excluded from the scope of this policy."

% of Discount on Own Damage Premium

Period of Insurance % of NCB on OD Premium
The Preceding Year 20%
Preceding Two Consecutive Years 25%
Preceding Three Consecutive Years 35%
Preceding Four Consecutive Years 45%
Preceding Five Consecutive Years 50%
The policy wording with detailed terms, conditions and exclusions are available on our website www.reliancegeneral.co.in.

Statutory Provisions:
"As per Section 146 of the Motor Vehicle Act, 1988 it is Mandatory to have your vehicle insured against third party risk.
As per Section 196 of the Motor Vehicle Act, 1988 driving an uninsured vehicle is punishable with fine or Rs. 2000 and/or imprisonment up to 3 months for the first
offence and fine of Rs. 4000 and/or imprisonment up to 3 months for the second offence."
I/We hereby certify that the Policy to which the certificate relates as well as this certificate of insurance are issued in accordance with the provision of Chapter X and
Chapter XI of M.V. Act, 1988.

Note :In the event of dishonor of cheque, this policy document automatically stands cancelled from inception irrespective of whether a separate communication is sent
or not.
The policy has been issued based on the information provided by you and the policy is not valid if any of the information provided is incorrect. Subject otherwise to the
terms, conditions and exclusions of the Reliance Miscellaneous and Special Types of Vehicles Package Policy Certificate Cum Policy Schedule. In witness whereof this
Policy has been signed at Mumbai on policy tax invoice date in lieu of Proposal/Covernote No. as mentioned in the policy.

Safeguard your transaction by paying your premium via crossed cheque/DD in favour of Reliance General Insurance Co. Ltd.
Updating Registration Number of vehicles within 15 days of policy inception is MANDATORY as per IRDA. Kindly provide the same to your Agent/Our Call
centre/Policy issuing Branch (Applicable for policies booked without Registration No of vehicles).

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 hold good.
In case of a renewal, the benefits provided under the policy and/or terms and conditions of the policy including premium rate may be subject to change.
As per National Highways Authority of India, kindly ensure to affixed FASTag on your vehicle.
Grievance Clause : For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 02248903009 or may
write an email at rgicl.services@relianceada.com. In case the insured is not satisfied with the response of the office, insured may contact the
Nodal Grievance Officer of the Company at rgicl.grievances@relianceada.com. In the event of unsatisfactory response from the Nodal
Grievance Officer, insured may email to Head Grievance Officer at rgicl.headgrievances@relianceada.com. In the event of unsatisfactory
response from the Head Grievance Officer, he/she may, subject to vested jurisdiction, approach the Insurance Ombudsman for the redressal of
grievance. Details of the offices of the Insurance Ombudsman are available at IRDAI website www.irda.gov.in or on company website
www.reliancegeneral.co.in or on www.gbic.co.in. The insured may also contact the following office of the Insurance Ombudsman within whose
territorial jurisdiction the branch or office of the Company is located.
Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0003V04202425 Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under. License RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
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Office of the Insurance Ombudsman,6-2-46,1st floor,"Moin Court",Lane Opp. Saleem Function Palace,A. C. Guards,Lakdi-Ka-Pool,Hyderabad -
500 004. Tel.: 040 - 65504123 / 23312122 Fax: 040 - 23376599 Email: bimalokpal.hyderabad@cioins.co.in
Note: Kindly acknowledge the receipt of this policy. In case you find any variations against your proposal or any discrepancy in the policy, kindly contact us immediately.
This document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services Tax Rules 2017.

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 subrule
(4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule
Fast Tag ID -

The policy does not cover liability for death, bodily injury or damage as excluded under Section 150 (2) (ii) and (iii): b and C of the Motor Vehicles Act 1988 (Inserted
Vide GSR no 164 (f) dated 25.02.2022 w. e. f 01.4.2022)
In the unfortunate event of a claim, please call quoting your Policy No. 022 48903009(Paid) on and register your claim immediately within 7days from the
date of loss.
In the absence of any communication from you within a period of 15 days of receipt of this letter, we will consider that the issued policy is in order and as per your
proposal.

Special Conditions : NA
Policy has been issued with reference to vehicle inspection report, reference lead no.InspectionID_HIDE & special conditions.The inspection
report remarks can be viewed on company's website by the lead no.

For Reliance General Insurance Co. Ltd.

Authorised Signatory

IRDAN103RP0008V02201819/A0001V01202122 IRDAN103RP0008V01201819/A0060V01201819

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0003V04202425 Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under. License RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
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Proposal Form For Reliance Two Wheeler Policy - Bundled

Is the vehicle made in India? Yes No Type of vehicle: Two Wheeler Three Wheeler Four Wheeler

For Office Use Only

Policy Number 180122423750044981 Date
Savvion Reference No. Inspection Lead No.

Intermediary Details (To be filled in BLOCK LETTERS)

Intermediary Name Raam Two Wheelers India Pvt Ltd Code 18M90202
Branch Name Hyderabad I Code 1801
Sales Manager Name Prashanth Kumar B Code 70316112

Details (To be filled in BLOCK LETTERS)

1. This Proposal is for A new Policy Renewal of Policy Endorsement Others (Please specify)
2a. Proposer's Full Name Mr. Mrs. Ms. GUNIMEDA VAMSEE KRISHNA

2b. Address Address for Communication Address where vehicle is normally kept and Used
PLOT NO 129 3RD FLOOR ROAD NO 7, HIGH
Flat/Building/Door/Block No. TENSION ROAD PANCHASHEEL
Road /Street/Sector ENCLAVE PET BASHEERABAD
QUTUBULAPUR, MEDCHAL DIST
Nearest Landmark
Area
City HYDERABAD
Pin Code 500055
State TELANGANA
Country India
Phone Mobile 9346******
Emergency Contact No. Blood Group
#Email R************@GMAIL.COM Fax
3. Period of Insurance From 08/10/2024 To: Midnight of 07/10/2029
4. Source of Funds Business Profession Salary Agricultural Income Savings Others
5. Period of Insurance : Section-I Period : From13:18 Hrs on 08-Oct-2024 to Midnight of 07-Oct-2025
Section-II Period : From13:18 Hrs on 08-Oct-2024 to Midnight of 07-Oct-2029

6. Monthly Income Upto `20,000 `20,001 to `50,000 `50,001 to `1,00,000 `1,00,001and above
7. UID Aadhaar No. 8. PAN No.
9. Fast Tag ID
10. Do you have a GST Registration Number Yes No
If Yes, please specify
11. Related Party Yes No
#The Policy copy and all related documents shall be sent to the email ID provided above. If you wish to receive Policy copy and related documents in physical form to
the aforesaid communication address, please drop us an email at [RGI email address]

Details of the Vehicle

12. Registration Number NEW 13. Date of Registration 08/10/2024
14. Registering Authority & Location TELANGANA - Medchal-Malkajgiri
15. Year & Month of Manufacture SEP-2024 16. Cubic Capacity 125
17. Engine Number JK13EW7288240
18. Chassis Number ME4JK13DJRW088070
19. Make of Vehicle HONDA
20. Type of Body/Model NA/ACTIVA 21. Seating Capacity including Driver 2

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0003V04202425 Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under. License RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
Page 5 of 9
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Details of the Vehicle Type and Use

22. a. Whether the Vehicle is driven by Non-conventional source of power? Yes No If yes Bi Fuel CNG LPG
Insured declared
Non-electrical Accessories Electrical & Electronics Side Car(Two_wheeler) Value of CNG/ LPG Kit Bi
value (IDV) of Total Value
fited to the Vehicle Accessories fited to the Vehicle Trailer(Pvt.Cars) Fuel
the Vehicle
82980 0 0 0 0 82980

b. Do you have a valid PUC? Yes No

(Note-Warranted that the insured named herein/owner of the vehicle holds a valid Pollution Under Control (PUC) Certificate and/or valid fitness certificate, as applicable, on
the date of commencement of the Policy and undertakes to renew and maintain a valid and effective PUC and/or fitness Certificate, as applicable, during the subsistence of
the Policy. Further, the Company reserves the right to take appropriate action in case of any discrepancy in the PUC or fitness certificate.)

23. Age of Owner Driver _________________ 24. D.O.B. _________________

25. Add On Covers (Subject to availability and eligibility)

a. Assistance Covers No
b. Nil Depreciation Cover Yes
c. NCB Retention Cover (Applicable only for Annual Policy) No
d. Easy Monthly Instalment (EMI) Protection Cover:
If Yes, please choose any one option;
Plan I - 1 EMI, EMI Amount : ₹
Plan II - 2 EMIs, EMI Amount : ₹
Plan III - 3 EMIs, EMI Amount : ₹
e. Total Cover No
f. Daily allowance benefits No
Per Day Allowance: ₹
Coverage Days :
g. Helmet cover: Sum Insured ₹ 1000 Yes
Number of Helmet Covered 1
h. Daily allowance benefits Plus No
Per Day Allowance: ₹
Coverage Days :
i. Voluntary Deductible
Voluntary Deductible amount opted: ₹ ______________________
j. Hospital Cash Cover (Applicable only for Annual Policy) No
Sum Insured: ₹
No of Days:
Convalescence Benefit SI: ₹
k. Emergency Hotel Accommodation No
Benefit Amount: ₹
l. Additional limit of TPPD No
Additional amount opted: ₹
m. Tyre Protector( Applicable only for annual Policy) No
Specifications of Tyres and Tubes:
For Tyre : Width in mm: ______________ Aspect Ratio: ______________
Tyre Serial Number 1 ______________ 2_______________
n. Rim Protector(Applicable only for annual Policy) No
Specification of Rims:
For Rim : Width in mm: ______________ Aspect Ratio: ______________

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0003V04202425 Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under. License RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
Page 6 of 9
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Rim Serial Number 1 ________________ 2 _______________

o. Consumable Expenses No
p. Engine Protector No
q. Return to Invoice (Applicable only for Annual Policy) No
r. Loss of Personal belongings (Applicable only for annual Policy) No
Sum Insured: ₹
s. Any other Details
___________________________________
t. Battery Protection Cover No
u. Electric Motor Protection Cover No
v. EV Charger Cover No
w. Assistance Cover (Two Wheeler Shield) No
x. Assistance Cover - Two Wheeler Shield No
26. Is the vehicle fitted with any Anti-theft device approved by the ARAI ? Yes No
If Yes,please attach certificate of installation in the vehicle,issued by automobile Association of India.
27. Are you a member of Automobile Association of India ? If Yes,please submit membership copy. Yes No
28. Will the Vehicle be used exclusively for
a. Private,social,domestic,pleasure and professional purposed ? Yes No
b. Carriage of goods other than samples or personal luggage? Yes No
29. Whether the Vehicle is used for Driving Tuitions? Yes No
30. Whether use of Vehicle is limited to Own Premises? Yes No
31. Whether the Vehicle is fitted with Fibre Glass Tank? Yes No
32. Whether the Vehicle belongs to the Embassy/Consulate of a Foreign Country? Yes No
If so, is the duty element included in the IDV?
33. Whether the Vehicle is design for use of Blind/Handicapped/Mentally Challenged Person? Yes No
34. Date of purchase of the Vehicle by the Proposer 08-Oct-2024
35. Whether the Vehicle at the time of purchase was New Second Hand

Risk Inclusions
36. Please select the higher deductible if you wish to opt for over and above the compulsory deductible
Two wheeler
37. Liability to third parties : The policy provides Third Party Property Damage(TPPD) of ` 1 lakh (Two wheelers) and ` 7.5 lakhs (Private car)
Do you wish to restrict the above limits to the statutory TPPD Liability limit of ₹ 6000/- only? Yes No
Legal Liability No of Person
Driver:

38. Personal Accident Cover for Owner Driver. Please give details of nomination
Name of the Appointee (if
Name Name of the Nominee Age of Nominee Relationship Address
Nominee is Minor)
SUNITHA 37 Spouse

(Note: 1. Personal Accident cover for owner driver is compulsory for Sum Insured of ₹ 15,00,000/- for Two Wheeler, Private Car, GCV, PCV and Misc-D
2. Compulsory PA cover for owner driver cannot be granted where a vehicle is owned by a company, a partnership firm or a similar body corporate or
where the owner-driver does not hold an effective driving license)

39. Extension of Geographical Area

Whether extension of Geographical Area to the following Countries required ?

1. Bangladesh
2. Bhutan

3. Maldives

4. Nepal

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0003V04202425 Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under. License RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
Page 7 of 9
 Trejhara

5. Pakistan

6. Sri Lanka

Details of Hire Purchase / Hypothecation / Lease

40. Please state if the vehicle is under Hire Purchase Lease Agreement Hypothecation Agreement
If so, give name and address of concerned parties.
41. Full Name M/s Kotak Mahindra Prime Ltd
42. Address SOMAJIGUDA

Details of Previous Insurance

43. Full Name of previous insurer
44. Address -
45. Policy Number Previous Policy Expiry
46. Type of Cover Package Policy Liability only others (to be describe)
47. Claims taken in previous policy Yes No
If yes, No. of Claims Claims Amount `
48. Are you entitled to No Claim Bonus Yes No
If yes, please submit/attached proof thereof
49. No Claim Bonus allowed under previous Policy (%) 0

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
undertake that if this declaration id found incorrect, all benefits under this policy in respect of Section 1 of the policy will stand `forfeited.

Signature of the Proposer _______________________________________________________

Payment Details
Cheque/ DD Cheque/ DD No.
Cheque/ DD Date Cash Credit Card Others

Proposer's Bank Details

50. Name of the Bank Account Holder
51. Bank Account No.: 52. Account: Saving Current
53. Name of the Bank
54. Branch
55. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque
issued by the bank)
56. IFSC Code (11 character code appearing on your cheque leaf)
I understand that any refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank Account .*
* As per IRDAI, its mandetory that all payments made to the insured are only through electronic mode.

AML Guidelines
"I/ We herby confirm that all premiums have been/ will be paid from bonafide sources and no premium have been/ will be paid out of the proceeds of crime related to
any of the offence listed in Prevention of Money Laundering Act 2002. I understand that the company has the right to call for the documents to establish source of funds.
The insurance company has the right to cancel the insurance contract in case I am/ have been found guilty by any competent court of law under any of the statues,
directly/ indirectly governing the prevention of Money Laundering in India.

Nationality Indian Non-Indian, If Non Indian Please specify the country

Type of organization Corporation Goverment Non Goverment Organizations Society Trust
Partenership International Organization Corporatives Section 25 Companies

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0003V04202425 Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under. License RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
Page 8 of 9
 Trejhara

Declaration by Proposer
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 RELIANCE General Insurance Company Limited. 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. I/We hereby declare that the
contents of the form and documents have been fully explained to me/us and that I/We have fully understood the significance of the proposed contract. I/We agree to accept
a policy subject to the condition prescribed by the company. • I have read and understood the brochure, prospectus, sales literature & Policy wordings and confirm to
abide by the same. • I/We declare that the rate of NCB stated above by me/us is correct and that no claim has arisen in the expiring policy (copy of the policy enclosed). •
I/We further undertake that, if this declaration is found to be incorrect, all benefits under the policy in respect of section I of the policy will stand forfeited. • I/We further
understand and agree that RELIANCE General Insurance will seek confirmation of above stated details from my/our previous insurers. Pending receipt of necessary
confirmation, I/We agree that, though coverage under the policy will be available to me/us, RELIANCE General Insurance will be liable to release the payment towards
any claims under section I of the policy only after a confirmation in this regard is received. In the event this declaration is found to be incorrect, any and all coverage
available under section I of the policy from the date of commencement of the policy shall stand automatically forfeited. Further, any survey arranged/allowed by
RELIANCE General Insurance of the motor vehicle, pending confirmation of the declaration from my/our previous insurers, shall be without prejudice to any of the rights
and remedies available to RELIANCE General Insurance as contained herein and under the relevant laws and regulations. • I/We acknowledge and agree that, Pending
receipt of confirmation of the declaration from my/our previous insurers, the "cash-less repair facility" provided by RELIANCE General Insurance shall stand suspended.
• I/We also shall endeavour to procure the renewal notice and pass on the same to RELIANCE General Insurance immediately upon the receipt of such renewal notice.
Mode of Payment: Secure your payment by cheque/DD favouring Reliance General Insurance CO.Ltd. This policy shall be voidable at the option of the Company in the
event of mis-representation, mis-description of nondisclosure of any material particulars by the Proposer. Any person who, knowingly and with intent to defraud the
Insurance Company or other persons, files a proposal fo insurance containing any false information, or conceals for the purpose of misleading, information, 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.• I/We here by state that the above mentioned address shall be taken as address on record for the purpose of GST. • I/We hereby confirm that the contents of the
proposal form and connected documents have been fully explained to me/us and I/We have fully understood the significance of the proposed contract.

This proposal form was completed by

Name ____________________________ Place : ____________________________

Date : 08 Oct 2024 01:18 Date : 08 Oct 2024 01:18

Signature Signature of Proposer & Company Seal

Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment ) Act, 2015
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 rupees.

Supporting Confirmation of Agent/Broker/SM/CSO

I confirm the above signature tobe of the registered owner of the vehicle proposed for insurance

Place
Date
(In case of Direct Business, Name & Signature of CSO /SM to be taken) Signature of IRDAI Agent/ Broker
The policy does not cover liability for death, bodily injury or damage as excluded under Section 150 (2) (ii) and (iii): b and C of the Motor Vehicles Act 1988 (Inserted
Vide GSR no 164 (f) dated 25.02.2022 w. e. f 01.4.2022)

Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off
Western Express Highway, Goregaon (East), Mumbai – 400 063
Corporate Identification No. U66603MH2000PLC128300. UIN: IRDAN103RP0003V04202425 Trade logo displayed above belongs to Anil Dhirubhai Ambani Ventures
Private Limited and used by Reliance General Insurance Company Limited under. License RGI/MCOM/CO/2312/PS/VER. 1.0/310118.
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