Bajaj Allianz General Insurance Company Ltd.

Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune

Transcript of Proposal for Long Term Two Wheeler Package Policy

Dear SRIKANT POTLURI,

We wish to inform you that the contract under policy number 'OG-23-9906-1843-00002271' has been finalized based on the
information and declaration given by you, the transcript whereof is mentioned below. You are requested to reconfirm the same.
In case of any disagreement or objection or any changes with respect to information mentioned below, we request you to
please revert back within a period of 15 days from date of your receipt of this, failing which it will be deemed that you are
satisfied with the correctness of the details mentioned below. Kindly note that as the contents and declarations contained in this
transcript is the basis on which we have issued the policy to you, we advise you to please ensure that you have
provided/disclosed and or not withheld any material facts/information and declarations, as Policy becomes Void ab initio if
material facts are not provided/disclosed and or withheld and in such case no claim, if any, will be considered by us apart from
forfeiture of the premium.
Details provided by you:

A. Proposer details
1. Proposer Name : SRIKANT POTLURI
2. Proposer Address : SECOND FLOOR 1 3 VALLI HOME MODEL DAYRI, CAN ROAD KVR COLONY
INIKEPADU VIJAYWADA ISHANA DIST
, , KRISHNA, ANDHRA PRADESH-521108
3. Proposer Mobile Number : 9492485040
4. Proposer Residential Number : NA
5. Proposer e-mail id : POTLURISRIKANT@GMAIL.COM
6. Proposer Profession : NA

B.Vehicle Details
Registration Month / Year Vehicle Vehicle Vehicle Sub Cubic Capa- Fuel Type Year of Man- Seating Ca-
Number of Regn Make Model Type city/Kilowatt ufacture pacity
AP16DD693 APR/2017 HONDA CB SHINE SP - STD 125 Petrol 2017 2
7

Engine Number Chassis Number Vehicle IDV (in Electrical Non-Electrical CNG/LPG Unit Total IDV (in
Rs.) Accessories Accessories (Extra fitted) Rs.)
IDV (in Rs.) IDV (in Rs.) IDV (in Rs.)
JC73ET0064511 ME4JC731LGT0 41,653.00 0 0 0 41,653.00
38048
 C. Coverage opted

1. Period of Insurance : From 30-APR-2022 00:01(Hrs)

To 29-APR-2025 Midnight
2. Is your vehicle fitted with external LPG/CNG kit : No.
3. Electrical Accessories cover Opted (If Applicable) : No.
4. Non - Electrical Accessories cover Opted (If Applicable): : No.
5. Is Voluntary Excess opted : No.
Amount of voluntary excess opted : Rs.NA.
6. Whether PA cover is opted for owner-driver : Yes.
7. compulsory deductible : Rs.100.00
8. Is any additional compulsory deductible imposed and agreed upon : No.
Amount of additional compulsory deductible imposed : NA.
9. Whether geographical area extension is opted : No.
Details of Countries to which geographical area extension cover is given : NA.
10. Is LL to person for Paid driver/Operation/Maintenance opted : No.
11. Whether PA cover is opted for paid driver other than owner driver : No.
Sum Insured for Paid Driver : Rs.NA.
13. Is TPPD restricted to statutory limit of Rs.6,000? : No.
14. Pre Existing damages in the vehicle : NA.
15. 1 Premium for Liability coverage, quoted and agreed upon is :
16. 1 Premium for OD coverage, quoted and agreed upon is :
17. Do you have valid PUC certificate of the vehicle : NA
18. Do you have valid Fitness certificate of the vehicle : NA
19. Total Premium (excluding Goods and Service Tax (GST)) for Liability and OD coverages, quoted and agreed upon is
:
20. NCB (No Claim Bonus) claimed by you and granted by us based on your declaration of no claim during your previous
previous policy : 0 %.
21. About the last insurance company
(i) Insurance Provider : ICICI Lombard General Insurance Company Limited..
(ii) Previous Policy No : na, Previous Policy Expiry Date :29-APR-22
22. Whether your vehicle is Hypothecated and if so the details of Pledgee whose name is registered by us: No.
Name of Pledgee : NA.
23. Add on Cover(s) optedm3: No.Plan name:NA

24. To support our Go Green initiative, send policy copy link on registered mobile number / email id: YES

I/We hereby give voluntary consent to BAGIC/Company to share my/our personal information and data provided in this
proposal form with its group companies or any other person in connection with the Insurance Policy or otherwise, including for
providing products and services of group companies that may be of interest to me/us, to be used in accordance with their
respective privacy policies and subject to appropriate measures being in place to safeguard my/our personal information : Yes
Please note Cover Note No. / issued to you basing on the above information.
In case of Disagreement or objection or any changes with respect to information and contents mentioned hereinabove, please
contact our toll free number & register your objections/changes/disagreement to the contents 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 with Policy:
I/We hereby unconditionally allow the Company to share all my / our information being collected in this proposal form or
through telephonic / email / web-inputs means or other means, as updated from time to time within group entities.
Toll free Number : 1800-102-5858,1800-209-5858
Email address : Bagichelp@bajajallianz.co.in
Website : www.bajajallianz.com
Contact our policy servicing branch at: Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar,
Pune-411014 PH:1800-209-0144.
INSURANCE ACT, 1938 SECTION 41 - PROHIBITION OF REBATES
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 a policy
accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.
ANY PERSON IN BREACH OF COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE
WITH FINE WHICH MAY EXTEND TO RUPEES TEN LAKH.Bajaj Allianz General Insurance Co Ltd
   

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

Regd. Office & Head Office: GE Plaza, Airport Road, Yerwada,Pune-411006(India)
IRDAI Registration No. 113
Corporate Identity Number: U66010PN2000PLC015329
LONG TERM TWO WHEELER PACKAGE POLICY Certificate of Insurance cum Policy Schedule
UIN : IRDAN113RP0008V01201617
Policy Number: OG-23-9906-1843-00002271 Customer ID: 268776983
Particulars of Vehicle Insured:
Registration Number Place of Registration Engine Number Chassis Number Make & Model
AP16DD6937 AP16-VIJAYWADA JC73ET0064511 ME4JC731LGT03804 HONDA - CB SHINE
8

Sub Type Year of Mfg NCB % CC Seating Capacity

SP - STD 2017 0 125 2

Name of Registration Authority : AP16-VIJAYWADA

Name and Address of Insured : SRIKANT POTLURI
: SECOND FLOOR 1 3 VALLI HOME MODEL
DAYRI, CAN ROAD KVR COLONY INIKEPADU
VIJAYWADA ISHANA DIST, , KRISHNA,
ANDHRA PRADESH-521108
Geographical Area : .00
Business or Profession : NA
Effective date of commencement of Insurance for the purpose of act:
Policy Inception Date: From 00:01 O' Clock on 30-APR-2022
Policy Expiry Date: Midnight on 29-APR-2025
Persons or Class of Persons entitled to drive:
Any person including the insured:
a) 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.
b) 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.
IMT-Endorsements/Add on Package
22,
Limitations as to Use:
The Policy covers use 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
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.
Policy issuing office and correspondence address for communication by holder of Certificate of Insurance for claim,
service request, notice, summons, etc:
Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune-411014 PH:1800-209-0144
Date of issue :29-APR-2022
For & On Behalf of
Bajaj Allianz General Insurance Company Ltd.
Now carry your m-policy on your mobile. Click here to download. https://bagic.page.link/hWC1nr

For help and more information:

Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at
Bagichelp@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 18-Feb-2024 14:00:52 PM- Silent_Printing (Web) (5557)
Authorized Signatory
   

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of
India [IRDA] vide Reg No.113)
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada,Pune-411006(India))
LONG TERM TWO WHEELER PACKAGE POLICY Certificate of Insurance cum Policy Schedule
UIN : IRDAN113RP0008V01201617
Policy issuing office and Correspondence address for communication by policyholder for claim, service request, notice, summons, etc:
Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune-411014 PH:1800-209-0144
INSURED DETAILS POLICY DETAILS
Insured Name SRIKANT POTLURI Policy Number OG-23-9906-1843-00002271
SECOND FLOOR 1 3 VALLI HOME Policy Issued on 29-APR-2022 18:50 PM
MODEL DAYRI, CAN ROAD KVR
Insured COLONY INIKEPADU VIJAYWADA From : 30-APR-2022 00:01 (Hrs)
Address ISHANA DIST , , KRISHNA, ANDHRA
PRADESH-521108 Policy Period To : 29-APR-2025 Midnight
Geographical India Cover Note
Area /
Details
Customer ID
268776983
Previous Policy No na
Bank Reference
No 1 Invoice No 349496154/1

GSTIN / UIN NA Company GST No 27AABCB5730G1ZX

Place of Supply/ 37 - Andhra Pradesh Company PAN AABCB5730G
State Code/Name
Make & Mod-
Registration Number Place of Registration Engine Number Chassis Number SubType
el
ME4JC731LGT03 HONDA - CB
AP16DD6937 AP16-VIJAYWADA JC73ET0064511 SP - STD
8048 SHINE
NCB % CC/KW Seating Capacity Year Of Manufacturing Hypothecation Details
0 125 2 2017
Non electrical Electrical/Elec- Value of CNG/
Vehicle IDV Value For Side Car Total Value
accessories tronic accessories LPG kit
41,653.00 0 0 0 0 41,653.00
Own Damage Premium(Rs.) Liability Premium(Rs.)
Own Damage Premium 1,478.00 Basic Third Party Liability 2,256.00
Special Discount PA Cover for Owner-Driver - SI - Rs.1500000 331.00
Total OD Premium - A 1,478.00 Period: From 30-Apr-2022 To 29-APR-2023
Total Premium (Net Premium) (A+B) 4,065.00 Total Act Premium - B 2,587.00
Integrated GST (18%) 732.00
Final Premium ( Rupees Four Thousand Seven Hun- 4,797.00
dred Ninety Seven Only )

**Note: The above Total OD Premium is inclusive of all applicable Loading /Discounts viz (Automobile association membership, Voluntary Excess,
Anti Theft, Handicap Person, Driver Tuition, Fiber Glass, CNG/LPG Unit, Geographical Extension, Imported Vehicle Etc. wherever Applicable)

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
I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover noti-
fied 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.

Policy Tenure Total SI The schedule of age wise Insured Declared

For help and more information:

Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at Ba-
gichelp@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 18-Feb-2024 14:00:52 PM- Silent_Printing (Web) (5557)
   

Insured Declared Value Year FromTo Value (IDV) as shown in the above table is
1 29-APR-23 41,653.00 applicable for the purpose of Total Loss in-
30-APR-22
cluding Theft/ Constructive Total Loss
2 30-APR-23
29-APR-24 39,460.00 (TL/CTL) claims only on basis of loss date
3 30-APR-24
29-APR-25 37,268.00 falling in the respective year. A vehicle will
be considered to be a CTL, where the ag-
gregate cost of retrieval and / or repair of
the vehicle subject to terms and conditions
of the policy exceed 75% of the IDV.
Limitation as to Use The Policy covers use of the vehicle for any purpose other than : Hire or reward, Carriage of
goods( other than samples or personal luggage),Organised racing,Pace making, Speed testing,
Reliability trials. Any purpose in connection with Motor Trade.
Driver Any person including the insured provided that a person driving holds an effective driving li-
cense 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
when not used for the transport of goods/passengers at the time of the accident and that such a
person satisfies the requirements of Rule 3 of the Central Motor Vehicle Rules, 1989.
Limits of Liability Under section II-I(i) of the policy -> Death of or bodily injury : Such amount is necessary to meet
there requirements of the Motor Vehicles Act,1988. Under section II-I(ii) of the policy -> Dam-
age to Third Party Property : Rs. 1,00,000.00
No Claim Bonus For No Claim Bonus details please refer to the policy wording attached with this schedule. In
case of you have not received policy wording kindly refer our web site.
Existing Damage Details NA
Nominee Details Name :NA - Relationship :NA
Subject to Warranties/ 22,
IMT-Endorsements/
Add on Package
Additional Details Coinsurance Details: - . Transaction Id: -
Premium Details Receipt No. 9906-06405215, Date 29-APR-22 ** If Premium paid through Cheque, the Policy is
void ab-initio in case of dishonour of Cheque.
Excess Details Compulsory Excess: Rs.100.00 Additional Excess: Rs.0 Voluntary Excess: Rs..00
Theft Excess: Rs.0
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.
On specific request and subject to terms and conditions, record of information exchange will be made available.
Warranted that insured named herein or owner of the vehicle insured holds a valid Pollution Under Control (PUC) and / or Fitness Certificate on the date of
commencement of the Policy. If the PUC and/or Fitness Certificate is not found to be valid on the date of commencement of the Policy, the Company reserves
its right to consider the policy void ab initio.
For & On Behalf of
Bajaj Allianz General Insurance Company Ltd.

Stamp
Duty Rs.
0.50

Authorized Signatory
This document is digitally signed, hence counter signature / stamp is not required.
Consolidated Stamp Duty of Rs. 0.50/- paid for insurance policy stamps vide Order No. dated 05-JUL-21 of General Stamp Office, Mumbai, India.

Principal Location : Bajaj Allianz House, Airport Road, Yerwada, Pune - 411006 PH:66026666 | Services Accounting Code : 997134 -
   

Motor vehicle insurance services. No reverse charge is payable on these services.

For help and more information:

Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at Ba-
gichelp@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 18-Feb-2024 14:00:52 PM- Silent_Printing (Web) (5557)
 Bajaj Allianz General Insurance Company Ltd.
Bajaj Finserv Building, 1st Floor, Behind Weikfield IT-Park, Viman Nagar, Pune - 411014 Contact No:
1800-209-0144

RECEIPT

Receipt Number 9906-06405215

Receipt Date 29/04/2022
Business Channel WS

Received with thanks from SRIKANT POTLURI

(Customer ID : 268776983 ) a total sum of Rupees Four Thousand Seven Hundred Ninety Seven Only by,

Instrument Inst./Ref No Instrument Bank Name Branch Name Amount

Type Date
Online Pay- 93076821 29/04/2022 NA NA 4,797
ment

Total Amount Rs. 4,797.00

Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General Insurance Company
Limited. The insurance cover for the risk shall be as per the terms and conditions of the Insurance Policy if and
when issued.
* Cheque/DD/PO receipt is valid subject to realisation of the instrument.

For & on behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory

Regd.Office: Bajaj Allianz House,Airport Road, Yerwada, Pune - 411006

CIN:U66010PN2000PLC015329; E-mail: Bagichelp@bajajallianz.co.in; Website:www.bajajallianz.com