EMPLOYEES' COMPENSATION INSURANCE

[UIN:IRDAN123RP0032V02200203]

CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LTD.

ADDRESS: BANGALORE BRANCH GST Invoice No.: 2712579150409
NIT # 04, 9TH FLOOR (LEVEL - 06), "GOLDEN HEIGHTS" DATE: 03/05/2025
COMPLEX, 59TH 'C' CROSS, PAN: AABCC6633K
INDUSTRIAL SUBURB, RAJAJINAGAR 4TH 'M' BLOCK, SAC Code: 997139
BANGALORE - 560010 SAC Description: Other non-life insurance services (excluding reinsurance services)
RAJAJINAGAR H.O
CITY: BANGALORE STATE: KARNATAKA

GSTIN: 29AABCC6633K5ZB

Policy Issuing Office: Bangalore Branch

Customer
Policy No: 2712/00153695/000/00 Code:
102119804882

1 Name of Insured PRATIK ART INTERIORS PRIVATE LIMITED

Name of Additional
1.a
Insured
2 Business/ Profession Civil & Interior Works
3 Nature of the work Civil & Interior Works

4 Address of Insured PENTAGON 304 11,MOSQUE RD FRASER,TOWN FRASER TOWN S.O BANGALORE KARNATAKA PIN - 560005
GST No.: 29AABCP9335K1ZX

7 Premium Receipt 1092753475 Date: 02/05/2025

8 Period of Insurance From 02/05/2025 00:00 Hours to Midnight on 07/07/2025
10 Total Sum Insured (Rs.) 51,25,500.00

11 Scope of Cover Table A

Employee compensation Act 2010(as amended from workmen's compensation Act 1923), Fatal Accidents Act, 1855 and
Common Law
Coverage Details/ Law Workmen's Compensation Act, 1923 and subsequent amendments of the said Act prior to the date of the issue of the
11.a
Applicable Policy provided that the Insurance granted hereunder is not extended to included:
i) any interest and or penalty imposed on the Insured on account of his/their failure to comply with the
requirements laid down under the W.C. Act, 1923.
12 Extensions
13 Specific Conditions/ Notwithstanding any provision to the contrary, this policy/insurance excludes any loss, damage, liability, expense, fines,
Warranties penalties or any other amount directly or indirectly caused by, in connection with, or in any way involving or arising out of
any of the following including any fear or threat thereof, any action taken or failure to take action in controlling, preventing,
suppressing or in any way responding to such whether actual/ alleged/ threat or perceived of: a ) Any infectious disease,
virus, bacterium or other microorganism (whether asymptomatic or not); or b ) Coronavirus (COVID-19) including any
mutation or variation thereof; or c ) Pandemic or epidemic, as declared as such by the World Health Organization or any
governmental authority. If the insurer alleges that, by reason of this exclusion, any amount is not covered by this
policy/insurance, the burden of proving the contrary shall rest on the insured
2. Warranted Fire fighting and other safety arrangements as per The Building and Ot
her Construction Workers Act 1996 & Central Rules 1998 Civil work as per IS7969
-1975 and further amendments (Indian Standard -Safety Code for handling and Stor
age of Building Material
3. Work involved in live Transmission & Distribution lines are absolutely excluded
from scope of cover
14 Specific Exclusions

15 Premium(Rs)
15,373.00

16 CGST (9%) 1,383.50

17 SGST (9%) 1,383.50

18 IGST (0%) 0.00

19 Amount Payable(Rs.) 18,140.00

20 Co-Insurance Details

Name/ Estimated Estimated Total Contractor Sub-

Occupation of
16 Number of Salaries Wages and Contractor Name(if Place or Places of Employment
Employees
Employees Other Money Earnings Applicable)
No.35/2,35/3a.37/1,39/1,39/2b,40/3,40/6,5th & 6th Floors, M3, Parcel
1 1 Engineers 100,500.00 Yes 2,Acacia, Epdpl , Rachenahalli Village,Early Ventions,
Krishnarajapur,Bangalore-560 045
No.35/2,35/3a.37/1,39/1,39/2b,40/3,40/6,5th & 6th Floors, M3, Parcel
2 100 Workers 5,025,000.00 Yes 2,Acacia, Epdpl , Rachenahalli Village,Early Ventions,
Krishnarajapur,Bangalore-560 045

1. Employee compensation Act 2010 (as amended from Workmen's compensation Act 1923) and subsequent amendments of the said Act prior to the date of the issue of the
policy provided that the insurance granted hereunder is not extended to include:
any interest and/or penalty imposed on the insured on account of his/their failure to comply with the requirements laid down under the Employee compensation Act 2010 (as
amended from Workmen's compensation Act 1923).

2. The Fatal Accidents Act, 1855 and subsequent amendments of the said Act prior to the date of the issue of the Policy provided that the Insurance granted hereunder is not
extended to include:any interest and/or penalty imposed on the Insured on account of his/their failure to comply with the requirements laid down under The Fatal Accidents Act,
1855.

3. Common Law.

Warranted that in case of a claim, if the declared wages is found to be less than the actual wages then three times the difference of the premium charged and the actual
premium payable shall be charged prior to settlement of the claim.
1. The coverage is for all or none basis. The number of employees / workers on the roll (including Contractor and Sub Contractor wherever
applicable) at no point of time should be more than the number of employees / workers insured at that point of time. Else admission of liability
under the policy will be prejudiced
2. The coverage does not extend to any medical expenses reimbursement
3. The liability of the company shall not exceed the amount arrived at as per provisions of W C Act considering the actual wages declared by
the insured under policy and which is the basis for premium computation. If the actual compensation awarded by the authority as per W C Act
exceeds the liability of the insurer as above, the difference shall have to be borne by the insured. This is not applicable for Common law
awards.
4. All contractors & sub contractors employees are not covered provided they are declared in the proposal form or endorsed from time to time
5. Premium computation is based on the average monthly income declared by the insured and its subject to adjustment depending on actual
disbursement of actual wages / salaries.
6. Occupational Diseases not covered
7. Workmens Compensation Amendment Act 1923 renamed as The Employees Compensation (Amendment) act, 2009 wherever Workman or
workmen is mentioned in the entire Act, the same need to be read as Employee
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 and also
as per Notification No. 13/2020-CT dated 21-03-2020. This policy schedule shall be in lieu of Tax Invoice and hence no separate GST invoice
required In compliance with Rule 54(2) of CGST Rules, 2017.

Consolidated Stamp Duty Paid Vide G.O. Rt No. 166 ,Commercial Taxes and Registration (j1) Department, Tamil Nadu dated 25/04/2025 .

Intermediary Name: SEEMA SANGHVI

Code: 202108456829 Contact No: 9880901619
POSP Aadhaar No.:
Note: The Certificate of Insurance / Policy Schedule is an important document issued based on your declaration. We request you to verify
the details and ensure that everything is in order. In case of any discrepancies, please contact us within 15 days from the date of issuance of
policy.

Place : CHENNAI For Cholamandalam MS General Insurance Company Ltd.

@CholaSign1

Date : 03/05/2025
CholaEsign
Authorised Signatory

Regd.&Head Office:Dare House, 2nd Floor, No.2, N.S.C Bose Road, Chennai-600 001, India
CIN: U66030TN2001PLC047977 | IRDAI Reg. No. 123

Whether tax is payable under reverse charge basis - No..

For Policy Wordings please refer our website www.cholainsurance.com
 Policy wording
Employees' Compensation Insurance

WHEREAS the Insured carrying on the Business described the Schedule and no other for the purpose of this insurance by a proposal and declaration
which shall be the basis of this contract and is deemed to be incorporated herein has applied to the Company for the insurance hereinafter contained and has
paid or agreed to pay the Premium as consideration for such insurance.
NOW THIS POLICY WITNESSETH that if at any time during the period of Insurance any employee in the Insured’s immediate service shall sustain personal injury by
accident or disease arising out of and in the course of his employment by the Insured in the Business and if the Insured shall be liable to pay compensation for such injury either
under :

the Law(s) set out in the Schedule

or at
Common Law

then subject to the terms exceptions and conditions contained herein or endorsed hereon the Company will indemnify the Insured against all sums for which the Insured shall be
so liable and will in addition be responsible for all costs and expenses incurred with its consent in defending any claim for such compensation.

PROVIDED ALWAYS that in the event of any change in the Law(s) or the substitution of other legislation therefor this Policy shall remain in force but the liability of the company
shall be limited to such sum as the Company would have been liable to pay if the Law(s) had remained unaltered.

EXCEPTION
The Company shall not be liable under the Policy in respect of :

a) any injury by accident or disease directly attributable to war invasion act of foreign enemy hostilities (whether war be declared or not) civil war mutiny insurrection rebellion
revolution or military or usurped power
b) the Insured’s liability to employees of contractors to the Insured.
c) any liability of the insured which attaches to virtue to an agreement but which would not have attached in the absence of such agreement
d) any sum which the Insured would have been entitled to recover from any party but for an agreement between the Insured and such party.

CONDITIONS

1. This Policy and the Schedule shall be read together as one contract and any word or expression to which a specific meaning has been attached in any part
of this Policy or of the Schedule shall bear such specific meaning wherever it may appear.

2. Every notice or communication to be given or made under this Policy shall be delivered in writing to the Company.

3. The Insured shall take reasonable precautions to prevent accidents and disease and shall comply with all statutory obligations.

4. In the event of any occurrence which may give rise to a claim under this Policy the Insured shall as soon as possible give notice thereof to the Company with
full particulars. Every letter claim writ summons and process shall be notified or forwarded to the Company immediately on receipt. Notice shall also be given
to the company immediately the Insured shall have knowledge of any impending prosecution inquest or fatal enquiry in connection with any such occurrence
as aforesaid.

5. No admission offer promise or payment shall be made by or on behalf of the Insured without the consent of the Company which shall be entitled if it so
desires to take over and conduct in his name the defense or settlement of any claim or to prosecute in his name for its own benefit any claim for indemnity or
damages or otherwise and shall have full discretion in the conduct of any proceedings and in the settlement of any claim and the Insured shall give all such
information and assistance as the Company may require.

6. The first premium and all renewal premiums that may be accepted are to be regulated by the amount of wages and salaries and other earnings paid by the
Insured to employees during each Period of Insurance. The name of every employee together with the amount of wages salary and other earnings shall be
properly recorded and the Insured shall at all times allow the Company to inspect such records and shall supply the Company with a correct account of all
such wages salaries and other earnings paid during any period of Insurance with one month from expiry date of such Period of Insurance. If the amount so
paid shall differ from the amount on which premium has been paid the difference in premium shall be met by a further proportionate payment to the Company
or by a refund by the Company as the case may be.

7. The Company may cancel this Policy by sending seven days notice by registered letter to the Insured at his last known address and in such event the
premium shall be adjusted in accordance with Condition 6.

8. The due observance and fulfillment of the terms, conditions and endorsements of this Policy so far as they relate to anything to be done or not to be done by
the Insured and the truth of the statements and answers in the Proposal shall be conditions precedent to any liability of the Company to make any payment
under this Policy.

1. Mechanism for Grievance Redressal:

As an esteemed customer of our Company, You can contact us to register complaint/ grievance, if any, including servicing of Policy,
claims etc. with regard to the insurance Policy issued to You. The contact details of our office are given below for Your reference.
If any Grievances / issues on claims pertaining to Senior Citizens, Insured can register the complaint / grievance which shall be
processed on Fast Track Basis by dedicated personnel.

9.1 Contact Information

SMS: "CHOLA" TO 56677 *(Premium SMS charges apply)
Email– customercare@cholams.murugappa.com
Web site: www.cholainsurance.com

9.2 For Complaints

If You have not received any reply from us within 3 days from the date of the lodgement of complaint or if You are not satisfied
with the reply of the Company, you can contact the IRDA Grievance Call Centre at the toll free no. 155255 or email at
complaints@irda.gov.in for registering the grievance or the nearest Insurance Ombudsman, whose addresses are mentioned below:

Nearest Insurance Ombudsman Offices

Sl. Office of the

Name of the Ombudsman and Contact Details JURISDICTION
No. Ombudsman
1 AHMEDABAD Office of the Insurance Ombudsman, 2nd floor, State of Gujarat and Union Territories
Ambica House, Near C.U. Shah College, 5, Navyug of Dadra & Nagar Haveli and Daman
 Colony, Ashram Road, Ahmedabad – 380 014 and Diu.

Tel.:– 079–27546150/139, Fax:– 079–27546142

Email:– bimalokpal.ahmedabad@gbic.co.in
Office of the Insurance Ombudsman, Jeevan
Soudha Building, PID No.57–27–N–19, Ground
Floor, 19/19, 24th Main Road, JP Nagar, 1st Phase,
2 BENGALURU Karnataka.
Bengaluru–560 078.
Tel.:– 080–26652048 / 26652049 Email:–
bimalokpal.bengaluru@gbic.co.in
Office of the Insurance Ombudsman, Janak Vihar
Complex, 2nd Floor, 6, Malviya Nagar, Opp.Airtel
Office, Near New Market, Bhopal – 462 033.
States of Madhya Pradesh and
3 BHOPAL Tel.:– 0755–2769200/201/202, Fax:– 0755–
Chattisgarh.
2769203

Email:– bimalokpalbhopal@gbic.co.in
Office of the Insurance Ombudsman, 62, Forest
park, Bhubneshwar – 751 009.Tel.:– 0674–2596461
4 BHUBANESHWAR State of Orissa.
/ 2596455, Fax:– 0674–2596429 –Email:–
bimalokpal.bhubaneswar@gbic.co.in
Office of the Insurance Ombudsman, S.C.O. No.
101, 102 & 103, 2nd Floor, Batra Building, Sector 17 States of Punjab, Haryana, Himachal
5 CHANDIGARH – D, Chandigarh – 160 017.Tel.:– 0172– Pradesh, Jammu & Kashmir and Union
2706196/5861 / 2706468, Fax:– 0172–2708274, territory of Chandigarh.
Email:– bimalokpal.chandigarh@gbic.co.in
Office of the Insurance Ombudsman, Fatima Akhtar
Court, 4th Floor, 453 (old 312), Anna Salai, State of Tamil Nadu and Union
Teynampet, CHENNAI – 600 018. Territories – Pondicherry Town and
6 CHENNAI
Karaikal (which are part of Union
Tel.:– 044-24333668 / 24335284, Fax:– 044– Territory of Pondicherry).
24333664, Email:– bimalokpal.chennai@gbic.co.in
Office of the Insurance Ombudsman, 2/2 A,
Universal Insurance Building, Asaf Ali Road, New
7 DELHI Delhi – 110 002.Tel.:– 011–23239611/7539/7532, State of Delhi
Fax:– 011-23230858, Email:–
bimalokpal.delhi@gbic.co.in
Office of the Insurance Ombudsman, 2nd floor,
Pulinat Building, Opp. Cochin Shipyard, M.G. Road,
Ernakulum – 682 015.Tel.:– 0484– Kerala, Lakshadweep, Mahe–a part of
8 ERNAKULAM
2358759/2359338, Fax:– 0484–2359336, Pondicherry

Email:– bimalokpal.ernakulum@gbic.co.in
Office of the Insurance Ombudsman, 'Jeevan
Nivesh’, 5th Floor, Nr. Panbazar over bridge,
S.S. Road, Guwahati – 781001(ASSAM).
States of Assam, Meghalaya, Manipur,
9 GUWAHATI Mizoram, Arunachal Pradesh,
Tel.:– 0361– 2132204 / 2132205, Fax:– 0361–
Nagaland and Tripura.
2732937,

Email:– bimalokpal.guwahati@gbic.co.in
Office of the Insurance Ombudsman, 6–2–46, 1st
floor, "Moin Court", Lane Opp. Saleem Function
Palace, A. C. Guards, Lakdi–Ka–Pool, Hyderabad –
States of Andhra Pradesh, Telangana
500 004.
10 HYDERABAD and Union Territory of Yanam - a part
Tel.:– 040–65504123/23312122, Fax:– 040–
of the Union Territory of Pondicherry.
23376599,

Email:– bimalokpal.hyderabad@gbic.co.in
Office of the Insurance Ombudsman, Jeevan Nidhi–
II Bldg., Ground Floor, Bhawani Singh Marg, Jaipur
11 JAIPUR – 302005. State of Rajasthan.
Tel.:– 0141–2740363, Email:–
bimalokpal.jaipur@gbic.co.in
Office of the Insurance Ombudsman,Hindustan
Building Annexe, 4th floor, 4, CR Avenue, Kolkata –
700 072. States of West Bengal, Bihar, Sikkim
12 KOLKATA Tel.:– 033–22124339 / 22124340, Fax:– 033– and Union Territories of Andaman and
22124341, Nicobar Islands.

Email:– bimalokpal.kolkata@gbic.co.in
 Office of the Insurance Ombudsman, 6th Floor, District of Uttar Pradesh: Lalitpur,
Jeevan Bhawan, Phase–II, Nawal Kishore Road, Jhansi, Mahoba, Hamirpur, Banda,
Hazratganj, Lucknow–226 001. Chitrakoot, Allahabad, Mirzapur,
Tel.:– 0522–2231330 / 2231331, Fax:– 0522– Sonbhabdra, Fatehpur, Pratapgarh,
2231310. Jaunpur, Varansi, Gazipur, Jalaun,
Kanpur, Lucknow, Unnao, Sitapur,
Email:– bimalokpal.lucknow@gbic.co.in Lakhimpur, Bahraich, Barabanki,
13 LUCKNOW
Raebareli, Sravasti, Gonda, Faizabad,
Amethi, Kaushambi, Balrampur, Basti,
Ambedkarnagar, Sulanpur,
Maharajganj, Santkabirnagar,
Azamgarh, Kaushinagar, Gorkhpur,
Deoria, Mau, Chandauli, Ballia,
Sidharathnagar.
Office of the Insurance Ombudsman, 3rd Floor,
Jeevan Seva Annexe, S. V. Road, Santacruz (W),
Mumbai – 400 054. States of Goa, Mumbai Metropolitan
14 MUMBAI Tel.:– 022–26106928/360/889, Fax:– 022– Region excluding Navi Mumbai &
26106052, Thane.

Email:– bimalokpal.mumbai@gbic.co.in
Office of the Insurance Ombudsman, Bhagwan States of Uttaranchal and the following
Sahai Palace, 4th Floor, Main Road, Naya Bans, Districts of Uttar Pradesh:. Agra,
Sector–15, Gautam Budh Nagar, Noida Aligarh, Bagpat, Bareilly, Bijnor,
Budaun, Bulandshehar, Etah, Kanooj,
Email:– bimalokpal.noida@gbic.co.in Mainpuri, Mathura, Meerut,
Moradabad, Muzaffarnagar, Oraiyya,
15 NOIDA
Pilibhit, Etawah, Farrukhabad,
Firozabad, Gautam Budh Nagar,
Ghaziabad, Hardoi, Shahjahanpur,
Hapur, Shamli, Rampur, Kashganj,
Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.
Office of the Insurance Ombudsman, 1st Floor,
Kalpana Arcade Building, Bazar Samiti Road,
16 PATNA States of Bihar and Jharkhand.
Bahadurpur, Patna – 800 006.
Email:– bimalokpal.patna@gbic.co.in
Office of the Insurance Ombudsman, Jeevan
Darshan Building, 3rd Floor, CTS Nos. 195 to 198, States of Maharashtra, Area of Navi
17 PUNE NC Kelkar Road, Narayan Peth, Pune – 411 030 Mumbai and Thane excluding Mumbai
Tel: 020 –32341320, Email:– Metropolitan Region. Bottom of Form
bimalokpal.pune@gbic.co.in

Cholamandalam MS General Insurance company Limited

HO: Dare House 2nd Floor, No. 2 NSC Bose Road, Chennai – 600 001.

Toll Free : 1800 200 5544