Ref No.: GEN/WEL/SG/0008.

3/5851333200

Date: 22/05/2025

To,
Mr. Sarvesh Tiwari
PRATAPGARH
Pratapgarh - 230129
District: PRATAPGARH
UTTAR PRADESH, India
Contact Details 94XXXXXX54

Policy number: 5851333200

CKYC ID:

Subject: Risk assumption for Liability only (Private Car)

Dear Mr. Sarvesh Tiwari,

We welcome you to Zurich Kotak General Insurance Company (India) Limited and thank you for choosing us as your preferred service
provider.

This is with reference to your above mentioned Policy issued under Liability only (Private Car).

Enclosed please find the Policy Schedule outlining the details of your policy. Kindly note that the proposal is underwritten and policy is
issued based on the information submitted to us by you, as well as acceptance of the terms and conditions. Policy schedule must be read
in conjunction with the product brochure and policy wordings. Please visit https://www.zurichkotak.com/customer-
support/downloads or scan above QR code for detailed policy wording.

We request you to carefully go through the same once again and in case of any disagreement, discrepancy or clarifications, please call us
on our toll free number 1800 266 4545 or write to us at care@zurichkotak.com within 15 days from the date of this letter. Alternatively, you
can also write to us at 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), ,Mumbai
– 400063. , Maharashtra, India.

Please note that the information provided by you will be verified at the time of claim and the captioned Policy shall be treated as void in
case of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure in any form whatsoever made by you or by
your agent, on your behalf, at any stage.

In case where premium is not received by us due to cheque dishonour or any other reason, the insurance cover shall be void ab-initio.

As a valued customer, we would like to provide regular updates on your policy through email and SMS. We therefore request you to keep
us updated of any change in your contact details.

Assuring you of our best services at all times.

Thanking you,

Yours sincerely,

For Zurich Kotak General Insurance Company (India) Limited

Authorised Signatory

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:care@zurichkotak.com Website: www.zurichkotak.com
 Liability Only (Private Car) UIN :IRDAN152RP0001V02201516

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:care@zurichkotak.com Website: www.zurichkotak.com
 Liability only (Private Car)
Certificate cum Policy Schedule
Policy / Certificate No: 5851333200
For any assistance please call 1800 266 4545 or visit www.zurichkotak.com

INSURED DETAILS POLICY DETAILS

Name: Mr. Sarvesh Tiwari Policy Issuing Office: 201-204, 301 Chintamani Classique Vishweshwar
Nagar, Off Aarey Road Mumbai Maharashtra 400063.
Address: PRATAPGARH Pratapgarh - 230129 District:
PRATAPGARH UTTAR PRADESH(09), India Period of Insurance:
Phone: 94XXXXXX54 From: 26/05/2025 00:00 to: 25/05/2026Midnight
Mobile: 94XXXXXX54 Type Of Vehicle: Private Car
Email: VXXXXXXX3@GMAIL.COM Policy issued on: 22/05/2025
Cover Note No: NA
GSTIN:
Hypothecated to: NA

INTERMEDIARY DETAILS

POLICYBAZAAR INSURANCE BROKERS

Intermediary Code 3 5 7 3 8 9 0 0 0 0 Intermediary Name
PRIVATE LIMITED

Intermediary's Mobile Intermediary's Landline

No. No.

Liability Only (Private Car) UIN :IRDAN152RP0001V02201516

VEHICLE DETAILS

Registration Manufacturer Model Variant Year of RTO Location Engine Vehicle Chassis/ Cubic Fuel Seating
Number Manufacture Number Trailer Chassis Capacity/KW Type Capacity
No.

UP 72 AA MARUTI WAGON R LXI BS III 2013 PRATAPGARH K10BN7 MA3EWDE1 1061 PETROL 5
3609 242411 SOO551642

PREMIUM COMPUTATION TABLE (IN ₹)

Section I Section II
Own Damage Liability
Basic TP Including TPPD Premium 3,416.00
Total Liability Premium (B) 3,416.00

Section III
Personal Accident
Total Own Damage Premium (A) 0.00 Total Personal Accident Premium (C) 0.00
Taxable value of Services (A+B+C) 3,416.00
IGST @ 18% 614.88
Total Premium (in ₹ ) 4,031.00

Compulsory Deductibles
Geographical Area INDIA Additional Excess ₹ 0 0
₹

Voluntary Deductible ₹ 0 Voluntary Deductible for Depreciation Cover ₹ 0 Total Deductible ₹ 0

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:care@zurichkotak.com Website: www.zurichkotak.com
CUSTOMER DECLARATION FOR CNG/ LPG KIT

I/ We agree and undertake to immediately inform the Company in case of change on account of addition of CNG/LPG kit and obtain necessary endorsement in
the Policy.

DISCLAIMER

For complete details on terms and conditions governing the coverage and NCB please read the Policy Wordings. This document is to be read with the Policy
Wordings(which are also available on the Company website i.e. www.zurichkotak.com). Please refer to the claim form for necessary documents to be submitted
for processing the claim.

PUC DECLARATION

This policy has been issued subject to valid Pollution Under Control (PUC) Certificate/Fitness Certificate disclosed to our representative / declared by You prior to
commencement of risk under this policy and further undertaking to renew and maintain a valid PUC throughout the duration of the Policy.

LIMITS OF LIABILITY

Under Section II - 1(i) of the policy -> Death of or bodily injury: Such amounts is necessary to meet their requirements of Motor Vehicles Act, 1988.
Under Section II - 1(ii) of the policy -> Damage to Third Party Property ₹ 7,50,000; PA Cover under Section III: for Owner Driver CSI ₹ 0

LIMITATIONS AS TO USE

Limitation as to use (Package Policy): The policy covers use of the vehicle 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 trails (g)Use in connection with Motor Trade. Note: In case of vehicles
used for Driving Tuition the words “other than for the purpose of driving tuition” to be read after the words „hire or reward.

DRIVER'S CLAUSES

Any person including the insured: Provided that a person driving hold an effective Driving License at the time of accident and is not disqualified from holding or
obtaining such a license. Provided also that the person holding an effective Learners’ License may also drive the Vehicle and that such a person satisfies the
requirements of Rule 3 of the Central Motor vehicles Rules 1989.

Liability Only (Private Car) UIN :IRDAN152RP0001V02201516

SPECIAL CONDITIONS
1. The Owner Driver does not require Compulsory Personal Accident Cover as Owner Driver has a separate existing Personal Accident Cover against Death and
Permanent Disability (Total and Partial) for sum Insured of atleast 15 lacs/ The Vehicle to be insured is not owned by an individual/ The Owner driver does not have
an effective driving license.

2. Previous policy document is required at the time of claim verification.

3. All type of pre – existing damages or cost of repair of such damage will be excluded at the time of claim settlement.

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 Policy 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.
Subject to I.M.T. Endt.Nos. & Memorandum Printed/herein/attached hereto Under Hire Purchase Agreement with NA

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:care@zurichkotak.com Website: www.zurichkotak.com
TAX DETAILS

Service Tax/GST Registration No. 2 7 A A F C K 7 0 1 6 C 1 Z T Category : General Insurance Services

SAC Code 997134 Description Motor Vehicle Insurance Services

Invoice Number 5851333200

DECLARATION

I/We hereby certify that the policy to which the certificate relates as well as the certificate of insurance are issued in accordance with the provision of chapter X, XI
of M.V.Act 1988.

In Witness whereof this Policy has been signed for and behalf of 201-204, 301 Chintamani Classique Vishweshwar Nagar, Off Aarey Road Mumbai Maharashtra
400063. at Mumbai this 22 day of May of 2025

Stamp Duty of 0.50 is paid as provided under Article 47(B) of Indian Stamp Act, 1899 and included in Consolidated Stamp Duty Paid to the Government of
Maharashtra Treasury vide Order of Addl. Controller Of Stamps, Mumbai at General Stamp Office, Fort, Mumbai - 400001., vide this Order No. (LOA/ENF-
2/CSD/14/2025/Validity Period Dt. 31/01/2025 To Dt. 31/12/2026 (O/w.No. 488)/Date: 29/01/2025).

For Zurich Kotak General Insurance Company (India) Limited

Authorised Signatory

This document is digitally signed, hence counter signature / stamp is not required.

Liability Only (Private Car) UIN :IRDAN152RP0001V02201516

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:care@zurichkotak.com Website: www.zurichkotak.com
 CUSTOMER INFORMATION SHEET

This document provides only key information about your policy. Please refer to the policy
document for detailed terms and conditions.

Description Policy Clause

S. NO Title
(Please refer to applicable Policy Clause Number in next column) Number

1 Product Name Liability only (Private Car)

2 Unique IRDAN152RP0001V02201516
Identification Number
(UIN)
allotted by
IRDAI

3 Structure • State basis of Sum/Limit Insured

• Indemnity
• Fixed Benefit

4 Interests Insured Liability only (Private Car) is designed to provide Third Party insurance coverage and PA Cover to Owner/
Driver (if opted) to Private Car Vehicles

5 Sum Insured / Motor

Section Coverage Sum Insured
Insured Declared
Value Scope Section I Liability to Third Parties As per Provisions of Motor Vehicles Act

Section II Personal Accident Cover for Owner-Driver INR 15,00,000/-

Liability Only (Private Car) UIN :IRDAN152RP0001V02201516

6 Policy Coverage The coverages available under this policy are listed in below and will be applicable as mentioned in the Policy Wordings-
Policy Schedule. Section I, Section II

Section I: Liability to Third Parties

Covers legal liability for third party property damage and third-party bodily injury (including death) due to an
accident.

Section II: Personal Accident Cover for Owner-Driver

Personal Accident cover is available under this policy if opted by insured. However, the cover is applicable
only for registered owner who is holding valid and effective Driving License. Further, this cover is
applicable, while the owner cum driver is travelling in the insured vehicle as driver, co-driver, while
mounting and dismounting. This cover is not available where the vehicle is owned by company,
partnership firm or any other body corporate. If the owner has taken personal accident cover under any
other policy, this cover is optional. Please refer to the policy wordings for detailed terms and conditions.

7 Add-on Cover Not Applicable

8 Loss Participation Not Applicable

9 Exclusions GENERAL EXCEPTIONS Policy Wordings -

1. The Company shall not be liable in respect of any claim arising whilst the vehicle insured herein General Exclusions
a. being used otherwise than in accordance with the "Limitations as to Use" or
b. being driven by or is for the purpose of being driven by him/her in the charge of any person other than
a Driver as stated in the Driver's Clause.
2. The Company shall not be liable in respect of any claim arising out of any contractual liability;
3. Except so far as is necessary to meet the requirements of the Motor Vehicles Act, the company shall
not be liable in respect of death arising out of and in the course of employment of a person in the
employment of the insured or in the employment of any person who is indemnified under this policy
or bodily injury sustained by such person arising out of and in the course of such employment.
4. Except so far as is necessary to meet the requirements of the Motor Vehicles Act, the Company shall
not be liable in respect of death or bodily injury to any person (other than a passenger carried by
reason of or in pursuance of a contract of employment) being carried in or upon or entering or
mounting or alighting from the Motor Vehicle at the time of the occurrence of the event out of which
any claim arises.
5. The Company shall not be liable in respect of any liability directly or indirectly or proximately or
remotely occasioned by contributed by or traceable to or arising out of or in connection with war,
invasion, the act of foreign enemies, hostilities or warlike operations (whether before or after
declaration of war) civil war, mutiny rebellion, military or usurped power or by any direct or indirect
consequences of any of the said occurrences and in the event of any claim hereunder the insured
shall prove that the accidental, loss, damage and/or liability, arose independently of and was in no
way connected with or occasioned by or contributed to by or traceable to any of the said occurrences
or any consequences thereof and in default of such proof, the Company shall not be liable to make
any payment in respect of such a claim.
6. The Company shall not be liable in respect of any liability directly or indirectly caused by or

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:care@zurichkotak.com Website: www.zurichkotak.com
 contributed to by or arising from nuclear weapons material.

Note 1: For Third Party Liability claims, the company reserves the right to invoke the defenses as provided
under the Motor Vehicles Act.

Note 2: The Risk for occupants is not covered under the liability only policy.

For complete list of exclusions including Section-wise exclusions, refer the policy wordings

10 Special Conditions Special Conditions Policy Wording -

and Warranties (if any) Conditions
• All type of pre - existing damages or cost of repair of such damage will be excluded at the time of claim
settlement.

Explain obligations of the Policyholder

The insured shall take all reasonable steps to maintain the insured vehicle in efficient condition and
the company shall have at all times free and full access to examine the insured vehicle or any part
thereof or any driver or employee of the insured.
The due observance and fulfilment of the terms, conditions and endorsements of this Policy in so far
as they relate to anything to be done or complied with by the insured and the truth of the statements
and answers in the said proposal shall be conditions precedent to any liability of the Company to make
any payment under this Policy.

11 Admissibility of Claim 1. Notice shall be given in writing to the Company immediately upon the occurrence of any accident and Policy Wording -
in the event of any claim. Every letter claim writ summons and/or process shall be forwarded to the Conditions
Company immediately on receipt by the insured. Notice shall also be given in writing to the Company
immediately the insured shall have knowledge of any impending prosecution, inquest or fatal inquiry
in respect of any accident which may give rise to a claim under this Policy.
2. No admission offer promise payment or indemnity shall be made or given by or on behalf of the
insured without the written consent of the Company which shall be entitled if it so desires to take over
and conduct in the name of the insured the defence or settlement of any claim or to prosecute in the

Liability Only (Private Car) UIN :IRDAN152RP0001V02201516

name of the insured for its own benefit any claim for indemnity or otherwise and shall have full
discretion in the conduct of any proceedings or in the settlement of any claim and the insured shall
give all such information and assistance as the Company may require.
3. In the event of the death of the sole insured, this policy will not immediately lapse but will remain valid
for a period of three months from the date of the death of insured or until the expiry of this policy
(whichever is earlier).

12 Policy Servicing - Toll free / IVRS number of the insurer : 1800 266 4545 (8 AM TO 8 PM)
Claim Intimation and www.zurichkotak.com/ care@zurichkotak.com
Processing Details of designated company officials to be contacted in time of claim:
zkgi.motorclaimservices@zurichkotak.com

13 Grievance Redressal For resolution of any query or grievance, Insured may contact the respective branch office of the Company Policy Wording -
and Policyholders or may call toll free number 1800 266 4545 or may write an e- mail at care@zurichkotak.com. In case the Grievance Redressal
protection Insured is not satisfied with the response, Insured may contact the Grievance Officer of the Company at
grievanceofficer@zurichkotak.com. In case if the Insured is not satisfied with the solution the Grievance
Officer has provided, Insured can write to seniorgrievanceofficer@zurichkotak.com/
chiefgrievanceofficer@zurichkotak.com.

However, if the resolution provided by us is not satisfactory you may approach Insurance Regulatory and
Development Authority of India (IRDAI) through the Bima Bharosa Portal: https://bimabharosa.irdai.gov.in.

You may also approach Insurance Ombudsman, subject to vested jurisdiction, for the redressal of
grievance.

The details of the Insurance Ombudsman/ complete Grievance Redressal Process is also available at
Company's website: www.zurichkotak.com

Note: The above grievance mechanism and claim intimation process is applicable for the compulsory
personal accident cover. The Claim for Third Party injury, death and property damage shall be routed
through judicial process.

14 Obligations of the To disclose all information correctly sought by the insurer at time of filling the proposal form
Policyholder/ In case of any change / modification / addition to the already declared information the same shall be
brought to the notice of the insurer immediately
Non-disclosure of material information may affect the claim settlement.
Disclosure of other material information during the policy period.

("Material Information" for the purpose of this policy shall mean all relevant information sought by the
company in the proposal form and other connected documents to enable it to take informed decision in
the context of underwriting the risk such as Purpose of the Vehicle, Usage of the Vehicle, Claim details
(accident date, spot of accident, damaged parts etc.), details of vehicle, NCB details etc.)

Declaration by the Policy Holder

I have read the above and confirm having noted the details.
Place:

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:care@zurichkotak.com Website: www.zurichkotak.com
 (Signature of the Policy
Date:
Holder)

Note:
i. Please visit https://www.zurichkotak.com/documents/customer-support/downloads for product related documents including CIS
ii. In case of any conflict, the terms and conditions mentioned in the policy document shall prevail.

Liability Only (Private Car) UIN :IRDAN152RP0001V02201516

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:care@zurichkotak.com Website: www.zurichkotak.com
 Transcript cum Proposal Form - Liability only (Private Car)

Important Information for the Insured:

1. This is a transcript of the details declared by you on the e-proposal and shall be the basis of underwriting of the policy. Request you to carefully review the
complete information provided under this transcript and get back to us within 15 days of issuance of this document, in case there is any discrepancy found.
2. The policy is subject to receipt of complete premium and the risk under the Policy shall commence only from the date as specified in the policy schedule.
3. This document has to be read in conjunction with the policy schedule/document.
Refund, if any, with regard to the premium paid, would be processed in the same source / account (net banking / credit card / debit card) from where the
4.
premium payment has been originally made subject to policy terms and conditions.
5. The policy is subject to the underwriting guidelines of the Company and the details as declared by the Insured under the e-proposal.
6. Online premium payment should be made by the policyholder himself. No third party payment should be made using this mode of payment.
7. The Policyholder/ Insured has fully understood the terms and conditions of the Policy including all the features available thereunder.

Proposal No : 202505220019611

Proposal for : Rollover Policy

4,031.00 Premium Amount (Inclusive of taxes)

Type of cover: Liability Only Policy

Vehicle Make/Model/
Registration No. Type of body Cubic Capacity/KW Fuel Type
Variant

MARUTI/WAGON R/LXI BS
UP 72 AA 3609 1061 Petrol
III

Liability Only (Private Car) UIN :IRDAN152RP0001V02201516

Year of Manufacture Insured Declared Value (IDV) Engine Number Chassis Number

2013 0 K10BN7 242411 MA3EWDE1 SOO551642

Special conditions :

PROPOSER / OWNER’S DETAILS

1. Title and Name of the Insured: Mr. Sarvesh Tiwari

2. Insured Permanent Address* PRATAPGARH District: PRATAPGARH 230129 UTTAR PRADESH(09), India

If Correspondence Address different from

PRATAPGARH Pratapgarh - 230129 District: PRATAPGARH UTTAR PRADESH, India
Permanent Address,please provide*:

3.Phone 94XXXXXX54 4.Mobile * 94XXXXXX54 5.Email ID* VXXXXXXX3@GMAIL.COM

6.Gender 7.Date Of Birth * 8.Nationality Indian Resident

Proposal Date & Time: 22/05/2025 12:55

Policy Start Date: 26/05/2025 00:00

Policy End Date:

25/05/2026 at midnight
(Comprehensive)

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:care@zurichkotak.com Website: www.zurichkotak.com
Limitation as to use (Private Car): The policy covers use of the vehicle 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 trails (g)Use in connection with Motor Trade. Note: In case of vehicles used
for Driving Tuition the words “other than for the purpose of driving tuition” to be read after the words „hire or reward.

Driver’s Clauses: Any person including insured: Provided that a person driving hold an effective Driving Licence at the time of accident and is not disqualified from
holding or obtaining such a licence. Provided also that the person holding an effective Learners’ Licence may also drive the Vehicle and that such a person satisfies
the requirement of Rule 3 of the Central Motor Vehicle Rules, 1989.

STATUTORY WARNING PROHIBITION OF REBATES (Under Section 41 of Insurance Act 1938)

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 punishable with fine, which may extend to ₹ 1,000,000/-
VEHICLE DETAILS

Registration Authority and RTO Date of CNG/LPG/Bi Lease / Hire / Hypothecation (Name and Color of Seating
Location Registration Fuel address of concerned parties) Vehicle Capacity

PRATAPGARH 17/06/2013 PETROL 5

*Non - Electrical *Electrical & Electronic

*Insured Declared
Accessories Accessories Trailer *CNG / LPG Kit *Total Value
Value
fitted to the Vehicle (in fitted to the Vehicle (in (in INR) (in INR) (in INR)
of the Vehicle (in INR)
INR) INR)

0 0 0 0 0 0

Liability Only (Private Car) UIN :IRDAN152RP0001V02201516

PUC - NO

OPTIONAL ADD-ON COVERS

1. Depreciation Cover# 2. Engine Protect #If Depreciation cover is selected: Voluntary Deductible offered under the
“Depreciation Cover”, which would be applied over and above the Compulsory
3. Return to Invoice 4. Consumable Cover Deductible? No

6. Key Replacement
5. Road Side Assistance
Sum Insured
7. Loss of Personal Belongings
8. Tyre Cover
Sum Insured
9. Daily Car Allowance 10. NCB Protect
11. Meter (Switch On/ Switch Off)
12. Battery Protect Cover
Cover
13. Clutch Protect

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:care@zurichkotak.com Website: www.zurichkotak.com
 RISK INCLUSION / EXCLUSION

*Name of Appointee (if Relationship to the

1. *Personal Accident Cover of INR *Nominee Name and Age *Relationship
nominee is a minor) Nominee
15,00,000 for the Owner Driver

2. Do you wish to include Personal Name CSI Opted (Rs) *Nominee Name Relationship
Accident cover for the Named passenger?
No
Please give details mentioned aside:

3. Do you wish to include Personal Accident cover for the Un-named Passengers / hirer / pillion No. of Persons
C. S. I. (Per Person)
passenger? No As Per Seating Capacity
Please give details mentioned aside:

# The maximum CSI available per person is ₹ 2,00,000, each in multiples of ₹ 10,000.

4. Do you wish to restrict Third Party Property Damage of ₹ 7.5 Lakh to the statutory TPPD liability limit of ₹ 6,000/- only? No

5. legal liability against Third Party Risks: A) Owner Driver Yes No Any person other than Paid Driver: No

B) Legal Liability to Employee (IMT 29) Yes No If Yes, no. of Person: C) Unnamed Passengers Yes No If Yes, no. of Person: 0

Compulsory Personal Accident (PA) Cover for owner-driver (PA Cover for Owner –Driver is compulsory for individual vehicle owners). I hereby declare below :

☑ The Owner Driver does not require Compulsory Personal Accident Cover as Owner Driver has a separate existing Personal Accident Cover against Death and
Permanent Disability (Total and Partial) for sum Insured of atleast 15 lacs/ The Vehicle to be insured is not owned by an individual/ The Owner driver does not have
an effective driving license.

DETAILS OF DEPRECIATION
Table 1:Schedule of depreciation for arriving at IDV:

Liability Only (Private Car) UIN :IRDAN152RP0001V02201516

The Insured's declared value (IDV) of the vehicle will be deemed to be the 'Sum insured' and it will be fixed at commencement of each policy period for each insured
vehicle
Age of The Vehicle % of Depreciation for fixing IDV Age of The Vehicle % of Depreciation for fixing IDV
Not exceeding 6 Months 5% Exceeding 2 years but not exceeding 3 years 30%
Exceeding 6 months but not exceeding 1 15% Exceeding 3 years but not exceeding 4 years 40%
year
Exceeding 1 year but not exceeding 2 years 20% Exceeding 4 years but not exceeding 5 years 50%
Note: IDV of obsolete models of vehicles (i.e. Models which the manufacturers have discontinued to manufacture) and vehicles beyond 5 years of age will be
determined on the basis of an understanding between the insurer and the insured.

PAYMENT DETAILS

Payment Mode : PAYMENT AGGREGATOR

Payment Reference No : PB126731116
Payment Amount: 4,031.00
Payment/Transaction Date: 22/05/2025
Bank Details:
I confirm that the premium is paid out of my legitimate sources of fund and the Company has the right to call for documents to establish sources of funds. The
Company has the right to cancel the policy in case I am/have been found guilty by any competent authority or court of law of violating any law/regulation.
Intermediary Code: 3573890000
As verified using OTP sent on mobile number ending with 0254 on 22/05/2025 or as submitted by you in the physical proposal form.

DECLARATION

PEP :
Are You or any of the proposed applicants or close relatives is/are associated to Politically Exposed Person (PEP ) ? Yes No

AML Declaration :
I / We hereby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been /will be paid out of proceeds of crime related to
any of the offence listed in Prevention of Money Laundering Act,2002. I / We understand that the Company has the right to call for document to establish sources of
funds. The Insurance Company has right to cancel the insurance contract in case I am/have been found guilty by any competent court of law under any of the
statutes, directly or indirectly governing the prevention of money laundering in India.

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:care@zurichkotak.com Website: www.zurichkotak.com
 TAX INVOICE

Details of Receiver (Billed To) Details of Supplier (billed by)

Zurich Kotak General Insurance Company
GSTIN/UIN Name :
(India) Limited
Customer ID 1020092367 GSTIN : 27AAFCK7016C1ZT
Customer Name SARVESH TIWARI Pan Number : AAFCK7016C
Email ID VXXXXXXX3@GMAIL.COM CIN: U66000MH2014PLC260291
201-204, 301Chintamani
Contact No 94XXXXXX54 Address: ClassiqueVishweshwar Nagar, Off Aarey
RoadMumbai Maharashtra 400063.
PRATAPGARH, PRATAPGARH, 230129,
Address Date of Invoice 22/05/2025
UTTAR PRADESH, India
IMD Code 3573890000 Invoice No 5851333200
Receipt No 1202600277842 Proposal No 202505220019611
Partner Application No Q4L000000220653954
State Code 09 State Code: 27
Place Of Supply Name UTTAR PRADESH - 09 State Name MAHARASHTRA
IRN

HSN/SAC Description HSN / SAC Code Total Value of Supply (Rs.) Taxable value of Supply (Rs.) IGST Rate IGST Amt (Rs.)
997134 3416 3416 18% 614.88
Motor Vehicle Insurance Services

Liability Only (Private Car) UIN :IRDAN152RP0001V02201516

Total 3416 3416 614.88
Total Invoice Value (In Figure) 4,031.00
Total Invoice Value (In Words) Four Thousand Thirty One
Whether Tax Payable on a Reverse Basis or Not No

For : Zurich Kotak General Insurance Company (India) Limited

Authorized Signatory

"I/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."

Zurich Kotak General Insurance Company (India) Limited (Formerly known as Kotak Mahindra General Insurance Company Limited) CIN:U66000MH2014PLC260291. IRDAI Reg. No. 152.
Registered & Corporate Office: 401, 4th Floor, Silver Metropolis, Jai Coach Compound, Off Western Express Highway, Goregaon (East), Mumbai – 400063. Maharashtra, India.
Toll Free: 1800 266 4545 Email:care@zurichkotak.com Website: www.zurichkotak.com