Q ezr-r^rr-rlAttianz@
MC1003845922
ianzGeneral
Insurance
Limited
Company
o: GEPlaza,
AirportRoad,
Yerwada,
Pune411 006.
,.
lmoortant
Notice*
I
I n t h e e v c n t o f a c l a i m , p l e a s e m a k e stuorcea l l o u r 2 4 h o u r sC a l l C e n t e r( f r o m B S N L L i n e s ) : 1 8 0 0 2 2 5 8 5
( f8r o
, m A i f t e /l B h a r r i l i n e s ) 1 8 0 0 1 0 2 5 8o5r83 0 3 0 5 8 5 8 ( R l t V I ) o r
email at : callcenterpune@bajajallianz.co.in
- t o g e t y o u r c l a i m r e g i s t e r e d i n o u r r e c o r d s a n d t h e c l a i m n u m b e r if sosr [uuetdu r e r e f e r e n c e .
- toknowabouttheclaimprocessandthenecessaryrequirementsforfastersettlementofclaim.
- to knowthe approvedgaragewherevehicleis to be takenfor qualityrepail, cashless
settlementandother valueadded services
? Please'efer to lhe ClaimCuidecopysuppliedbyyour agentfor more detailson claimsettlementprocess,
requirements
and the BajajAllianzPreferredWorkshopslist. In case
you havenot received,pleasecontactournearestofficeorthe
agent.
3Shou|dyoudecideongarageo[yourchoice,companycannotassurethesericessuchascash|e5ssettIernentfaci|ity,qua|ityof
)d a proportionatepart or the premiumothemisepayablefor suchInsurance
shallbe chargedfor the
timetheCompany
hadbeerron risk
RegistrationNur;,oer
Passenqers
\,b1
Engine
No _
chass,s
No
Make
SubType
Model
Yearor
lvlanufa.hrre
:ubicCapacity
lP-arrAt$wflt--tD etA\(? q --S)'( S. gPSF$
D:t'-h,
NFrr.l
LI!tj1l5e( i_dl I
Coods
Registfation
Authority
Insured'sdeclaredvalue
Electrical
Accessories
NonElectrical
Accessories
CNC/ LPCKit
4+!-+a
Lease/ Hire-Purchase/
Hypothecation
\1 eR AS s q F o.$ A-0\q*il6
Additional
Riskif anySpecial
Conditions
Private
Commercial
t_l
Farmer
Name ofthe Ftnancier
Add on Package__
Form52 (lndia)
142 1) OFMOTORVEHICTE
RUI.E1989
1 Nameoflnsured
IaDOB
2 Addressoflnsured
State
2,aOccupanon:ousiness[
Seruicel-l
Student
3 TeleDhoneNumber
4 Periodof Insurance
Ftom:
NOTVALIDFORRISKSTARTING
BEFORE
161112013
ANDAFTER
151412013
5 Personor classesof personsentitled to drive
p a s s e n q e r s a t t h e t i m e o f l h e a c c i d e n t a n d t ah pa et sr u
ch
so
nsatisfiesrequirementsofR[le3oftheCentrallvlototVehicleRulesl9S9
requirements
ofRule3ofthe Central
N,4otorVehrcle
Rulesl989
(iii) NONTRANSPORT
VEHICLES
: Anypersonincluding
insuredprovided
thata persondrivingholdsa drivingeffective
licer]se
at the trmeof accider
s u c h a l i c e n s e p r g v i d e d a l s o t h a t t h e p e r s o n h o l dLi negaar n e rf f' sc L
c ti ci veen s e m a y a l s o d r i v e t h e v e h i c l e a n d s [ c h a p c r r o n s a t i s f i e s r e q u i r e m e n t s o f R u l e
6, Dateof lssue
.rm /p m
Time
7 Limitation
asto use(seeoverleaf)
8. Theperiodof thisCoverNotewill expireon completion
of 60 daysfromthe dateof issue.
9. THECOVERNOTEBECOMES
VOIDAB INITIOIN CASEOFDISHONOUR
OFPREMIUMCHEOUE
10. PremiumCalculation
(ODPremium)
Basic
Electrical
Accessories
Non-Electrical
Accessories
r_PC/CNC
Kit
NCB
%
ThirdPanyPremium
0wner DriverCover
PaidDriver
Passengers
Addon Package
NetPremium
Service
Taxasapplicable
FinalPremium
Addressof lssuingOffice
9,
IMD Code :
S u bI M DC o d e :
Payment Details:Cash/Cheque/
(Srfikeourwhich
Orhers
isnotapplicabie)
ChequeNo:
ChequeDate:
Bank:
Others:
D e d u c t i b lAed: d i t i o n aRl s . _ _ . _ , - _ V o l u n t a r y
Rs.
ANT : lA/Ve declare that l/we have read the oolicv schedule and
____3ES!--L-:
'
t
lhe rale of NCB claimedby me/usis correctand that no claimhas ariseniil
lhe expiring policy period (copy of the pohcy enclosed).l/VVefurther
undertakethat if this declarationis foundto be incotrecl,all benefitsunder
the policy in respectof seclion 1 of the policy will stand forfeited.l,^/Ve
herebyagreeto confirmwithin7 days fromissuanceof policyin caseof any
objectionor disaqreement
withthe ebove
IMPORTANT: l/We heiebyagreeand undertaketo receiveone pagepolicy
document,
withoutenclosing
thetermsandconditions
of policy,.rnd
l/we hereby
authorise
companythatall termsandcorrditions
of policycanbe displayed
in the
websiteof companyThesaltent
features
of thepolicy,
termsandconditions
of this
covernotehavebeenexplained
to me/usin vernacular
language,
andl/weagreeto
thesame
l/We herebycertifythat this CoverNoteis issuedin accordance
with the
of chapterXl of the motorVehicle
act 1988.
3 provisions
d
Signature of the insured
(Authorised
Insurer)
DulyConstituted
(s)
Artorney
(30) DAYS
3 IFYOUDON'TRECEIVE
YOURPOLICY
CONTRACT
WITHINTHTRTY
FROM
ISSUANCE
OFTHISCOVERNOTE
ISANYOTHER
DISCREPANCY
INTHEPOLTCY
/THERE
i coNTRAcr,
pLEASE
DtREcrLy
CALL
ouR24HouRs
cAtLCENTER
ToLLFREE
NUMSERS
GtvEN
ABovE
Thiscovernote
isissuedbasinqoninformationanddeclarationprovidedbv
vouandthetranscriptwhereofisbeinqdispatched
withthePolicv,
A484595
ORICINALTO
INSUR[D
