PDF

Proposal cum Acknowledgement Page
Page 1 of 3
CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

PROPOSAL FORM CUM PAYMENT
ACKNOWLEDGEMENT
Issuing Office Address :
AHMEDABAD - BRANCH
OPTIONZ,2ND FLOOR,
OPP HOTEL NEST,S.P COLONY, OFF C G ROAD,
AMBAWADI VISTAR S.O
AHMEDABAD
GUJARAT
PIN-380015
: 3362143515503
Proposal Type : Market Renewal
Type of vehicle : Private Car
Agent Code
: 201570367334
Proposal No
1.Name of the Insured SATISHKUMAR WAZIRSINGH SAROHA

Vehicle Registration Address
Area
City
State
Pincode
Financier Type: Hypothecation
A 28 NARSHI NAGARA OPP BALIYADEV MANDIR LAMBHA GAM

NAROL S.O
AHMEDABAD
GUJARAT
382405
Financier Name: MAHINDRA AND MAHINDRA FINANCIAL SERVICES LIMITED
2.Registration Mark,Number and Description of the Vehicle Insured.
Date of Registration 25 Feb 2015
Registration No.
Engine No.
EAST AHMEDABAD
129968
Make
MARUTI
Cubic
Capacity
Year of
Manufacture
GJ-27-AH-3845
Place of Registration
7072132
Chassis No.
CIAZ - VXI
Model
Variant
VXI PLUS
PLUS
Gross
Vehicle
Weight
(GVW)
in kilos
Type of
Body
SALOON
Fuel Used
PETROL
Licensed Carrying Capacity

Public /
Private
Carrier
Licensed
Passenger
Carrying Capacity
Driver and Others
Total Seating
Capacity
Including Driver
2015
0
1
3.Effective Date & Time of Commencement of Insurance for the purpose of the Act.
From
14 Feb 2016 00:01 Hrs
4.Date of Expiry of Insurance To Midnight of 13 Feb 2017
Value of Chassis(Rs.)
Value of Body(Rs.)
For Vehicle(Rs.)
For trailer(Rs.)
Value of CNG/LPG (Rs.)
0.00
0.00
602,000.00
0.00
0.00
Non Electrical Accessories (Rs.)
Electrical / Electronic Accessories (Rs.)
Total Value (Rs.)
0.00
0.00
602,000.00
PREVIOUS INSURANCE PARTICULARS(If Applicable)
Name of Previous Insurer : NEW INDIA
Policy No: 31260031140302399479
Period From : 14 Feb 2015
Type of Earlier Policy
To: 13 Feb 2016
Comprehensive Package
Past Claims History
Number of Claims Made

Claim Paid Amount (Rs.)
Are you entitled for No Claims Bonus(NCB)
Previous Policy
1
1.00
No
LIMITATIONS AS TO USE :
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 Trials g) Use in connection with motor trade.
Benefit No.
Name of the Cover Opted
Waiver of Reduction in Depreciation
If Yes,then NCB %
DRIVER:
Any person including insured.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.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.
Discount
Additional Premium
0.00
1,505.00
EMI Protection Cover

Coverage for Disabled vehicle
Daily cash allowance
Net Premium
(Rs.)
Service Tax Including Cess (Rs.)
13,385.00
1,941.00
https://proposalonline.cholainsurance.com/ecovernote/Reports/frmAckPage.aspx?PDF=No&Child=Y
1/25/2016
Page 2 of 3
Total Premium (Rs.)
15,326.00
IMT Nos:22,28,16,7
Applicable benefits
Warranty
Special Conditions
Compulsory Excess (Rs.)
1,000.00
Additional Imposed Excess (Rs.)
Issuing Office Address :

AHMEDABAD - BRANCH
OPTIONZ,2ND FLOOR,
OPP HOTEL NEST,S.P COLONY, OFF C G ROAD,
AMBAWADI VISTAR S.O
AHMEDABAD
GUJARAT
PIN-380015
: 3362143515503
Proposal Type : Market Renewal
Type of vehicle : Private Car
Agent Code
: 201570367334
Proposal No
NOMINEE DETAILS :
S.No Name of the Nominee RelationShip Age of the Nominee % of Share Name of the Guardian
1
SUNITA
Date of Issue
25 Jan 2016
Wife
32
Time
Relationship With Guardian
100
13:31 Hrs
Place:
AHMEDABAD - BRANCH
Regd & H.O: "Dare House" 2nd Floor, 234 N.S.C Bose Road, Chennai 600 001 E-mail
Customercare@Cholams.Murugappa.com
For more Information: Contact on Cholamandalam MS Toll-Free 24 hours Helpline at 1800-200-55-44: Web:
www.cholainsurance.com
Declaration:
I/ We have remitted an amount of Rs.15326/- (Rupees) to vide Cheque/DD No. 224021 dated 19/01/2016 in favour of M/s
Cholamandalam MS General Insurance Company Limited (Chola MS) drawn on Bank towards premium to avail insurance for my / our
vehicle bearing No.GJ-27-AH-3845.
The terms and conditions of the insurance policy have been explained by the Intermediary and understood by me/us.
I/We acknowledge that this is only an E-Proposal and acceptance of the same is subject to approval by the company and realization of
the premium cheque. In the event of non-realization of premium cheque due to any reason, proposal is deemed to be cancelled from
inception. I /We will not hold Chola MS responsible for any liability of whatsoever nature.
I / We hereby declare that the statements made by me / us in the proposal form are true and complete to the best of my / our
knowledge and belief. I / We hereby agree that this declaration shall form the basis of the contract between me / us and the
company. I / We also declare that if any alteration / addition is carried out after the submission of this proposal; the same shall be
conveyed to the Company immediately. I / We are aware that mere remittance of payment does not guarantee acceptance of this
risk, which decision shall be made by the Company. I / We agree to the Company taking appropriate measures to capture the voice
log for all such telephonic transaction carried out by me / us in accordance with procedures / regulations, internal or external. This
cover is valid in India only.
Declaration for No Claim Bonus (NCB)*(if NCB confirmation is not submitted but NCB claimed).
I /We declare that the rate of NCB of 0 % claimed by me/us is correct and that NO CLAIM has arisen in the expiring Policy Period
(Copy of Policy enclosed). I/We further undertake that if this declaration is found incorrect, all benefits under the Policy in respect of
Section - 1 (own damage) of the Policy will stand forfeited.
Signature of the Proposer:
Date:
Place:
1/25/2016
Page 3 of 3
1/25/2016

PDF

Uploaded by

Copyright:

Available Formats

PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

PDF

Uploaded by

Copyright:

Available Formats

Proposal cum Acknowledgement Page

CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

1.Name of the Insured SATISHKUMAR WAZIRSINGH SAROHA

A 28 NARSHI NAGARA OPP BALIYADEV MANDIR LAMBHA GAM

2.Registration Mark,Number and Description of the Vehicle Insured.

Date of Registration 25 Feb 2015

Licensed Carrying Capacity

Driver and Others

To: 13 Feb 2016

Past Claims History

Number of Claims Made

Name of the Cover Opted

Waiver of Reduction in Depreciation

EMI Protection Cover

Service Tax Including Cess (Rs.)

Proposal cum Acknowledgement Page

Total Premium (Rs.)

Additional Imposed Excess (Rs.)

Issuing Office Address :

Relationship With Guardian

Proposal cum Acknowledgement Page

You might also like