MAGMA HOUSE, 24 Park Street , Kolkata -700016

(www.magmahdi.com)
IRDA REG NO. 149 DATED 22nd MAY,2012
CIN: U66000WB2009PLC136327
In case of any query, assistance or claims, please contact us at 1800 266 3202
UIN: IRDAN149RP0002V01201920
Date : 09/02/2022

To,
Mrs PADMAPRIYA R
NO 2/7 AKSHYA PLOT G1 BHARATHIDASAN STREET NILLAMAGGAI NAGAR ADAMBAKKAM 600088
KANCHIPURAM
TAMILNADU 600088
Mobile:9840584756

Sub: Risk Assumption Letter

Dear Sir /Madam,

Thank you for choosing Magma-HDI General Insurance Company Limited as your preferred General Insurance Company. Please find enclosed Policy
No. P0022200002/4115/113553, which has been issued based on the details furnished to us as below:

Insured & Vehicle Details

Name of Insured Mrs P A D M A P R I Y A R

Period of Insurance 10/02/2022 TO 09/02/2023

Vehicle Make/Model HONDA / ACTIVA 125 DISC
RTO CHENNAI
Vehicle Registration No. TN 0 1 BL 3 8 4 7
Vehicle Registration Date 22/02/2021
Engine No. JF49EW4111638
Chassis No. ME4JF49NBMW005097

Previous Policy Details

Previous Policy No 3005/2011507686/00/0000004094
Previous Policy Period 06/02/2021 TO 05/02/2022
Previous Year NCB% 25
Previous Insurer Name ICICI LOMBARD GENERAL INSURANCE CO. LTD.
Previous Policy Type Bundled Policy

The information provided above is based on the information received from you and accordingly, the proposal has been processed.
Coverage of risk is subject to realisation of the full premium post which, insurance coverage under the policy would commence. In case the premium is not
received by us due to cheque dishonour or any other reason, the insurance cover shall be void ab-initio.
If you require any changes in the certificate of insurance cum policy schedule, you are requested to inform us by either writing to us at customercare@magma-
hdi.co.in or calling our toll free helpline on 1800 266 3202. Absence of any communication from you in this regard within a period of 20 days of date of this letter,
would mean that the issued policy is in order and as per your proposal.The Risk Assumption Letter is to be read in conjunction with the policy and shall be
considered as null and void without the same.

Thanking You,
Regards

For Magma HDI General Insurance Co Ltd.

Authorised Signatory
 MAGMA HOUSE, 24 Park Street , Kolkata -700016
In case of any query, assistance or claims, please contact us at 1800 266 3202
UIN: IRDAN149RP0002V01201920

STAND-ALONE OWN DAMAGE POLICY FOR TWO WHEELER

CERTIFICATE OF INSURANCE CUM SCHEDULE /TAX INVOICE
Policy Servicing Office NAVIN''S PRESIDIUM, 3RD FLOOR, N.M ROAD, NEW NO: 17/19, OLD NO: 103, "B" BLOCK, 3A, NELSON MANICKAM ROAD, ,CHENNAI -600029 ,TAMILNADU , PH:
(0) 9042004935
Policy No P0022200002/4115/113553
Insured Mrs PADMAPRIYA R
Address NO 2/7 AKSHYA PLOT G1 BHARATHIDASAN STREET
NILLAMAGGAI NAGAR ADAMBAKKAM 600088 Period Of Insurance 00:00 Hrs of 10/02/2022
KANCHIPURAM To Midnight of 09/02/2023
TAMILNADU 600088
Mobile:9840584756 Hypothecation with L & T FINANCE LTD
Contact Number 9840584756
Email ID:
GST Number Unregistered
INSURED MOTOR VEHICLE DETAILS AND PREMIUM COMPUTATION
Registration Mark & No. & RTA Year of
Engine No. Chassis No. Make/Model/Type of Body CUBIC CAPACITY SEATING CAPACITY
Location Manufacture
TN 01 BL 3847 /
2021 JF49EW4111638 ME4JF49NBMW005097 HONDA ACTIVA 125 DISC/SCOOTER 125 2
CHENNAI
IDV (INSURED'S DECLARED VALUE)
IDV of Vehicle Non Electrical Accessories Electrical/electronic Accessories Bi-Fuel kit(LPG/CNG) Other accessories Total Value
58184 0 0 0/0 0 58184
OWN DAMAGE LIBALITY COVER DETAILS
Basic OD 795.02 ICICI LOMBARD GENERAL
Insurer Name
INSURANCE CO. LTD.
Zero Depreciation 232.74
Policy (Liability Cover) Start Date 06/02/2021
Sub Total 1,027.76
Policy (Liability Cover) Expiry Date 05/02/2026
Less:
Policy Number 3005/2011507686/00/0000004094
No claim bonus 35% 278.26
Sub-Total Deductions 278.26
Total Own Damage Premium 750.00

Premium Computation
Total Package Premium 750.00
CGST @ 9% 67.50
SGST @ 9% 67.50
TOTAL 885.00

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
Driver
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
Clause
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.
:
LIMITS OF LIABILITY
Under Excess in respect of each and every claim under Sec I of motor policy
Section I Compulsory : Rs. 100/- Voluntary : Rs. 0/- Imposed : Rs. 0/- Total : Rs. 100/-
Subject to I.M.T Endorsement Nos. IMT 7,IMT 22
Pollution Under Control(PUC)
Warranted that the insured named herein/owner of the vehicle holds a valid Pollution Under Control (PUC) Certificate and/or valid fitness certificate, as applicable, on the date of commencement of
the Policy and undertakes to renew and maintain a valid and effective PUC and/or fitness Certificate, as applicable, during the subsistence of the Policy. Further, the Company reserves the right to
take appropriate action in case of any discrepancy in the PUC or fitness certificate at the time of issuance of policy.

Date of Signature of proposal 09/02/2022

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.
Premium Collection Details :- [Collection No - ReceiptDate - Amount] : P/200002/22/100671747- 09/02/2022 , 885
Premium Amount in Word's ( ) :- Eight Hundred Eighty-Five Only
For Magma HDI General Insurance Co. Ltd.
In case of Claims, please contact us at 1800 266 3202

Date of Issue : 09/02/2022

Place : Kolkata

Consolidated Stamp Duty on the issue of General Insurance Policies Paid vide G.O No. 1661 FT, dated 25.09.2019
GST Number of MHDI - 33AAGCM1685C1ZQ
GST Invoice Number - POL3302220006330
Accounting Code for Service - 997134, Motor vehicle insurance services

Place of Supply:TAMILNADU ( 33 )
Authorised Signatory
Whether Tax is payable on Reverse Charge - No
UIN : IRDAN149RP0002V01201920
This is a valid Tax invoice in terms of Sub-rule 2 of Rule 54 of CGST Rule 2017. Further, being an Insurer, issuing of e-invoice
and QR Code are not applicable on us in terms of Notification No 13 and 14 of 2020 dated 21st March 2020 issued from Central
Board of Indirect Taxes and Customs.
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". For legal
interpretation English version will be good.

For Complete details of coverage , terms, conditions & exclusion please refer the standard policy wording attached with this schedule

IMPORTANT - 1) The Validity of this Certificate of Insurance cum Schedule is subject to realisation of the premium cheque.
2) No Claim Bonus will only be allowed provided the Policy is renewed within 90 days of the expiry date of the previous policy.
3) This document is digitally signed, hence counter signature / stamp is not required.
4) The coverage provided in this policy is only for Own Damage and no other liability in connection with the vehicle.
 We at MAGMA HDI prefer receiving premium amount through cheque
No. TW./202202090072875

Call Us : 1800 266 3202

(Information for fields marked with asterisk [*] is mandatory)

Proposal Form for Stand-Alone Own Damage Policy for Two Wheeler
Customer ID 20009493005
*Proposal For: New Policy Roll- Over Renewal Endorsement
*Type of Vehicle : Two Wheeler Private Car Three Wheeler *Vehicle Insured is: New Used
*Coverage Comprehensive Package Cover Third Party Liability only Cover Third Party, fire & theft only Cover

Required: Third Party and Fire only Cover Third Party and Theft only Cover Standalone OD Cover

Intermediary Code: Intermediary Name:

* Period of Insurance: 10/02/2022 Time: 00:00 ,To Midnight of 09/02/2023

(Note: Cover shall not commence earlier than the date and time of acceptance of risk and/or issuance of cover note and subsequent to payment of premium)

1. *Proposer Details:
1. Name (Registered Owner of the Vehicle): Mrs PADMAPRIYA R

PAN No: *DOB: 07/07/1979 *Gender: M F *Occupation: Others *Marital Status: Married

Bank Name Branch Name A/c Type- Saving Current

Account No. MICR IFSC
2. *Address where Vehicle Registered and Based
NO 2/7 AKSHYA PLOT G1 BHARATHIDASAN STREET NILLAMAGGAI NAGAR ADAMBAKKAM 600088, KANCHIPURAM, TAMILNADU 600088, 9840584756 ,Mobile:9840584756 Whatsapp Number:9840584756 Would you like to opt for
Whatsapp notification
GST Number Unregistered
3. *Communication Address (For policy dispatch)
NO 2/7 AKSHYA PLOT G1 BHARATHIDASAN STREET NILLAMAGGAI NAGAR ADAMBAKKAM 600088, KANCHIPURAM, TAMILNADU 600088
GST Number Unregistered
4. City where the vehicle will primarily be used: KANCHIPURAM
5. Have you been previously insured in respect of this vehicle? Yes No Policy No. 3005/2011507686/00/0000004094
If so, are you entitled to No Claim Bonus from your previous Insurer? Yes No

If Yes, Kindly indicate the percentage: 20% 25% 35% 45% 50% 55% 65%

I/We hereby declare that the rate of NCB 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 respectof Section1 of the Policy will stand forfeited.

Signature of Proposer
6. About the Motor Vehicle to be Insured
*Make HONDA *Chassis No ME4JF49NBMW005097 Speedometer reading as on date
*Model ACTIVA 125 DISC RTO where vehicle will be registered CHENNAI *Vehicle IDV 58184
*Year of Manufacture FEBRUARY - 2021 Date of Registration /Purchase 22/02/2021 Trailer(s) Identification No. 1_________
*CC/GVW 125 Licensed Carrying Capacity 2 2_________
(No of Passengers Including driver)
*Registration No. TN 01 BL 3847 3_________
Type of Body SCOOTER Colour of the vehicle 4_________
*Engine No. JF49EW4111638 Vehicle Make (Indigenous or Imported) ACTIVA 125 DISC
Note: Either Registration no or Engine and Chassis Number is mandatory

*Vehicle Rate Under: Zone -A Zone -B

*Fuel Used: Petrol Diesel Bi Fuel LPG/CNG Electric Hybrid Others (please specify)
*Type of Permit: Express Way National/State Highways City/Town Road District Roads Private Road
* Average Monthly usage : Less Than 50 Kms Between 50 and 100 Kms Between 101 and 250 Above 251 Kms
Whether any modification or conversion has been done in the vehicle from the maker’s standard specification? Yes No
If Yes, please give details of such modifications/conversions...................................
Is the vehicle in good state of repair? Yes No If No, please furnish details ................
Where will the vehicle be generally parked?

Roadside Public Parking Road Outside Parking lot open or covered Within compound of residence open

Within compound of residence covered

7. Financier Details: Hypothecation Hire Purchase Lease Financier Name : L & T FINANCE LTD

8. Nominee Details : Nominee Name: DOB Relationship

Appointee Name & age *If Nominee is minor (below 18 yrs) Appointee Name is mandatory.
9. Insured Declared value of the Vehicle:
The IDV of the vehicle will be deemed to be the Sum-Insured for the purpose of the Policy and will be fixed on the basis of the manufacturer’s listed selling price of the brand and model as the vehicle proposed for insurance at the time of
commencement of insurance / renewal and adjusted for depreciation as per the schedule specified below.
Age of the Vehicle % of Depreciation Insured Decleared Value 1st Year ( ) 2nd Year ( ) 3rd Year ( )
Not exceeding 6 months 5% *Vehicle Chassis Value 58184 0 0
Exceeding 6 months but not exceeding 1 year 15% Vehicle Body Value
Exceeding 1 year but not exceeding 2 years 20% Non- Electrical Accessories (Other than factory fitted): Details 0 0 0
Exceeding 2 years but not exceeding 3 years 30% Electrical Accessories (Other than factory fitted) Details 0 0 0
Exceeding 3 years but not exceeding 4 years 40% Bi- Fuel/ CNG/LPG Kit 00 00 00
Exceeding 4 years but not exceeding 5 years 50% Trailer(s)/ Side Car Value (only for 2 wheelers): 0 0 0
Total IDV: 58184 Not Applicable Not Applicable
Note - For vehicles more than 5 years old, please contact the Company for fixing the IDV
 We at MAGMA HDI prefer receiving premium amount through cheque
10. Extended Covers/ Extra Benefits at Additional Premium:
Extension of Geographical Area: Vehicle is fitted with Fibre Glass Fuel Tank Yes No

Bangladesh Bhutan Nepal Vehicle will be used for Driving Tuitions Yes No

Maldives Pakistan Sri Lanka Imported vehicle without payment of customs duty Yes No

Compulsory Personal Accident for 15,00,000/- Per Yes No N/A Is the vehicle Company Yes No
Annum (If owner has a valid driving license) Maintained?
Will the vehicle be let out on occasional Hire? Yes No

Whether the vehicle is certified as Vintage Car by Yes No

Vintage and Classic Car Club of India ?
Vehicle used for commercial purposes: Yes No

Yes No N/A Do you wish to include Personal Accident cover for unnamed occupants of the vehicle in excess of the compulsory
Do you want to opt for wider legal liability to Paid Driver Personal Accident cover for the Owner/Driver?

Yes No
Other employees Yes No
(If Yes, No. of persons tobe covered.........) Sum Insured per person to be Rs 0
Nominee Details : Name _________________
Do you want to cover loss of accessories due
to burglary, Age _______________ Relationship _______________
Yes No If yes, please indicate the Sum-Insured per person (In multiples of Rs.10000/- for a maximum of Rs.1 lakh per person
housebreaking or theft?
for Two Wheelers and Rs. 2 lakhs per person for Private Cars. The number of persons to be covered for the purpose of
(Applicable only for Two-Wheelers) this Add-on will be equivalent to the registered carrying capacity of the vehicle)

Do you wish to have an enhanced Personal Do you wish to cover Hospital Cash for hospitalisation arising out of accident for Yourself/Your Driver/Unnamed
accident cover for Yourself/ occupants of the vehicle?
Your Driver/Unnamed occupants of the
Yes No N/A Yes No
vehicle?

If Yes, please provide the Sum Insured per

person............

Do you wish to include Personal Accident cover for named persons? Yes No N/A

If YES, give name and Capital Sum Insured (CSI) opted for :

(Note : The maximum CSI available per person is Rs. 2 lakhs in case of Private Cars and Rs.1 Lakh in the case of motorized Two wheeler)

11. Add On Coverage at additional :

Extra Coverage: Zero Depreciation

Whether Add-on cover is present in previous expiry policy: Yes No
12. Restrictions of Cover/ Discounts:
Is the vehicle designed for use of Blind / Handicapped/Mentally challenged persons and duly endorsed as such by RTA ?
Vehicle fitted with Anti-theft device approved by ARAI: Yes No N/A
Yes No
Vehicle will be used within own premises : Yes No N/A
Are you a member of Automobile Association of India? Yes No
Third Party Property Damage cover restricted to 6000 Yes No N/A If yes, please state
(Third Party Property Damage cover of Rs 1 lakh for 2 wheelers and Rs 7.5 lakhs for Private cars) a. Name of Association
b. Membership No. c. Date of expiry
*Voluntary Deductible :
Two Wheeler : None 500/- 750/- 1,000/- 1,500/- 3,000/-

I hold a valid and effective PUC and/or fitness certificate, as applicable, for the vehicle mentioned herein above and undertake to renew the same during the policy period.

Signature of Proposer
13. Previous Insurance Details:
Previous Insurer Name: ICLB Type of cover: Bundled Policy
Policy/ Cover note number: 3005/2011507686/00/0000004094 Period of Insurance: From 06/02/2021 To 05/02/2022
Has any Insurance Company ever: Claims reported in last 5 years
1) Declined the proposal Year 1 2 3 4 5
2) Cancelled & Refused to renew
3) Required an increase in Premium Type of Claims
4) Imposed special conditions or excess (OD/TP)
No. of Claims
Amount
14. Driver Details:
a. Age & Date of Birth of the Owner : Age:_______ Yrs DOB:_____/_____/_____
b. Age & Date of Birth of the Driver : Age:_______ Yrs DOB:_____/_____/_____
c. Does the driver suffer from defective
vision or hearing or any physical infirmity? Yes No
lf YES, please give details of such infirmity :
d. Has the driver ever been involved/convicted
for causing any-accident of loss? Yes No

lf YES, give details as under including the pending prosecutions:

-Driver's Name :
-Date of Accident:
-Loss / Cost ( Rs.)
-Circumstances of Accident / Loss
15. Premium Details

Total Premium (Including GST): 885.00 Payment Mode : Cash Cheque DD

Cheque/DD, Cheque No Bank/Branch Date.

Declaration: I/We hereby declare that the statements made by me/us in this Proposal Form are true to the best of my / our knowledge and belief and I/We hereby agree that this declaration shall form thebasis of the contract between
me/us and the Magma HDI General Insurance Co. Ltd.
I/We also declare that any additions or alterations carried out after the submission of this Proposal Form would be conveyed to Magma HDI General Insurance Co. Ltd immediately.
I/We hereby agree to receive a One Page Motor Insurance Policy in Physical Form, to be read along with the detailed Terms and Conditions available on the website www.magmahdi.com
Yes No
I/We further confirm that the existing damages as per the pre inspection report, if any, have duly been shared with me & my consent has been obtained for the same.
I/We hereby declare and undertake that the amount paid by me/us as premium for the aforementioned vehicle is out of my/our lawful and declared source of Income.

__________________________________
Place: Kolkata Date: 09/02/2022 Signature of Proposer
INSURANCE ACT 1938, SECTION 41 – PROHIBITION OF REBATES
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 or 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
prospectus 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 Ten Lakhs Rupees.
Name: PADMAPRIYA R
Date & Time: 09/02/2022 4:16:38 PM
Place: KANCHIPURAM
IP Address: 106.198.24.50

Signed by : Magma HDI General Insurance Company limited

Time & Date : 10-Feb-2022 14:24:15 IST