STANDARD PROPOSAL FORM FOR "LIABILITY ONLY" POLICY

(For Commercial Vehicles other than Motor Trade Internal Risks Policies)

Proposal No.PF07939212

Name of Intermediary: Policy Bazaar AG Code: AG043210

IMPORTANT
*It is an offence under the Motor Vehicles Act, 1988 to make a false statement or withhold any material information for the purpose of obtaining a a Certificate of
Motor Insurance.*Please complete the form in capital letters using a pen.* All questions in the form must be answered in full and it must be signed and dated.
Continue on a separate sheet if necessary and attach as part of the Proposal Form all supporting information and documents.* Royal Sundaram may seek any other
information as desired for underwriting purposes * The liability of the Company does not commence until the Company has accepted the Proposal Form and the full
premium is paid. For any clarification on the cover,terms,etc.,Please contact Royal Sundaram.* Attach any other information material to the risk proposed or
requested by Royal Sundaram.

ABOUT YOURSELF
Title Mr.
Name RAM ASRE MAURYA .
Are you Married Yes No

Permanent Address S/O Kakore Prasad, Arkha, Thana Tahsil Unchahar, Unchahar s, Rae Bareli, Uttar Pradesh - 229404 -229404

Communication RAM ASRE MAURYA .

Address S/O KAKORE PRASAD, ARKHA
THANA THASIL UNCHAHAR

City RAEBARELI
State UTTAR PRADESH Pincode 229406
Daytime Phone(s) Mobile Number 93xxxxxx47
Email isa*********@gmail.com
KYC Documents PAN Form 60 Form 49A PAN No.CMNPM5233Q DOB:01/11/1969
(Mandatory)
CKYC Number
Occupation: Please tick against the applicable description, if you fall under any of the below listed categories. If you fall under more than one of the
listed titlesbelow, please tick against all the applicable heads.
Pvt.Sector Govt.Employee Self Employed RS Employee Film Industry Real Estate
Employee - IT and ITES Heads of States or of Governments Sports Person Senior Government/Judicial/Military Officer
Senior Executives of State - Owned Corporations Student Senior Politician Important Political Party Official
House wife Retired Employee Company Owned

AADHAR NUMBER
a) For Individual Customer:
Name as per Aadhar
Aadhar Number Date of birth of Insured 01/11/1969 Gender Male
b) For Corporate Customer:
Principal Officer Name
as per Aadhar
Aadhar Number Date of birth of Insured Gender

GST NUMBER
Name as per GST Certificate
Registered GST Number
Address as per GST Certificate
District and State as per GST
Certificate

ELECTRONIC INSURANCE ACCOUNT(EIA) NUMBER

Do you have Electronic Insurance Account Yes No (If yes please provide)

Account No
Repository Name
Nominee Name
Nominee Age Nominee Relationship

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ABOUT YOUR BANK DETAILS Please attach a copy of cancelled cheque for verification of details, remittance of claim payment/refund if any
Bank Name Branch
Type of Account: Saving Current Account No:
IFSC Code: MICR Code:
Customers are requested to remit the premium by way of cheque or demand draft or credit card. Cash remittance to be avoided.

A.VEHICLE DETAILS(Vehicle Specifications)

1. Registration Number of the Vehicle UP33BT5050
2. Date of Registration of the Vehicle 16/05/2019
3. Registering Authority & Location UP33-RAEBARELI
4. Year of Manufacture 2019
5. Engine Number WJK6C31452
6. Chassis Number MA1XM2WJXK5D40190
7. Make of the Vehicle MAHINDRA
8. Model Bolero Power + SLE
9. Type Of Body SUV
10. Gross Vehicle Weight (GVW) & Cubic Capacity (C.C) 0.0 & 1493
11. Max. licensed carrying capacity (No. of Passengers) in case 7
ofPassenger Carrying Vehicles?
12. Whether the vehicle is driven by non - conventional source of power / Yes No
CNG / LPG / Bi-Fuel?
If 'YES' , please give details Diesel
13. Whether use of vehicle is limited to own premises? Yes No

14. Whether the commercial vehicle is also used for Private Yes No
purposes(excluding use for hire or reward )?
15. Whether the vehicle is used for driving tuitions? (GR-44) Yes No

16. Details of Hire Purchase / Hypothecation / Lease (IMT - 5)

a) Is the vehicle proposed for insurance is:
(i) Under Hire Purchase ? Yes No
(ii) Under Lease Agreement? Yes No
(iii) Under Hypothecation? Yes No
b) If 'YES", give name and address of concerned party/parties:
(Note:Note: Copies of R.C Book, Permit & Fitness Certificate Should Be Submitted Along With Proposal Form
17. Vehicle mostly driven on: City Roads Highways Hilly Areas Village Roads Airport/Airside
Others ____________________________(Please Specify)

18. Period of Insurance

From: 09/05/2023 00:00 To: 08/05/2024 23:59:59

BENEFITS UNDER OUR POLICY:

Compulsory Personal Accident (CPA) Cover For Owner Driver Yes No

Nomination for PA Cover Age Relationship Name of the Appointee (if Nominee is a minor)

If No, Tick any of the three options

Registered owner does not have valid driving license
Registered owner having CPA cover with other motor policies
Registered owner having PA cover of Rs.15 lakhs and above
* The Standard Coverage for Third Party Property Damage is
` 7,50,000/-. Do you wish to restrict the same to `6,000/- only, as per Motor Vehicles Act to avail applicable discount Yes No

* Do you wish to include PA cover for Paid Driver/Conductor/Cleaner?s (IMT No 17) Yes No
If Yes, give no of persons and Capital Sum Insured (CSI) opted. Maximum CSI available per person is `200,000
(Maximum restricted to seating capacity)
Number of Persons Capital Sum Insured

* Do you wish to cover wider legal liability to employees who are 'workmen'? (IMT No. 28) [This information is sought to cover in addition to liability under the
Workmen's Compensation Act-1923,also liability under the Fatal Accidents Act -1855 and the Common Law] Yes NO
If Yes, No. of persons _________________________________________________________________________________________________
* Do you wish to cover Legal Liability for accidents to Non-fare Paying Passengers who are Employees of the Insured but not 'workmen' under the Workmen's
Compensation(IMT NO 37)? Yes No
If Yes, No. of persons _________________________________________________________________________________________________

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 * Do you wish to cover Legal Liability for Accidents to Non-fare Paying Passengers, Owner of goods who are not Employees of the Insured, carried in a Goods
Carrying Vehicle? (IMT No.37 A) Insured, carried in a Goods Carrying Vehicle? (IMT No.37 A) Yes No
If Yes, No. of persons _________________________________________________________________________________________________
* Do you wish to cover Legal liability to persons employed in connection with operation and/or maintenance and/or loading and/or unloading (IMT No. 39) Yes
No
If Yes, No. of persons _________________________________________________________________________________________________
* Do you wish to cover Legal Liability to passengers excluding liability for accidents to employees of the Insured arising out of and in course of their employment
(Applicable to Ambulance under class D of Commercial vehicles) Yes No
If Yes, No. of persons _____________________________________________________________(Maximum restricted to seating capacity excluding
driver)
* Whether extension of geographical area to the following countries required? Yes No
Bangladesh, Bhutan, Maldives, Nepal, Pakistan and Sri Lanka.
1)________________________ 2)__________________________ 3)_____________________________ 4)________________________
Questions that are elicited for information and data collection purposes
a.Is the vehicle in good condition ? Yes No If No please give details
If No please give full details:__________________________________________________
b. Name and Address of the previous insurance company: SHRIRAM GENERAL INSURANCE CO. LTD. FARRUKHABAD ,FARRUKHABAD ,
c. Previous policy number : 108054/31/23/000507
d. Period of Insurance: From: 09/05/2023 00:00 To: 08/05/2024 23:59:59
e. Claims lodged during the preceding 3 years
Year No. of Claims Claim Amount (Rs.)
_________________________ _________________________ ________________________
_________________________ _________________________ ________________________
_________________________ _________________________ ________________________

Does the vehicle have valid Pollution Under Control (PUC) Certificate? Yes No
PUCC Number : PUC expiry date :
*"In line with the Central Motor Vehicle Act, 1989 and as per the directive of Hon'ble Supreme Court of India, it is mandated that insured must produce a valid
"Pollution Under control" Certificate as and when asked by the insurer and it is the responsibility of the insured to renew the same before expiry of the validity of the
PUC certificate. Absence of Valid certificate may lead to cancellation of insurance"
PAYMENT DETAILS: Please tick payment option
Cheque/DD Number___________________ Credit Card Debit Card Payzaap Paytm Bill Desk
Bank____________________________________________________________________________________________________________________
NEFT RS Account No__________________________ Transaction Ref No_____________________

Date__________________________ Amount__________________________________ Cash Amount_________________________

*Payment must be made favouring Royal Sundaram General Insurance Co. Limited
Authorization for electronic policy fulfilment and service communications (Please read carefully and put a check mark against each before signing)
I hereby consent that the proposal status, policy details and renewal reminders may be sent to me by email and SMS .

I hereby consent to and authorize Royal Sundaram General Insurance Co. Limited (Company) to make welcome calls, service calls or any other communication (electronic or
otherwise) with respect to the proposed or existing policy of Company from time to time.
We hereby unconditionally allow the Company to share all my / our information being collected in this proposal form or through telephonic / email / web-inputs means or other means,
as updated from time to time within group entities.
PREMIUM COMPUTATION SUMMARY
Basic OD Premium 0.00 Basic TP 7,940.00
Other OD Covers 0.00 Other TP Covers 6,243.00
Total TP Premium 14,183.00
NCB 0% Total OD + TP 14,183.00
Add on premium GST 2,553.00
Total OD Premium 0.00 Premium inclusive of GST 16,735.94

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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 the basis of the contract between me/us and Royal Sundaram General Insurance Co. Limited.

I/We also declare that any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the Insurance
Company immediately
Place :
Date : 04/05/2023 Signature of the proposer (Vehicle Owner)

Section - 41 of Insurance Act, 1938 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 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 continuing the policy accept any rebate except such rebate as may be allowed in accordance with the published prospectus or tables of
the Insurer.
2. If any person fails to comply with sub-regulation (1) above, he shall be liable to payment of a fine which may extend to Ten Lakh Rupees.
Note: Denial of "Third Party Liablity Only Cover" by Insurer, for reasons other than fraud/misrepresentation by proposer, will entail Regulatory action

Royal Sundaram General Insurance Co. Limited

(Formerly known as Royal Sundaram Alliance Insurance Company Limited)
Corporate Office: Vishranthi Melaram Towers, No. 2 / 319, Rajiv Gandhi Salai (OMR), Karapakkam, Chennai - 600097. Registered Office: 21, Patullos Road, Chennai - 600 002.
Royal Sundaram IRDAI Registration No.102 | CIN:U67200TN2000PLC045611
Call: 1860 425 0000,1860 258 0000 | Mail:customer.services@royalsundaram.in | Website: www.royalsundaram.in

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