MOTOR GOODS CARRYING VEHICLE - CUM TAX INVOICE POLICY PROPOSAL FORM

IMD Name SHRINITHI INSURANCE IMD Code 200279539754

BROKING PVT.LTD- AG
Sub IMD Name Sub IMD Code
USGI Branch Location CHENNAI BRANCH OFFICE Marketing Official Name

Proposal for: New Business Rollover Renewal Endorsement

Instructions to the Applicant

1. Please fill in the Proposal Form in BLOCK LETTERS and tick boxes wherever applicable
2. Attach additional sheets if the space given is insufficient
3. The queries made/ details stated below are the minimum requirement to be furnished by a proposer.
(The Company may seek any other document as desired for underwriting purpose)

Intermediary Details
IMD Name : SHRINITHI INSURANCE BROKING PVT.LTD- AG
IMD Code : 200279539754
Contact Details: 8925815500
Proposer's (Owner's) Full Name: K. MUPPUDATHI Gender:Male
Date of Birth:23/06/1967 Occupation / Business: (For Individual Customers)
PAN Card No. : Address proof details :
Address for Communication: NO 5/146, WEST STREET,, POTTALUR, PETHANADARPATTI , ALANGULAM TALUK,
TIRUNELVELI, TAMIL NADU, INDIA, 627808
Address (Address where vehicle is normally kept and used with Pin code):
Mobile No: 9488490439 E-Mail Address: santhosh.57575@gmail.com
Tel. No. (Residence/office) GSTIN :
E Insurance Account No. : NA
Type of Cover: Package Fire Only Theft Only Fire and Theft Only Liability Only and Fire Only Liability Only
and Theft Only Liability Only and Fire and Theft Only
Period of Insurance: 25/11/2023 12:02:37 To 24/11/2024 11:59:00

Details of Vehicle:
Vehicle Make Model Variant Year of Cubic Seating Body Type
Manufacture Capacity/KW Capacity/LCC
(Including
Driver/Cleaner)
MAHINDRA & BOLERO BSIV 2019 2523 3 OPEN
MAHINDRA PICKUP FB
12.5T BSIV

Vehicle Registration No. TN-76-AM-9832 Vehicle type Indigenous Imported

Chassis No. MA1ZU2TBKK1K75688 Engine No.TBK1K81539
Place of Registration TENKASI Date of Registration 11/12/2019
Trailer Chassis No. (if any) Colour of Vehicle White
Registration Address : NO 5/146, WEST STREET,, POTTALUR, PETHANADARPATTI , ALANGULAM TALUK, TIRUNELVELI,
TAMIL NADU, INDIA, 627808
Details Pertaining to the use of Vehicle:
1.Whether extension of geographical area to the following countries required? Yes No

Bangladesh Bhutan Nepal Sri Lanka Maldives Pakistan

2. Whether the vehicle is driven by non-conventional source of power? If yes, please give details. Yes No

Proposal form – MOTOR GOODS CARRYING VEHICLE - CUM TAX INVOICE Policy UIN: IRDAN134RP0009V02200809
3. Whether the vehicle is used for driving tuitions? Yes No
4. Whether the use of the vehicle is limited to own premises? Yes No
5. Whether the use of the vehicle is limited to confined site? Yes No
6. Whether the commercial vehicle is also used for Private purposes (Excluding use for hire or reward)? Yes No
7. Whether vehicle belongs to foreign embassy/ consulate? Yes No
8. Whether vehicle is designed for use of Blind Handicapped / mentally challenged persons and duly endorsed as such by
RTA? Yes No
9. Whether vehicle is fitted with fibre glass tank? Yes No
10. Are you entitled to No Claim Bonus ?If yes, please submit proof thereof. Yes No
11. Is the vehicle fitted with the any Anti-theft Device approved by the AARI, Pune ? Yes No
If yes, attach Certificate of Installation in the vehicle issued by Automobile Association of India.

Liability to Third Parties

1. The policy provides Third Party Property Damage (TPPD) of Rs. 1 lakh (Two wheelers) and Rs.7.5 lakhs ( other class of
vehicles ). Do you wish to to restrict the above limits to the statutory TPPD Liability limit of Rs.6000/-? Yes No
Do you wish to to restrict the above limits to the statutory TPPD Liability limit of Rs.6000/-? Yes No
2. Do you wish to cover Legal Liability to ?
A. Driver/Conductor/Cleaner (No. Of persons _________) Yes No
B. Other employees (No. of persons__________) Yes No
C. Non-fare paying passenger (No. of persons________) Yes No
3. Do you wish to include Personal Accident (P.A.) Cover for paid drivers, cleaners and conductors? Yes No
If yes, give name and Capital Sum Insured (CSI) opted for. The maximum CSI available per person and Rs.2 lakhs for other
classes of vehicles.

Sr No Name CSI Opted

1.
2.
3.

Insured Declare Value

Insured’s Declared Non - electrical Electrical and Trailers / Side Car ( Value of CNG / LPG Total Value
Value of vehicle accessories fitted to electronic If Any ) Kit
the vehicle accessories fitted to
the vehicle
650000.00 650000.00

Personal accident Cover for Owner Driver is compulsory in liability only Cover. Please give details of nomination:
Particulars Name of Nominee Age Relationship Name of Appointee Relationship with
(If Nominee is a the nominee
minor)

Or

Do you have any existing CPA cover or Personal Accident Cover of SI 15 Lakhs or above? Yes/No If Yes*, Please provide
below mentioned details:
Policy Number Capital Sum Insured Name of the Company Policy Duration Coverage Details:

(*please provide the policy copy for the same)

Previous Insurance Details

Name and Address of Previous Insurer :
Policy/Covernote no:

Proposal form – MOTOR GOODS CARRYING VEHICLE - CUM TAX INVOICE Policy UIN: IRDAN134RP0009V02200809
Type of Cover: Package (Comprehensive) Policy Act only Policy Others
NCB in expiring policy %
Claim lodged in preceding years:
Year
No. of claims
Amount

1. Date of purchase of the vehicle by the Proposer: 11/12/2019

2. Whether the vehicle was new or second hand at the time of purchase? New Second Hand
3. Is the vehicle in good condition? Yes No
If NO, please give details:
4. Has any insurer ever declined/cancelled the insurance of the proposed vehicle? Yes No
5. Policy Period: From To:

NCB Details
1. Are you entitled for No Claim Bonus on Renewal? Yes No * If yes, Please mention the %

Details of the Purchase/ Hypothecation/ Lease

Financier Details : Hypothecation Agreement Hire Purchase Lease Agreement
Name of Financier and Address : INDUSIND BANK LTD,TIRUNELVELI

Details of Driver:

(a) Age Owner -Driver /Others

b). Does the driver suffer from defective vision or hearing or any physical infirmity. Yes No
If “Yes" please give details.
(c) Has the driver ever been involved/convicted for causing any accident or loss ?
If yes, please give details as under including the pending prosecution, if any :-
Driver’s Name Date of Accident Circumstances of Accident/ Loss/Cost Rs.
Claim

29. Any other relevant information:

Do you wish to Opt for Add On coverage:-

Loss of Personal Belongings Clause No
Additional Expenses Coverage clause No
Accidental Hospitalization Clause for Family No
Hospital Daily Cash Cover No
Return to Invoice No
Key Replacement No
Loss of Driving License/ Registration Certification No
Insurance at manufacturing selling price No
Depreciation Waiver No
Daily Cash Allowances Benefit No
Daily Cash Allowances No
Cost of Consumable No
Secure Towing (Higher towing & removal costs) No
Hydrostatic Lock Cover No
Road Side Assistance Yes
NCB Protector No

Proposal form – MOTOR GOODS CARRYING VEHICLE - CUM TAX INVOICE Policy UIN: IRDAN134RP0009V02200809
Engine Protector No
Tyre and Rim Cover No
Wrong Fuel Cover No
EMI Protection No
Addtional Towing Charges No

Payment Details:

Premium Payment Details: Cash Cheque Demand Draft Credit Card

Premium Amount (including service tax): Insured Bank Details:
Cheque / DD No.: Bank A/C No.:
Cheuqe / DD Date: Bank Name and Branch:
IFSC Code:
In case the annualized premium is more than Rs. 25000/-, the proposer is requested to provide a cancelled cheque of his/her
bank account if the premium is not paid from the same.

AML Guidelines:
1. I/We hereby confirm that all premiums have/will be paid from bona fide sources and no premium have/will be paid out of
proceeds of crime related to any of the offence listed in prevention of Money Laundering Act, 2002.
2. I understand that the company has the right to call for documents to establish the sources of funds.
3. The insurance company has the right to cancel the insurance contract in case I am/have been found guilty by any competent
court of law under any of the statues, directly or indirectly governing the prevention of money laundering in India.
4. Nationality: Indian Non-Indian
5. If Non-Indian, please specify the country___________________________________________

NCB Declaration
I/We declare that the rate of NCB claimed by me/us is correct and that no claim as arisen in the expiring policy period (copy of
the policy enclosed) I/We further undertake that if this declaration is found to be incorrect, all benefits under the policy in
respect of Section I of the policy will be forfeited.

Declaration by Insured
“I/We desire to insure with Universal Sompo General Insurance Company Limited in respect of the vehicle described in this
proposal form and confirm that the statements contained in this application are my/our true and accurate representations. I/We
undertake that if any of the statements are found to be false or incorrect, the benefits under this policy would stand forfeited.
I/We agree that this application and declaration shall be promissory and shall be the basis of the contract between me/us and
Universal Sompo General Insurance Company Limited.
I/We confirm that I/We have read and understood the coverages, the terms and conditions and agree to accept the company's
policy of insurance along with the said conditions prescribed by the Company. I/We also declare and undertake that if any
additions or alterations are carried out by me/us in this proposal form or if there is any change in the information as submitted
by me/us after the submission of this proposal form then the same would be conveyed to Universal Sompo General Insurance
Company Limited immediately failing which it is agreed and understood by me/us that the benefits under the policy would stand
forfeited.
I/We agree that the insurance would be effective only on acceptance of this application by the Company and the payment of the
requisite premium by me/us in advance. In the event of non-realization of the cheque or non-receipt of the amount of premium
by the Company the policy shall be deemed cancelled 'ab-initio' and the Company shall not be responsible for any liabilities of
whatsoever nature under this Policy”.
# “I am/we are aware that the complete terms and conditions of this insurance policy are available at the official website of the
insurer (www.universalsompo.com). I/We hereby consent to receiving only the certificate and schedule of insurance upon the
undertaking of the insurer that the complete policy terms and conditions will be made available free of cost upon my/our
request”.
# I hereby agree to receive a one pager policy document.

Place TENKASI
Date Signature of Proposer

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 whole or part of the

Proposal form – MOTOR GOODS CARRYING VEHICLE - CUM TAX INVOICE Policy UIN: IRDAN134RP0009V02200809
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
Ten Lakhs Rupees.

Universal Sompo General Insurance Co. Ltd.

Unit No 601/602, A wing, 6th Floor, Reliable Tech Park, Cloud City Campus, Gut No 31, Mouje Elthan,
Thane Belapur Road, Airoli -400708
Toll Free No: 1800224030(MTNL)/18002004030(Reliance) Direct No: 022 27639800(MTNL) 39133700(Reliance)

Proposal form – MOTOR GOODS CARRYING VEHICLE - CUM TAX INVOICE Policy UIN: IRDAN134RP0009V02200809