Bajaj Allianz General Insurance Company Ltd.

Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune

Transcript of Proposal for Two Wheeler Policy - Bundled

Dear DIVYANSH AGRAWAL,

We wish to inform you that the contract under policy number 'OG-24-4323-1826-00004941' has been finalized based on the
information and declaration given by you, the transcript whereof is mentioned below. You are requested to reconfirm the same.
In case of any disagreement or objection or any changes with respect to information mentioned below, we request you to
please revert back within a period of 15 days from date of your receipt of this, failing which it will be deemed that you are
satisfied with the correctness of the details mentioned below. Kindly note that as the contents and declarations contained in this
transcript is the basis on which we have issued the policy to you, we advise you to please ensure that you have
provided/disclosed and or not withheld any material facts/information and declarations, as Policy becomes Void ab initio if
material facts are not provided/disclosed and or withheld and in such case no claim, if any, will be considered by us apart from
forfeiture of the premium.
Details provided by you:

A. Proposer details
1. Proposer Name : DIVYANSH AGRAWAL
2. Proposer Address : 25 ASHISH AGENCY WORLD CUP SQUARE PIPLIYAHANA RING ROAD
INDORE,
, , INDORE, MADHYA PRADESH-452001
3. Proposer Mobile Number : 9425316123
4. Proposer Residential Number : NA
5. Proposer e-mail id : AGRAWALDIVYANSH07@GMAIL.COM
6. Proposer Profession : NA

B.Vehicle Details
Registration Month / Year Vehicle Vehicle Vehicle Sub Cubic Capa- Fuel Type Year of Man- Seating Ca-
Number of Regn Make Model Type city/Kilowatt ufacture pacity
MP09ZW250 AUG/2023 HERO MO- SPLENDOR SELF AL- 97 Petrol 2023 2
2 TOCORP PLUS LOY DRUM
100 MIL-
LION EDI-
TION BS VI

Engine Number Chassis Number Vehicle IDV (in Electrical Non-Electrical CNG/LPG Unit Total IDV (in
Rs.) Accessories Accessories (Extra fitted) Rs.)
IDV (in Rs.) IDV (in Rs.) IDV (in Rs.)
HA11E8P4H150 MBLHAW238P4 70,443.00 0 0 0 70,443.00
05 H09808
 C. Coverage opted

1. Period of Insurance
For Own Damage Section From 31-AUG-2023 11:51(Hrs) To 30-AUG-2024 Midnight
For Third Party Liability Section From 31-AUG-2023 11:51(Hrs) To 30-AUG-2028 Midnight
2. Is your vehicle fitted with external LPG/CNG kit : No.
3. Electrical Accessories cover Opted (If Applicable) : No.
4. Non - Electrical Accessories cover Opted (If Applicable): : No.
5. Is Voluntary Excess opted : No.
Amount of voluntary excess opted : Rs.NA.
6. Whether PA cover is opted for owner-driver : No.
PA cover is exempted for owner-driver with Reason :Owner does not have Valid Driving
License
7. compulsory deductible : Rs.100.00
8. Is any additional compulsory deductible imposed and agreed upon : No.
Amount of additional compulsory deductible imposed : NA.
9. Whether geographical area extension is opted : No.
Details of Countries to which geographical area extension cover is given : NA.
10. Is LL to person for Paid driver/Operation/Maintenance opted : No.
11. Whether PA cover is opted for paid driver other than owner driver : No.
Sum Insured for Paid Driver : Rs.NA.
13. Is TPPD restricted to statutory limit of Rs.6000? : Yes.
14. Pre Existing damages in the vehicle : NA.
15. 1 Premium for Liability coverage, quoted and agreed upon is :
16. 1 Premium for OD coverage, quoted and agreed upon is :
17. Do you have valid PUC certificate of the vehicle : NA
18. Do you have valid Fitness certificate of the vehicle : NA
19. Total Premium (excluding Goods and Service Tax (GST)) for Liability and OD coverages, quoted and agreed upon is
:
20. NCB (No Claim Bonus) claimed by you and granted by us based on your declaration of no claim during your previous
previous policy : 0 %.
21. About the last insurance company
(i) Insurance Provider : .
(ii) Previous Policy No : NA , Previous Policy Expiry Date : NA
22. Whether your vehicle is Hypothecated and if so the details of Pledgee whose name is registered by us: No.
Name of Pledgee : NA.
23. Add on Cover(s) optedm3: No.Plan name:NA

24. To support our Go Green initiative, send policy copy link on registered mobile number / email id: YES

I/We hereby give voluntary consent to BAGIC/Company to share my/our personal information and data provided in this
proposal form with its group companies or any other person in connection with the Insurance Policy or otherwise, including for
providing products and services of group companies that may be of interest to me/us, to be used in accordance with their
respective privacy policies and subject to appropriate measures being in place to safeguard my/our personal information : Yes
Please note Cover Note No. / issued to you basing on the above information.
In case of Disagreement or objection or any changes with respect to information and contents mentioned hereinabove, please
contact our toll free number & register your objections/changes/disagreement to the contents of this transcript or you may also
send us email or written correspondence at the following details within a period of 15 days from date of your receipt of this
transcript along with Policy:
I/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.
Toll free Number : 1800-102-5858,1800-209-5858
Email address : Bagichelp@bajajallianz.co.in
Website : www.bajajallianz.com
Contact our policy servicing branch at: 12th floor Dr. Gopaldas Bhawan,, 28 Barakhamba Road ,, Connaught Place , New
Delhi, , CENTRAL DELHI-110001 PH:011-46561306.
INSURANCE ACT, 1938 SECTION 41 - PROHIBITION OF REBATES
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 renewing a policy
accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.
ANY PERSON IN BREACH OF COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE
WITH FINE WHICH MAY EXTEND TO RUPEES TEN LAKH.Bajaj Allianz General Insurance Co Ltd
  

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

Regd. Office & Head Office: GE Plaza, Airport Road, Yerwada,Pune-411006(India)
IRDAI Registration No. 113
Corporate Identity Number: U66010PN2000PLC015329
Certificate of Insurance (Two Wheeler Policy - Bundled)
UIN : IRDAN113RP0008V01201819
Policy Number: OG-24-4323-1826-00004941 Customer ID: 439134820
Particulars of Vehicle Insured:
Registration Number Place of Registration Engine Number Chassis Number Make & Model
MP09ZW2502 THANE HA11E8P4H15005 MBLHAW238P4H09 HERO MOTOCORP -
808 SPLENDOR PLUS

Sub Type Year of Mfg NCB % CC Seating Capacity Final Premium

SELF ALLOY DRUM 100 MILLION EDI- 2023 0 97 2 4817
TION BS VI

Name of Registration Authority : THANE

Name and Address of Insured : DIVYANSH AGRAWAL
: 25 ASHISH AGENCY WORLD CUP SQUARE
PIPLIYAHANA RING ROAD INDORE, , , INDORE,
MADHYA PRADESH-452001
Geographical Area : .00
Business or Profession : NA
Effective date of commencement of Insurance for the purpose of act:
For Own Damage Section From 31-AUG-2023 11:51(Hrs) To: 30-AUG-2024 Midnight
For Third Party Liability Section From 31-AUG-2023 11:51(Hrs) To: 30-AUG-2028 Midnight
Persons or Class of Persons entitled to drive:
Any person including the insured:
a) 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.
b) 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.
IMT-Endorsements/Add on Package
22, 20
Beneficier Details:
Beneficier1 Beneficier2 Beneficier3 Beneficier4 Beneficier5

Limitations as to Use:
The Policy covers use 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) Any purpose in connection with Motor Trade
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 provi-
sions of Chapter X and Chapter XI of M.V. Act, 1988.
Policy issuing office and correspondence address for communication by holder of Certificate of Insurance for claim,
service request, notice, summons, etc:
12th floor Dr. Gopaldas Bhawan,, 28 Barakhamba Road ,, Connaught Place , New Delhi, , CENTRAL DELHI-110001
PH:011-46561306
Date of issue :17-JUN-2024
For help and more information:
Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at
Bagichelp@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 17-Jun-2024 19:29:11 PM- rajesh lot (Web) (NA)
For & On Behalf of
Bajaj Allianz General Insurance Company Ltd.
Now carry your m-policy on your mobile. Click here to download. https://bagic.page.link/zNwbgG

Authorized Signatory
  

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of
India [IRDA] vide Reg No.113)
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada,Pune-411006(India))
TWO WHEELER POLICY - BUNDLED SCHEDULE
UIN : IRDAN113RP0008V01201819
Policy issuing office and Correspondence address for communication by policyholder for claim, service request, notice, summons, etc:
12th floor Dr. Gopaldas Bhawan,, 28 Barakhamba Road ,, Connaught Place , New Delhi, , CENTRAL DELHI-110001 PH:011-46561306
INSURED DETAILS POLICY DETAILS
Insured Name DIVYANSH AGRAWAL Policy Number OG-24-4323-1826-00004941
25 ASHISH AGENCY WORLD CUP Policy Issued on 17-JUN-2024 19:28 PM
Insured SQUARE PIPLIYAHANA RING ROAD
INDORE, , , INDORE, MADHYA PRA- For Own Damage Section
Address DESH-452001
Geographical From : 31-AUG-2023 11:51 (Hrs)
India,000
Area To : 30-AUG-2024 Midnight
Customer ID Policy Period For Third Party Liability Section
439134820
From : 31-AUG-2023 11:51 (Hrs)
Bank Reference
No 1 To : 30-AUG-2028 Midnight
Cover Note
GSTIN / UIN NA /
Details
Place of Supply/ 23 - Madhya Pradesh
State Code/Name Previous Policy No 0

Invoice No 390748766/4

Company GST No 07AABCB5730G1ZZ

Company PAN AABCB5730G

Make & Mod-

Registration Number Place of Registration Engine Number Chassis Number SubType
el
SELF ALLOY
HERO MOTO-
DRUM 100
MBLHAW238P4H CORP -
MP09ZW2502 THANE HA11E8P4H15005 MILLION
09808 SPLENDOR
EDITION BS
PLUS
VI
NCB % CC/KW Seating Capacity Year Of Manufacturing Hypothecation Details
0 97 2 2023
Non electrical Electrical/Elec- Value of CNG/
Vehicle IDV Value For Side Car Total Value
accessories tronic accessories LPG kit
70,443.00 0 0 0 0 70,443.00
Own Damage Premium(Rs.) Liability Premium(Rs.)
Own Damage Premium 481.00 Basic Third Party Liability 3,601.00
Special Discount 0.00 Total Act Premium - B 3,601.00
Total OD Premium - A 481.00
Total Premium (Net Premium) (A+B) 4,082.00
Integrated GST (18%) 735.00
Final Premium ( Rupees Four Thousand Eight Hundred 4,817.00
Seventeen Only )
**Note: The above Total OD Premium is inclusive of all applicable Loading /Discounts viz (Automobile association membership, Voluntary Excess,

For help and more information:

Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at Ba-
gichelp@bajajallianz.co.in or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 17-Jun-2024 19:29:11 PM- rajesh lot (Web) (NA)
  

Anti Theft, Handicap Person, Driver Tuition, Fiber Glass, CNG/LPG Unit, Geographical Extension, Imported Vehicle Etc. wherever Applicable)

As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th September of the next financial year
I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover noti-
fied under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.

Limitation as to Use The Policy covers use of the vehicle for any purpose other than : Hire or reward, Carriage of
goods( other than samples or personal luggage),Organised racing,Pace making, Speed testing,
Reliability trials. Any purpose in connection with Motor Trade.
Driver Any person including the insured provided that a person driving holds an effective driving li-
cense 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
when not used for the transport of goods/passengers at the time of the accident and that such a
person satisfies the requirements of Rule 3 of the Central Motor Vehicle Rules, 1989.
Limits of Liability Under section II-I(i) of the policy -> Death of or bodily injury : Such amount is necessary to meet
there requirements of the Motor Vehicles Act,1988. Under section II-I(ii) of the policy -> Dam-
age to Third Party Property : Rs. 1,00,000/- for Motorized Two Wheelers and Rs.7,50,000 for
others or Rs.6,000/-,where the proposer / insured opts to limits the TPPD liability to the statutory
limit of Rs.6,000/-
No Claim Bonus
Existing Damage Details NA
Nominee Details Name :NA - Relationship :NA
Subject to Warranties/ 22, 20
IMT-Endorsements/
Add on Package
Additional Details Coinsurance Details: - . Transaction Id: -
Premium Details Receipt No. 1101-01326361, Date 31-AUG-23 ** If Premium paid through Cheque, the Policy is
void ab-initio in case of dishonour of Cheque.
Excess Details Compulsory Excess: Rs.100.00 Additional Excess: Rs.0 Voluntary Excess: Rs..00
Theft Excess: Rs.0
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 & On Behalf of
Bajaj Allianz General Insurance Company Ltd.

Stamp
Duty Rs.
0.50

Authorized Signatory
This document is digitally signed, hence counter signature / stamp is not required.
Consolidated Stamp Duty of Rs. 0.50/- paid for insurance policy stamps vide Order No. CSD/105/2023/3494 dated 21-AUG-23 of General Stamp Office, Mumbai, India.

Principal Location : Block No-4, 7th Floor, DLF Towers, 15, Shivaji Marg, -, New Delhi - 110015 PH:011-66278000 | Services Accounting
Code : 997134 - Motor vehicle insurance services. No reverse charge is payable on these services.