TWO WHEELER PROPOSAL FORM

Proposal No. :QVMPB156165605

Name of Intermediary : Policybazaar Insurance Brokers Private Limited AG Code : AG023760

IMPORTANT (All Fields are mandatory) The details provided in this proposal form is based on the details as shared by you to Policybazaar Insurance Brokers
Private Limited and is factually correct.
❖ Please complete the form in CAPITAL LETTERS, using a black pen. ❖ The liability of the Company does not commence until the Company has accepted the Proposal Form duly filled in all respects
and the full premium is paid. For any clarification on the cover, terms, etc., please contact Royal Sundaram.❖ All questions in the form must be answered and it must be signed and dated. Continue on a
separate sheet if necessary and attach as part of the Proposal Form.❖ Attach latest proof of No Claim Bonus if applicable.❖ Attach any other information material to the risk proposed.❖ 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 Certificate of Motor Insurance.

ABOUT YOURSELF
Title Mr. Mrs. Miss Others (please specify)
Name: RAMYA MANI
First Name Middle Name Last Name

Date of birth: Are you Married? Yes No

Permanent D/O: MANI, NO 32 B, MELATHERU, KOVILPATHTHU, SIRKALI, NAGAPATTINAM, SIRKALI, TAMIL NADU, 609110
Address

City:
State:
Pincode: 609110
Communication NO 32 B MELATHERU KOVILPATHU S
Address IRKALI TK

City: NAGAPATTINAM
State: TAMILNADU Pincode: 609110
Daytime Phone(s):
Mobile No. : XXXXXX1203
STD CODE
KYC Documents (Mandatory)
Pan FORM60 PAN No. : DOB : CKYC Number :
(For Individual Customer) (For Corporate Customer)
Driving License No Passport No Aadhar Number
Principal Officer
Name as per Aadhar Passport File No
Name as per Aadhar
Aadhar Number Registration Certificate Power of Attorney to transact business
Certificate of Incorporation and Memorandum & Article of Association
Any official document identifies partners/trustee/Foundations
Voter ID Card No NREGA Job Card
Please Specify_____________________________
Resolution of Board of directors to open account/
Mobile/Telephone Bill Bank Passbook/Account Statement
Resolution of managing body of the foundations/Association
Partnership/Trust deed
Electricity Bill Ration Card Employer Certificate
PAN allotment letter
Lease Agreement with Letter from any Public
Rent Receipt Authority or from UIDAI
Activity proof 1(for sole proprietorship only)
Activity proof 2(for sole proprietorship only)
Others Please Specify__________________ Others Please Specify__________________
E-mail: P**************7@G***L.COM
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 titles below, please tick against all the applicable heads.
Low Risk Category
Pvt. Sector Govt. Employee Self Employed RS Employee Head of the state or Government Employee - IT or ITES
Sports Persons SeniorGovernment/judicial/Military Officer Senior Executives of State - Owned Corporations Student
Retired Employee Company Owned Others Others(Please Specify)
High Risk Category
Film Industry Real Estate Senior Politician Important Political Party Official House Wife Jewelry Proprietor
Chit fund Proprietor Bullion Dealers Trust,Charities,NGO with Foreign Funding Others Others(Please Specify)
AADHAR NUMBER
a) For Individual Customer:

Name as per Aadhar :

Aadhar Number : Date of birth of Insured : Gender :
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 :

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.

UIN-IRDAN102RP0001V01200607
Two Wheeler
ABOUT YOUR TWO WHEELER. Please give full details:
Address as per NO 32 B MELATHERU KOVILPATHU S Fastag _________________________________
Registration Certificate : IRKALI TK

City: SIRKAZHI
State: Tamilnadu Pincode: 609110
Period of Insurance: From 22/12/2024 To 21/12/2025

Registration No. : TN82V0412 Date of Registration : 30/08/2019

Engine No. : XXXXXXXXXX1878 Cubic Capacity : 100

Chassis No. : XXXXXXXXXXXXX2395 Seating Capacity(including Rider) : 2

Make & Model : HERO HONDA, Pleasure Scooter - 2 Seater Current ownership New Vehicle Used Vehicle
Registering Authority : SIRKAZHI Type of Fuel Petrol Diesel CNG LPG
Others_____________________________________________(please specify)
Year of Manufacture : 2019

(Please tick appropriate)

1. Is the vehicle financed HYPOTHECATION Hire Purchase/Hypothecation/Lease? Yes No
Name and address of the finance company SHRINITHI CAPITAL PRIVATE LIMITED
2. Do you wish to opt for higher deductible over and above the compulsory deductible of Rs.100? Yes No
If 'Yes' please specify the amount. 500/750/1000/1500/3000 ______________________
3. Whether use of the vehicle is limited to own premises? Yes No
4. Whether vehicle is used for commercial purposes? Yes No
5. Whether vehicle belongs to foreign embassy/consulate? Yes No
6. Whether the vehicle is fitted with fibre glass tank? Yes No
7. Whether the vehicle is driver by non-conventional source of power? Yes No
If 'Yes' please give details ___________________________________________________________________________________________________________
8. Whether vehicle is designed for use of Blind/Handicapped/mentally challenged persons and duly endorsed as such by RTA? Yes No
9. Are you a member of Automobile Association of India? Yes No
If 'Yes' please state: Name of Association_____________________Membership No.________________________Date of expiry_________________________
10. Whether the vehicle is used for driving tuitions? Yes No
11. Whether extension of geographical area to the following countries required ? Yes No
Bangladesh, Bhutan, Maldives, Nepal, Pakistan and Sri Lanka.
If 'Yes' state the name of the countries. 1)____________________________ 2)______________________________ 3)________________________________
12. Is the vehicle fitted with an anti-theft device approved by Automobile Research Association of India (ARAI), Pune and the installation certified by a
recognised Automobile Association? Yes No
If 'Yes' attach full details, including copies of purchase & installation and Automobile Association approval Documents.

Additional Towing charges of 100 or 200 or 300 opted for over and above the limit prescribed in the policy.
If you wish to include this cover, state the limits required.
INSURED DECLARED VALUE OF THE VEHICLE & ANY ACCESSORIES

Vehicle* Non-electrical accessories Electrical & Electronic Side Car (Two Wheeler) Value of Total
fitted to the vehicle accessories fitted to the vehicle CNG/LPG Kit
30,117.00 0.00 0.00 30,117.00
Note :
The Insured's Declared Value (IDV) of the vehicle will be deemed to be the 'SUM INSURED' for the purpose of this Policy which is fixed at the commencement of
each Period of Insurance for the insured vehicle.
The IDV of the vehicle (and side car/accessories, if any, fitted to the vehicle) is to be fixed on the basis of the manufacturer's listed selling price of the brand and model
as the insured vehicle at the commencement of insurance/renewal and adjusted for depreciation (as per schedule below).
The insured vehicle shall be treated as CTL if the aggregate cost of retrieval and/or repair of the vehicle, subject to Terms and Conditions of the Policy, exceeds 75%
of the IDV of the vehicle.

Age of Vehicle % of Depreciation for fixing IDV

Not Exceeding 6 months 5%
Exceeding 6 months but not exceeding 1 year 15%
Exceeding 1 year but not exceeding 2 years 20%
Exceeding 2 year but not exceeding 3 years 30%
Exceeding 3 years but not exceeding 4 years 40%
Exceeding 4 years but not exceeding 5 years 50%

UIN - IRDAN102RP0001V01200607
Two Wheeler
BENEFITS UNDER OUR POLICY:
• LIABILITY TO THIRD PARTIES
The policy provides Third Party Property Damage (TPPD) of Rs 1 lakh. Do you wish to opt for statutory TPPD liability coverage of 6000/-
only. Yes No
Do you wish to cover legal liability to a) Paid Driver Yes No b)Employess Yes No
If yes, number of employees______________________(Maximum restricted to seating capacity)
PERSONAL ACCIDENT (PA) COVER
• Registered owner has valid driving license Yes No
• Compulsory Personal Accident (CPA) Cover For Owner Driver Yes No
If Yes, Capital Sum Insured lakhs (15 lakhs to 50 Lakhs) *Multiples of Lakhs

If No, Tick any of the three options

Registered owner doesn’t have valid Driving License

Registered owner having CPA cover with other motor policies

Registered owner having PA cover of Rs.15 lakhs and above

• Do you wish to include PA cover for unnamed persons/pillion passengers? Yes No
If yes, give the number of persons and Capital Sum Insured (CSI) opted. The maximum CSI available per person is 1 lakh
Number of Persons CSI Opted ( )

• Do you wish to include PA cover for Paid Driver? Yes No

If yes, Capital Sum Insured opted__________________________________________________
• Imposed excess Rs 1000 for each and every claim.

ADD ON COVERS
Enchaned PA Cover RSMOAC401 Would you like to opt for the Enchanced PA Cover? Yes No
What limit would you like to opt for PA to Owner-Driver 0 (In lakhs)
What limit would you like to opt for PA to each Unnamed Passenger 0 (In lakhs)
What limit would you like to opt for PA to Paid Driver 0 (In lakhs)

Depreciation Waiver Clause RSMOAC402 Would you like the Depreciation applicable on parts to be waived, in case of a partial loss claim. Yes No

Engine Protector Cover TWAC03 Would you like to opt for Engine Protector Cover? Yes No
Type of Parking (Please tick)
Covered
Covered Parking
Parking (Basement Unknown
(Not basement)
Parking in ground)

Return to Invoice Cover TWAC04 Would you like to opt for Return to Invoice Cover? Yes No
PlanA PlanB
Plan A - Invoice Value + First time Registration Charges + Road tax + Cost of Insured Accessories
Plan B - Invoice Value + First time Registration Charges + Road tax + Insurance Cost + Cost of Insured
Accessories

RoadSideAssistance Cover Would you like to opt for RoadSideAssistance Cover? Yes No

PREVIOUS HISTORY
1. Is the vehicle in a roadworthy condition and free from damage? Yes No If 'No' please give full details
If 'No' please give full details:_____________________________________________________________________________________________________________
2. Will the vehicle be used exclusively for:
a. Private, social, domestic, pleasure & professional purposes Yes No_________________________________________________________________
b. Carriage of goods other than samples or personal baggage Yes No_________________________________________________________________
3. Name and address of the previous insurer___________________________________________________________________________________________________
4. Previous Policy No.______________________________________________ Policy Period 16-Sep-24
5.Add on covers in previous policy:
6. Type of cover Liability only cover Package cover Others (specify)______________________________________________________________________
7. Has any insurance company ever:
a) Declined the proposal Yes No
b) Cancelled & refused to renew Yes No
(If 'Yes' reasons there of ________________________________________________________________________________________________________
c) Imposed special condition or excess Yes No
(If 'Yes' reasons there of ________________________________________________________________________________________________________
DECLARATION - NO CLAIM BONUS
 Imposed Excess for each and every claim: Deductible for Partial Loss : Rs. 0 and Deductible for Theft Loss : Rs 0 and Deductible for
Total Loss : Rs.0 and Deductible for Total Fire Loss : Rs. 0 and Deductible for Total Flood
Loss : Rs. 0.
Are you entitled to No Claim Bonus Yes No (If 'Yes' please submit proof from your previous insurer.)
I hereby declare that I have not made claim (or) I have made claim under my previous Policy No_____________________________________ issued by
___________________________________I/We declare that the rate of NCB of 0% claimed by me/us is correct. 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 stand forfeited.

Does the vehicle have valid Pollution Under Control (PUC) Certificate? Yes No
PUC 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

UIN - IRDAN102RP0001V01200607
Two Wheeler
 *Payment must be made favouring Royal Sundaram General Insurance Co. Limited

Authorization for electronic policy fulfilment and service communication(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.
AML Guidelines- Declaration of Insured
I/we hereby confirm that all premiums have been/will be paid from bonafide sources and no premiums have been/will be paid out of proceeds of crime related
to any of the offence listed in Prevention of Money Laundering Act, 2002.

I understand that the Company has the right to call for documents to establish sources of funds.

The insurance company has right to cancel the insurance contract in case I am/ have been found guilty by any competent court of law under any of the statutes,
directly or indirectly governing the prevention of money laundering in India.

I hereby authorize Royal Sundaram General Insurance Co. Limited to upload/download the required KYC documents pertaining to me in/from the CKYC
portal.

PREMIUM COMPUTATION SUMMARY

Basic OD Premium 302.00 Basic TP 714.00

Other OD Covers 0 Other TP Covers 0
Total TP Premium 714.00
NCB(0%) 0.0 Total OD + TP Premium 1,016.00
Add on Premium 0 IGST : 182.88
Total OD Premium 302.00 Premium inclusive of GST 1,198.88
COMPULSORY DEDUCTIBLE
The Policy excludes the first portion of each claim for loss or damage to the Motor Car. The amount of the Deductible is Rs.100.
DECLARATION
Before signing the Declaration check your answers carefully, particularly if this Proposal Form was completed by another person on your behalf.
I/we declare that to the best of my/our knowledge and belief the answers given are true and all material information has been disclosed.
I/we agree that if any answers have been completed by any other person such person shall for that purpose be regarded as my/our agent and acting on my/our behalf and not the agent of
Royal Sundaram General Insurance Co. Limited.
I/we declare that this Proposal Form is for insurance in the normal terms and conditions of the Insurer's Policy and shall be incorporated in and form part of the insurance contract.
• If any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the Insurers immediately
• 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 Certificate of Motor Insurance.
• Attach any other information material to the risk proposed
Place: NAGAPATTINAM
Date: 20/12/2024 *Signature of the proposer (Vehicle Owner)
This proposal form is electronically signed by the proposer by way of
validating One Time Password(OTP) send to his/her registered mobile number

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 p rospectus 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.
Dear Customer, Thank you for choosing Royal Sundaram as the Insurer of your vehicle.We are delighted to have you as our customer. Please find enclosed Two
Wheeler Quote No. QVMPB156165605 which has been issued based on the details submitted to us by the Insurance Broker - Policybazaar Insurance Brokers Private
Limited. The details provided in this proposal form is based on the details as shared by you to Policybazaar Insurance Brokers Private Limited and is factually correct.
 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-600002
Royal Sundaram IRDAI Registration No.102 | CIN:U67200TN2000PLC045611

✆1860 425 0000 | 1860 258 0000 ✉ customer.services@royalsundaram.in | www.royalsundaram.in

Insurance is the subject matter of solicitation. PR18300/JAN19

UIN - IRDAN102RP0001V01200607
Two Wheeler