DEVELOPMENT 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: IRDAN149RP0006V02201213
COMMERCIAL VEHICLE CLASS (GCV) PACKAGE POLICY
Date : 28/12/2024

To,
Mr DEEPAK KUMAR PASI
AT PASI DHOWRA KARKEND GOPALI
DHANBAD
JHARKHAND 828116
Mobile:6205914587

Agent/ Intermediary Name and Code:RAM NARAYAN SINGH POS0014898

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. P0025400015/4103/102742, which has been issued based on the details furnished to us as below:

Insured & Vehicle Details

Name of Insured Mr D E E P A K K U M A R P A S I

Period of Insurance 28/12/2024 TO 27/12/2025

Vehicle Make/Model TATA / 407 STANDARD
RTO DHANBAD
Vehicle Registration No. JH - 10 - X - 3008
Vehicle Registration Date 07/09/2010
Engine No. 497SPTC35GZY629839
Chassis No. MAT357514A8G26667
Partial PA cover opted
Existing cover of Rs 0
Previous Policy Details
Previous Policy No P0024400010/4103/102710
Previous Policy Period 15/12/2023 TO 14/12/2024
Previous Year NCB% 50
Previous Insurer Name MAGMA HDI GENERAL INSURANCE CO. LTD.
Previous Policy Type Package

The information received from you is reproduced in the proposal attached with this Risk Assumption Letter and your proposal has been processed accordingly.
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 physical policy or any changes in the certificate of insurance cum policy schedule, you are requested to contact 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 issued policy is in order and as per 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.

Note: ,
Dear Customer , Magma HDI general Insurance Company may be storing your AML/KYC details and might require you to update the information submitted from
time-to-time, in accordance with and requirements under the Master Guidelines on Anti-Money Laundering/ Counter Financing of Terrorism (AML/CFT), 2022
issued by the Insurance Regulatory Development Authority of India.

Thanking You,
Regards

For Magma HDI General Insurance Co Ltd.

Authorised Signatory
 DEVELOPMENT HOUSE, 24 Park Street , Kolkata -700016
In case of any query, assistance or claims, please contact us at 1800 266 3202
UIN: IRDAN149RP0006V02201213

COMMERCIAL VEHICLE CLASS (GCV) PACKAGE POLICY

CERTIFICATE OF INSURANCE CUM SCHEDULE /TAX INVOICE
Policy Servicing Office 2ND FLOOR, SUN RISE HOTEL COMPLEX, BANK MORE, KATRAS ROAD, OPP. BARA GURUDWARA, ,DHANBAD -826001 ,JHARKHAND , PH: (1800) 2663202
Policy No P0025400015/4103/102742
Insured Mr DEEPAK KUMAR PASI
Period Of Insurance 00:10 Hrs of 28/12/2024
Address AT PASI DHOWRA KARKEND GOPALI
To Midnight of 27/12/2025
DHANBAD
RAM NARAYAN SINGH-POS0014898-
JHARKHAND 828116 Agent No.:
AGRPS5948Q-
Mobile:6205914587
Agent Contact No.: 7061088329
Contact Number 6205914587
Email ID: VIRSGIA1@GMAIL.COM
Email ID:
GST Number Unregistered
INSURED MOTOR VEHICLE DETAILS AND PREMIUM COMPUTATION
Registration Mark
Trolley Serial Trolley Year of
& No. & RTA Engine No. Chassis No. Make/Model/Type of Body GVW POLICY CLASS SEATING CAPACITY
ID Chassis No. Manufacture
Location
A1 GCV Public
JH 10 X 3008 /
2010 497SPTC35GZY629839 MAT357514A8G26667 TATA 407 STANDARD/TRUCK 5700 Carriers other 2
DHANBAD
than 3 wheelers
IDV (INSURED'S DECLARED VALUE)
Electrical/electronic
IDV of Chassis IDV of Body Trailers Non Electrical Accessories Bi-Fuel kit(LPG/CNG) Other accessories Total Value
Accessories
225000 0 0 0 0 0/0 0 225000
OWN DAMAGE(A) LIABILITY(B)
Basic - OD 815.40 Basic - TP 16,049.00
Loss/damage to lamps/tyres/mud guards etc. - IMT-23 122.31 PA Owner Driver -SI Rs.1500000 Tenure 1 Year(s) 450.00
Sub Total 937.71 Under WC act-Driver/cleaner/employees-IMT 28 100.00
Less: Sub Total 16,599.00
No claim bonus 50% 468.86
Sub-Total Deductions 468.86
Total Own Damage Premium(A) 469.00
CGST @ 9% 42.21
SGST @ 9% 42.21

Total Liability Premium(B) 16,599.00

GST on TP Premium
CGST @ 6% 962.94
SGST @ 6% 962.94
GST on Other Liability Premium
CGST @ 9% 49.50
SGST @ 9% 49.50
Premium Computation
Total Package Premium(A+B) 17,068.00
TOTAL CGST 1,054.65
TOTAL SGST 1,054.65
TOTAL 19,177.00
Disclaimer:The Exclusions in this policy are as specified in the pre inspection report ID :I/2024/400015/00580011
LIMITATIONS AS TO USE - The Policy covers use only under a permit within the meaning of the Motor Vehicles Act, 1988 or such a carriage falling under Sub-section 3 of
Section 66 of the Motor Vehicle's Act 1988.
The Policy does not cover use for a) Organised racing, b) Pace Making, c) Reliability Trials, d) Speed Testing, e) Use whilst drawing a trailer except the towing (other than for reward) of any one
disabled Mechanically propelled vehicle (only for Passenger Carrying Vehicles).
Persons or classes
of persons entitled Any person including Insured:
to drive:
Provided that the 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
Goods carriage person holding an effective learner's license may also drive the vehicle when not used for the transport of passengers at the time of the accident and that such a person satisfies
the requirements of Rule 3 of The Central Motor Vehicles Rules, 1989.
Provided that the 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
Non-transport
person holding an effective learner's license may also drive the vehicle when not used for the transport of passengers at the time of the accident and that such a person satisfies
Vehicles
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 Under In respect of any one Under Damage to Third Party Property Rs. Under PA Owner – Driver as per
Section I motor policy Section accident -- As per Section 750000/- in respect of any one claim Section III: premium computation
Compulsory : Rs. 500/- Voluntary : Rs. 0/- Imposed : II-I (i) Motor Vehicle Act II-I (ii) or series of claims arising out of one table
Rs. 0/- Total : Rs. 500/- event.
Subject to I.M.T Endorsement Nos. IMT 21,IMT 23,IMT 28
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.
NOMINATION DETAILS
Name Of the Nominee Date of Birth of Nominee Age of Nominee Relationship Percentage
MRS PASI 01/01/1981 43 Wife 100
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/400015/25/100802760- 28/12/2024 , 19177
Premium Amount in Word's ( ) :- Nineteen Thousand One Hundred Seventy-Seven Only
In case of Claims, please contact us at 1800 266 3202 For Magma HDI General Insurance Co. Ltd.
Date of Issue : 28/12/2024
Place : Kolkata
Consolidated Stamp Duty on the issue of General Insurance Policies Paid vide G.O No. 1289, dated 09/08/2024
GST Number of MHDI - 20AAGCM1685C1ZX
GST Invoice Number - POL2012250002675
GST Invoice Date - 28/12/2024
Accounting Code for Service - 997134, Motor vehicle insurance services

Place of Supply:JHARKHAND ( 20 )
Authorised Signatory
Whether Tax is payable on Reverse Charge - No
UIN : IRDAN149RP0006V02201213
This is a valid Tax invoice in terms of Sub-rule 2 of Rule 54 of CGST Rule 2017. Further, being an Insurance Company, 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. I/We hereby declare that though our aggregate turnover in any preceding financial year from
2017-18 onwards is more than the aggregate turnover notified 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.
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. Please note that any misrepresentation, non disclosure or withholding of material facts will lead to cancellation of policy ab initio with forfeiture of premium
and non consideration of claim, if any.

As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 31st October of the next financial year.
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) For detailed terms & conditions please refer our website www.magmahdi.com
 CUSTOMER INFORMATION SHEET

This document provides only key information about your policy. Please refer to the policy document for detailed terms and conditions.

Description
Sr No Title
(Please refer to the Policy Clause Number in next column)
1 Product Name COMMERCIAL VEHICLE CLASS (GCV) PACKAGE POLICY
2 Policy Number P0025400015/4103/102742
Unique Identification Number (UIN)
3 UIN: IRDAN149RP0006V02201213
allotted by IRDA
4 Structure Indemnity
Vehicle
Third Party liability
5 Interests Insured
Third party property Damage
Personal Accident cover - Driver
Sum Insured / Motor Insured Declared Vehicle Total IDV: 225000
6
Value Scope *IDV illustration as shown in the CIS
7 Policy Coverage As mentioned in policy schedule
PA Owner Driver -SI Rs. 1500000 Tenure 1 Year(s)
LL to Paid Driver IMT 28
Cover for Lamps Tyres and Tubes etc - IMT23
Basic - TP
Basic - OD
Damage to Third Party Property Rs. 750000

8 Add-on Cover
9 Loss Participation We will not pay the amount mentioned as deductible in the policy.
GENERAL EXCEPTIONS (Applicable to all Sections of the Policy)

Each vehicle should be used only for the purposes listed in the RC. We won't cover any loss, damage, or liability if the vehicle is
10 Exclusions used for other purposes or driven by someone who isn't an approved driver. Check the driver's clause for details.
Nuclear radiation related damages are not covered
We won't cover any accidental loss, damage, or liability related to war, invasion, civil unrest, and you will need to prove your
claim is unrelated to these issues to receive payment.
CONDITIONS

Please read the policy wording and the policy schedule together. The words and expressions mean the same whether it appears
in either of the document
•Immediately inform us if the insured vehicle meets with an accident or there is a situation for which you would want to claim.
Be transparent and submit all communications that you may receive from a third party. If you suspect any legal action related to
your claim do inform us in advance
•We will manage the claim process on your behalf. Do provide any information that we may need
•We can either repair, replace, or pay the cash value for the vehicle or its parts. The amount we will pay is limited to:
(a) For a total loss: the vehicle's Insured Declared Value (IDV) minus the value of the wreck.
(b) For partial losses: the reasonable repair or replacement costs, minus depreciation.
•Please maintain and protect the vehicle. Leaving it unattended after a break down or using in damaged condition can cause
further damage which will not be paid. We expect you will allow us to speak to the drive and your employees if required
•This policy can be cancelled by you any time buy giving us a 7 days' notice in advance. We will refund the premium that you
11 Special Conditions and Warranties (if any)
had paid after collecting short period charges. In the rare event, if required we can also cancel the policy but by sending a 7
days' notice. We will refund the premium after deducting the amount for the period your policy was active.
•If you will try to claim under other polices for the same incident, we will share the cost proportionately
•You and the other party can agree to resolve any disputes about this policy through arbitration, following the rules of the
Arbitration and Conciliation Act, 1996. (This doesn't apply to retail customers.)
•You must follow all the terms and conditions and provide truthful information in the proposal form. If not followed the Company
is not obligated to make any payments.
•If you are the only person insured by the policy and you pass away, the policy won't end right away. It will remain active for
three months from the date of your death, or until it expires, whichever comes first. During this time, your legal heirs can either
transfer the policy to their name or get a new one for the vehicle. They need to apply within the three-month period and
provide:
a) The Insured's Death Certificate
b) Proof of ownership of the vehicle
c) The original Policy
•You need to inform us in writing as soon as an accident or loss happens.
•We must have a chance to inspect the damaged vehicle before any repairs are started.
•If your vehicle meets with an accident or gets damaged, do not drive it in the same condition to avoid further damage. Also,
don't leave it unattended without securing it adequately to prevent further loss.

INDICATIVE LIST OF DOCUMENTS REQUIRED FOR CLAIM SETTLEMENT

Accident Claims
•Duly signed claim form
•Registration Certificate* of the vehicle
•Driving license* of the driver at the time of accident
•Police panchanama / FIR, if accident reported to the police
•Original estimate of repairs
•KYC documents
•Fitness certificate of the vehicle (for commercial vehicles)
•Road permit of the vehicle (for commercial vehicles)
•Goods receipt/ Lorry Receipt of the vehicle (for commercial vehicles)
•FIR in case of Riots, Strike & Malicious acts. It is mandatory
•Original repair invoice with payment receipt after repairs have been completed
Theft of Entire Vehicle Claims
•Duly signed Claim Form
•FIR Copy
•RTO transfer papers* (Form 28 , 29 and 30) and
•Form 35/NOC signed by financier, if applicable
•Letter of subrogation
•KYC documents
•NOC from financier, if hypothecation exists
•Copy of intimation letter to RTO on the vehicle theft
•Original policy document
•Non traceable certificate
•Original vehicle registration certificate
•All original keys of the vehicle/service book/original purchase invoice
*Original documents to be shown when requested by the company

if we need any more documents that can assist the claim process, we will seek your help on getting those
We will process your claim within 7 days after receiving all the necessary documents. If we decide to deny your claim, we will do
so within 7 days of the Survey Report or any additional reports, following the IRDAI (Protection of Policyholders' Interests,
Operations and Allied Matters of Insurers) Regulations, 2024 and any updates to these regulations.
12 Admissibility of Claim
Sample Claim Calculation Process for Motor Repair Loss

Price Tax
Parts Allowed *Depreciation (D) Total Assessed Value (V)
(P) (T)
Replaced Parts M A1 B1 D1 M1=A1+B1-D1
Replaced Parts R A2 B2 D2 M2=A2+B2-D2
Replaced Parts G A3 B3 D3 M3=A3+B3-D3
Total Parts Cost M = M1+M2+M3

Price Tax
Labour Allowed *Depreciation (D) Total Assessed Value (V)
(P) (T)
Labour 1 a1 b1 d1 L1=a1+b1-d1
Labour 2 a2 b2 d2 L2=a2+b2-d2
Labour 3 a3 b3 d3 L3=a3+b3-d3
Total Labour Cost L = L1+L2+L3

Compulsory Policy Excess As per Policy C

Voluntary Policy Excess As opted by Insured V
 Spot Repair / Towing Charge As per policy Section 1. Point 3, 4 T

Total Insurer Liability Total Liability = M+L+T-C-V

•Depreciation %
Depreciation will apply according to Section 1 of the policy conditions and the current policy terms.
•Salvage
We won't take any salvage costs directly from you. We'll handle the disposal ourselves. If you want to keep the salvage, we'll
subtract its value from your total claim and pay you the rest.

Here's how you can reach us: our helpline is available

Toll Free No- 1800 266 3202
24/7. Feel free to contact us whenever you need!
Website https://www.magmahdi.com/
Email customercare@magma-hdi.co.in

Chat with us at
www.magmahdi.com
Policy Servicing - Claim Intimation and Or
13 WhatsApp on 7208976789
Processing

For Senior Citizens Namaskar@magma-hdi.co.in

Social media Facebook and LinkedIn

Office Address: To know your nearest branch visit

www.magmahdi.com >> Contact Us >> Locate Us
https://www.magmahdi.com/more/contact-us?f=b.

For redressal of grievance you may contact:

Level 1: Grievance Redressal Officers at our branches available at

www.magmahdi.com >> Contact Us >> Grievance Redressal
https://www.magmahdi.com/documents/d/magma-hdi/branch-grievance-officer-list

Level 2: gro@magma-hdi.co.in

Level 3: Raise a complaint with the Insurance Regulatory and Development Authority (IRDAI)
Call us on our toll-free number 1800 266 3202 To register complaint online log on to www.bimabharosa.irdai.gov.in
Grievances Redressal and Policyholders
14
Protection Level 4: If you are still dissatisfied with the resolution offered by us you have the option to contact the Office of the Insurance
Ombudsman

To know the guidelines, log on to

www.cioins.co.in/About

To check list of Insurance Ombudsman Offices, log on to

www.cioins.co.in/Ombudsman

To know about our policy on Protection of Policy Holder's Interest log on to

www.magmahdi.com >> Legal >> Protection Of Policyholder's Interest Policy
Your policy will be canceled if you omit any key information on the proposal form.
15 Obligation of Policyholder If you need to update or change any important information about your policy, please contact our Customer Service at 1800 266
3202 or email us at customercare@magma-hdi.co.in.
IDV Illustration:
Ex-showroom price of vehicle: Rs. 10 Lakh
Vehicle Age at the time of renewal: 5 years
% Depreciation basis age of vehicle: 50%
IDV of car: Rs 5 lakh

Constructive Total Loss (CTL):

A vehicle is considered CTL if the aggregate cost of retrieval or repair exceeds 75% of its IDV.
No further depreciation is applied for TL/CTL claims

Declaration by the Policy Holder

I have read and confirm having noted the details.

Place: DHANBAD

Date: 28/12/2024
(Signature of the Policyholder)

Digital Acknowledgement Received.

*For detailed policy terms and conditions please refer to the policy wordings available on www.magmahdi.com or contact us on toll free number 1800 266 3202
 We at MAGMA HDI prefer receiving premium amount through cheque
No. CV/202412280001341

Helpline No : 1800 266 3202

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

Proposal Form for Commercial Vehicles

Customer ID 20015625932
*Proposal For: New Policy Roll- Over Renewal Endorsement

*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

* Period of Insurance: 28/12/2024 Time: 00:10 ,To 27/12/2025

(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)
Intermediary Code: POS0014898-AGRPS5948Q Intermediary Name: RAM NARAYAN SINGH

1. *Proposer Details:
1. Name (Registered Owner of the Vehicle): Mr DEEPAK KUMAR PASI

PAN No: DIDPP0975D *DOB: 01/01/1981 *Gender: M F *Occupation: Others *Marital Status: Married
Bank Name Branch Name A/c Type- Saving Current
Account No. MICR IFSC
Nationality Indian Non-Indian If, Non-Indian, please specify the Country:

Are you or any of the proposal applicants PEPs* or a close relative/associate of PEPs*? YES NO
If yes, please share the details of "Politically Exposed Persons" (PEPs):
* (PEPs) are individuals who have been entrusted with prominent public functions by a foreign country, including the heads of States or Governments, senior politicians, senior government or judicial or military officers, senior executives of
state-owned corporations and important political party officials

Type of Organization: (Applicable where an organization is the proposer. In case of proposer being Individual, Sole Proprietor or HUF, please select 'others' option)
Corporations Government Non-Government organizations Society

Trust Partnership / LLP Private Limited Company Co-operatives

Public Limited Company others, please specify: Individual

2. *Address where Vehicle Registered and Based
AT PASI DHOWRA KARKEND GOPALI, DHANBAD, JHARKHAND 828116, 6205914587 ,Mobile:6205914587
GST Number Unregistered
3. *Communication Address (For policy dispatch)
AT PASI DHOWRA KARKEND GOPALI, DHANBAD, JHARKHAND 828116
GST Number Unregistered
4. City where the vehicle will primarily be used: DHANBAD
5. Have you previously insured this vehicle? Yes No Policy No. P0024400010/4103/102710

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
*Vehicle Type: 2 Wheeler 3 Wheeler 4 Wheeler More than four wheels *Vehicle Insured is: New Used

*Make TATA *Chassis No MAT357514A8G26667 Speedometer reading as on date

*Model 407 STANDARD RTO where vehicle will be registered DHANBAD *Vehicle IDV 0
*Year of Manufacture SEPTEMBER - 2010 Date of Registration /Purchase 07/09/2010 Trailer(s) Identification No. 1_________
*CC/GVW 0 Licensed Carrying Capacity 2 2_________
(No of Passengers Including driver)
*Registration No. JH - 10 - X - 3008 Â 3_________
Type of Body TRUCK Colour of the vehicle 4_________
*Engine No. 497SPTC35GZY629839 Vehicle Make (Indigenous or Imported) 407 STANDARD
Note: Either Registration no or Engine and Chassis Number is mandatory
*Vehicle Rate Under: Zone -A Zone -B Zone -C
*Fuel Used: Petrol Diesel Bi Fuel LPG/CNG Electric Hybrid Others (please specify)
*Purpose of Use: Good Carrying (Private Carrier) Passenger Carrying (Private carrier) Good Carrying (Public Carrier)
Passenger Carrying (Public Carrier) Others (Please specify)
Proposed usage of the vehicle? (Applicable only to passenger carrying vehicles with seating capacity not exceeding 6)
Driven by the owner(s) only, Driven by the owner(s) only along with other drivers, Driven by other drivers, For rent to tourists, For rent to individuals for personal use,
Business purposes by Hotels, Business purposes by Corporates, Official purposes by foreign embassy/ consulate
*Type of Permit: Hilly National/State Highways City/Town Road District Roads Others
* Average Monthly usage : Less Than 500 Kms; Between 501 and 2500 Kms; Between 2501 to 5000 Kms ; Above 5001 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 ..........................................

Nature of Goods carried by vehicle Hazardous Non-Hazardous

7. Financier Details: Hypothecation Hire Purchase Lease Financier Name :

8. Nominee Details : Nominee Name: MRS PASI DOB 01/01/1981 Relationship Wife
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 *Vehicle Chassis Value 225000
Not exceeding 6 months 5% Vehicle Body Value
Exceeding 6 months but not exceeding 1 year 15% Non- Electrical Accessories (Other than factory fitted): Details

Exceeding 1 year but not exceeding 2 years 20% Electrical Accessories (Other than factory fitted) Details
Exceeding 2 years but not exceeding 3 years 30% Bi- Fuel/ CNG/LPG Kit
Exceeding 3 years but not exceeding 4 years 40% Trailer(s)/ Side Car Value (only for 2 wheelers):
Exceeding 4 years but not exceeding 5 years 50% Total IDV:
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 (If owner has a valid driving license) Personal Accident Cover ( Max Rs 1 lakh for two-wheelers and Rs 2 Lakh for other class of vehicles each in multiples
Yes No of Rs. 10000/- ) for paid driver / cleaner / conductors

No. of Persons. 0 CSI per person 0

Legal liability to paid driver/ conductor/ cleaner employed in operations of vehicle

No of Persons 2
Legal liability to employees travelling in/driving the vehicle other than paid driver. Legal liability non-fare paying passengers
No. of Persons No. of Persons. ___________________ CSI per person _______________________
Additional Towing charges: Amount: ..........
Vehicle used for Private and commercial purposes : Yes No

Cover for overturning of Mobile Cranes, Mechanical Navies, Shovels, Grabs, Rippers and Excavators, Dragline
Do you wish to cover for loss or damage to lamps, tyres, tubes, mudguard, bonnet
Excavators, Mobile Drilling Rigs and Mobile Plants?
side parts, bumper and paint work? ( Not applicable for taxis ) Yes No
Yes No
Do you wish to have an enhanced Personal accident cover for Yourself Do you wish to cover Hospital Cash for hospitalisation arising out of accident
Your Driver / unnamed occupants of the vehicle ? for Yourself / Your Driver / Unnamed occupants of the vehicle?
Yes No Yes No
If Yes, please provide the Sum Insured per person
11. Add On Coverage at additional :

12. Restrictions of Cover/ Discounts:

Vehicle fitted with Anti-theft device approved by ARAI : Yes No Is the vehicle specially designed for the use by a handicapped person and/ or owned by an institution
exclusively engaged in service of the blind, handicapped and mentally regarded children or adults?
Vehicle will be used within own premises : Yes No
Yes No
Third Party Property Damage cover restricted to 6000 Yes No

*Voluntary Deductible : Yes No

Amount: ..........
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: MAGMA Type of cover: Package
Policy/ Cover note number: P0024400010/4103/102710 Period of Insurance: From 15/12/2023 To 14/12/2024
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): 19,177.00 Payment Mode : Cash Cheque DD
Cheque/DD, Cheque No 305649 Bank/Branch AXIS BANK LTD. / RAMGARH [JHARKHAND] Date. 28/12/2024
Source of Funds for premium payment: Business: Salaried: Others (please specify):
16. Electronic Insurance Details
• Do you wish to have this Policy credited to an eIA? (Please select any one)
• No, I do not have an eIA and do not wish to open one Yes, Credit this Policy to my e-Insurance account
• If yes, Please share existing e-Insurance Account No :
• Please select Insurance Repository Name (you have opened your account with)
• M/s NSDL Database Management Limited M/s Karvy Insurance Repository Limited
• M/s Central Insurance Repository Limited M/s CAMS Repository Services Limited (Please select any one) Or
• I do not have existing e-Insurance account and I am interested in creating a new e-Insurance account (Please submit electronic insurance account opening form (eIA form) along with relevant documents)
• My CKYC No. (Central Know Your Customer registry number) is (if available):
• Representative Details (only if eIA is to be opened for any other person other than Proposer and primary Insured)
First Name :
Middle Name :
Last Name :
Gender :
DOB :
PAN :
Address Line 1 :
Address Line 2 :
Address Line 3 :
Pin Code :
Telephone Number :
Mobile Number :
Relationship :
Other Relationship :
Email Id :
UID :
LandMark :
State :
City :
Country :

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 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 confirm that all premiums paid / payable in future are from bonafide sources and not paid out of proceeds of crime and that such premiums are not disproportionate to my/our income.
I / we understand that the Company has the rightPF to call for documents to establish sources of funds and to cancel the insurance policy in case
I / we are found guilty by any competent court of law under any of the statutes, directly or indirectly governing the prevention of money laundering law in India.
I hold a valid and effective PUC and/or fitness certificate, as applicable, for the vehicle mentioned herein and undertake to renew the same during the policy period.
I wish to get all policy related communications on My Whatsapp Number:_____________________ and allow to make welcome calls, Services calls or any other communication(electronic or otherwise),subject to the provision of
applicable law. The salient features of the policy,terms and conditions of this proposal have been explained to me/us in___________________ language, and I/we agree to the same.
I/We hereby give my/our consent to the Company to verify and obtain my/our identity/address proof as well as the identity/address proof of the insured through Central KYC Registry or UIDAI or through any other permitted modes for the
purpose of undertaking applicable KYC.

__________________________________
Place: Kolkata Date: 27/12/2024 Signature of Proposer
SECTION 41 INSURANCE LAWS (AMENDMENT) ACT, 2015 - 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.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.