Bajaj Allianz General Insurance

Generation Date: 19-Oct-2010

Name of Insured: Ashis Kumar Rout
Address : 2225,R G MANSION, CHANDRA NAGAR, KUMARSWAMY LAYOUT,2ND STAGE
, BANGALORE, KARNATAKA-560081

Dear Ashis Kumar Rout,

We thank you for utilizing the online services of Bajaj Allianz General Insurance Co. Ltd. This has
reference to your policy number OG-11-9906-1802-00011443 for your Two Wheeler - Package Policy
Insurance.

Enclosed please find the policy schedule ,policy wordings containing detailed terms and
conditions of the coverages and the online Proposal Form cum declaration submitted by
you ,before buying the policy . We wish to inform you that the premium quoted is based on the
information submitted in the proposal forms as well as the acceptance of the terms and
conditions online . Request you to kindly go through the same once again & in case of any
disagreement/discrepancy / clarifications please call us on our toll free number 1800 102 5858
or log on to www.bajajallianz.com or revert back within 15 days of the letter date.

Please note that the information provided by you will be verified at the time of claim & the
insurance cover available to you (or other person or categories of person covered in the policy)
shall become void in the event of any untrue or incorrect statement, misrepresentation, non
description or non-disclosure in any form what so ever .

As a valued customer, we would like to provide regular updates on your policy, launch of new
products and promotions so that you can take advantage of the same. However if you do wish
not to receive any such updates, we would request you to please register for 'Do Not Call'
registry on our website www.bajajallianz.com

With Best Regards,

Mahima Tankha
Web Sales

Regd. Office : GE Plaza, Airport Road, Yerwada, Pune - 411006

 Proposal Form
Bajaj Allianz General Insurance Company Ltd.
GE Plaza, Airport Road, Yerwada, Pune -411006 (India)

Personal Information Policy Address

First Name ASHIS House No. / Building Name - Flat No 2225,R G MANSION, CHANDRA
NAGAR
Middle Name KUMAR Street / Locality / Landmark KUMARSWAMY LAYOUT,2ND
STAGE
Surname ROUT State KARNATAKA

Email Address ashisrout@gmail.com City BANGALORE

Mobile Number 9741344440 Area Tavarekere

PAN Number NA Pincode 560081

Gender NA Mailing Address

Date of Birth NA House No. / Building Name - Flat No 2225,R G MANSION, CHANDRA
NAGAR
Marital Status NA Street / Locality / Landmark KUMARSWAMY LAYOUT,2ND
STAGE
Education Completed NA State KARNATAKA

Occupation City BANGALORE

License Type Na Area Tavarekere

Age received your driving license NA Pincode 560081

Vehicle Information

Vehicle Reg No KA05Y0096 Cover My Driver YES(Default Cover)

Policy Start Date 20-OCT-2010 PA cover for co-passengers worth 0

Vehical Make HERO HONDA Your IDV Value 11803

Vehical Model CD 100 vehicle under a bank loan NO

Vehical Subtype SS Bank Name

Year Of Manufacture 1998 Engine Number 10751

Fuel Type Petrol Chassis Number 10302

Do you also want to cover accessories installed in your Car

Value Of Elec Accessories 0 Previous NCB 25%

Value Of Non-elec Accessories 0 NCB Offered 35%

Value Of CNG Kit

Information about your existing policy

Your existing policy is with United India Insurance Existing policy Number 072581/31/07/01/00002249

Policy Expiry Date 19-OCT-2010

 Bajaj Allianz General Insurance Company Ltd.
GE Plaza, Airport Road, Yerwada, Pune - 411006

DECLARATION:

I/We, the undersigned hereby declare and warrant that the insurance policy is issued by Bajaj Allianz General Insurance Company Ltd
[Company] subject to the declarations, warranties, statements and particulars given in this proposal form during the process of my/our online
purchase through web. The statements and particulars given in this proposal form are complete, true and accurate to the best of my/our person-
al knowledge and belief. I/we have understood the terms and conditions to the contract and agree that the statements and particulars given in
this proposal form shall be held to be promissory and shall be the basis of the insurance contract between me/us and the Company and the
Company shall have no liability under the insurance contract if it is found that any of the statements or particulars or declarations in this proposal
form or other documents are incorrect and or untrue or suppressed any information or provided misleading or false information in any respect on
any matter to the grant of a cover. I/we will accept the usual conditions and form of the policy prescribed and issued by Company. I/We hereby
agree and undertake that I/we are agreeable to receive policy document [without enclosing the terms and conditions of policy] from the company
and I hereby authorise company that all terms and conditions of policy can be displayed in the website of company that enables access by me/
us if I/we want to know the terms and conditions of policy displayed on website. @@I also agree that the various documents required under
KYC norms [such as identity proof, residence proof, income proof etc.,] shall be submitted by me before expiry of 15 days from the date of issu-
ance of policy [Please click here to view the list of KYC documents required to be submitted].

ADDITIONAL DECLARATION TO BE GIVEN BY CUSTOMER SEEKING NO CLAIM BONUS:

I/We declare that the rate of NCB claimed by me/ us is correct & that no claim has arisen in the expiring policy period. I/We further undertake
that if this declaration is found to be incorrect, all benefits under the policy will stand forfeited. I/We declare that to the best of my personal
knowledge and belief that the vehicle is in sound and roadworthy condition. I/We undertake that the vehicle to be insured shall not be driven by
any person who to my/our knowledge has been refused insurance or continuance thereof.

STATUTORY WARNING:

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 or continuing a policy accept any rebate, except such rebate as may
be allowed in accordance with the published prospectus or tables of the insurer.
@@Note: required to be activated only in case of (i) online proposal form and issuing web sales, and (ii) in cases where premium is
Rs.100000/- and above. Further our system has to automatically detect the name of The insurer should not enter into a contract with a customer
whose identity matches with any person with known criminal background or with banned entities and those reported to have links with terrorists
or terrorist organizations. There has to be suitable inbuilt provisions for compliance of these requirements [this entire para will be in the system
and will not be in proposal form, when printed for sending to online web purchasers].

Disclaimer # This is a computer generated statement and does not require signature.
 Bajaj Allianz General Insurance Company Ltd.
GE Plaza, Airport Road, Yerwada, Pune - 411006
CERTIFICATE CUM POLICY SCHEDULE
Policy Issuing Office Bajaj Finserv,1st Floor , Survey # 208/1-B, Behind Weikfield IT-Park, Viman Nagar 411014 Pune-
411014 Ph:020-66495000
Policy Number OG-11-9906-1802-00011443 Product Two Wheeler - Package Policy
Period Of Insurance From: 20-Oct-2010, 00:00 Policy issued Online On 19-Oct-2010 14:39:30
To : 19-Oct-2011 Midnight Cover Note No
Insured Name Ashis Kumar Rout Zone A
Insured Address 2225,R G MANSION, Insured ID 36384501
CHANDRA NAGAR, KU-
MARSWAMY LAYOUT,2ND
STAGE , BANGALORE,
KARNATAKA-560081
Premium Payer ID 36384501
Intermediary 55555557 - WEB SALES
Sub Imd Code
Hypothecated with : Policy Status ISSUED
Registration Make Model SubType CC Year Of Mfg Seat Cap Chassis No. Engine No.
Number
KA05Y0096 HERO HONDA CD 100 SS 100 1998 2 10302 10751

Vehicle IDV Elec. Accessories Non-Elec. Acc. Side Car CNG/LPG Unit Total Sum Insured
11803 0 0 0 0 11803

SCHEDULE OF PREMIUM
Own Damage Liability
Total Own Damage Premium: 141 Basic Third Party Liability 300
PA Cover for Owner-Driver of 50
Rs. 100000
Total Act Premium: 350
Total Premium 491
Special Discount 0
Net Premium 491
Service Tax 49
Education Cess : 1
Final Premium Rs. 541
Geographical Area : India No Claim Bonus : -35% Voluntary Excess : Nil
Compulsory Deductible : Rs. 50 Additional Compulsory Deductible : Rs. 0
Previous Policy No : 072581/31/07/01/00002249 Expired On : 19-OCT-10
The above Total OD Premium is inclusive of all applicable Loading/Discounts viz (Automoble Association Membership,Voluntary
Excess,Anti-Theft,Handicap Person,Driver Tution,Fibre Glass,Cng/Lpg Unit,Geographical Extn,Imported Vehicle etc wherever ap-
plicable)
LIMITS OF LIABILITY:
Under section II-I(i) of the policy -> Death of or bodily injury : Such amount as is necessary to meet there requirements of the Mo-
tor Vehicles Act,1988.
Under section II-I(ii) of the policy -> Damage to Third Party Property : Rs. 100000
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 licence at the time of the accident and is
not disqualified from holding or obtaining such a licence. Provided also that the person holding an effective Learner's licence may
also drive the vehicle and that such a person satisfies the requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.
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 recov-
erable from the Insured. See the clause headed AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY.
Warranted that the information provided in the online insurance proposal form is the basis of providing insurance cover
and such online proposal form is a part and parcel of this policy.The cover would become null and void if the information
therein is incorrect
Subject to IMT Endorsement Nos: 22, & Policy wordings attached herewith

Premium Collection Details :- [Receipt No/Collection No/Amount] 9906-00030337,/1,/ Rs.541,

*** If premium paid through cheque, the policy is void ab-initio in case of dishonor of cheque.
This certificate of insurance is issued in accordance with the provision of Chapter X and Chapter XI of M.V.Act, 1988.
*** In case of any claim, please contact our 24 Hour Call centre at 1800-22-5858, 1800-102-5858 (Toll Free) / 30305858
(chargeable, add area code before this number in case of mobile call).
Kindly contact our nearest / local office(s) for No Claim Bonus Confirmations.
For & on the behalf of
Bajaj Allianz General Insurance Company Ltd.
This document is a pre signed document and will not be valid unless QC Verified and Signed/Counter Signed by an authorized signat-
ory of Bajaj Allianz General Insurance Co.Ltd.
For & Behalf of Bajaj Allianz General Insurance Company Ltd. QC Verified and Signed/Counter Signed by
Stamp
Duty
Rs. 0.5

Authorized Signatory
Printed , Signed and Executed at QC signed and verified Consolidated stamp Duty paid vide Receipt No: .12800 dated
Pune 29-JUN-10
Regd Office : GE Plaza,Airport Road, Yerwada Pune-411006 (India)
Regd. Office : GE Plaza, Airport Road, Yerwada, Pune - 411006