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M / S SUDEEP LOGISTICS PRIVATE LIMITED
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314 PROGRESIVE MODEL COLONY
VAIDUWADI HADAPS
PUNE CITY
My Policy Claim Status
MAHARASHTRA India - 411013
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9326 ******
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Your Reliance Commercial Vehicles ( Passengers
Carrying 4W > 6 & 3W > 17 ) Package Policy -
Schedule , with Policy
Number 170122423400001769 is now live to
access your policy anytime , anywhere download
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Best Regards ,
reliancegeneral.co.in 022 4890 3009 ( Paid ) D 74004 22200 ( WhatsApp )
Reliance General Insurance Company Limited . IRDAI Registration No. 103 An ISO 9001 : 2015 Certified Company
Registered & Corporate Office : Reliance General Insurance Company Limited , 6th Floor , Oberoi Commerz , International Business Park , Oberoi Garden City , Off Western
Express Highway , Goregaon ( East ) , Mumbai - 400 063 .
Corporate Identity No. U66603MH2000PLC128300 . UIN : IRDAN103RP0012V02100001 .. Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private
Limited and used by Reliance General Insurance Company Limited under . License RGI / MCOM / CO / PCV / PS / Ver . 1.3 / 310118 .
Page 1 of 12
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tan
Digitally signed by Reliance reliancegeneral.co.in
GENERAL
RELIANCE General Insurance
INSURANCE Company Limited 022 4890 3009
Date : 2024.10.19 12:58:34
74004 22200
Insence
IST
mited
mpany
surance
Reliance Commercial s ( Passengers Carrying 4W 6 & 3W Package Policy - Schedule
>
,
Policy Number : 170122423400001769 Proposal / Covernote No : R181024105273
Insured Name : M / S SUDEEP LOGISTICS PRIVATE LIMITED Period of Insurance : From 00:00 Hrs on 29 - Oct - 2024 to Midnight of
28 - Oct - 2025
Communication Address & Place of Supply : 314 PROGRESIVE MODEL Policy Issuing Branch : A Block , Heritage House , Ground floor , 6 Ramabai
COLONY VAIDUWADI HADAPS PUNE CITY , PUNE , MAHARASHTRA , India , Ambedkar Road ,, PUNE , MAHARASHTRA , 411001 .
411013 .
Mobile No : 9326 * ****** Tax Invoice No. & Date : R181024105273 & 19 Oct 2024 12:58
Email - ID : NA GSTIN / UIN & Place of Supply : 27AATCS2867F1ZS and MAHARASHTRA
ance
Insured Vehicle Details
Registration No. MH12KQ2268 Mfg . Month & Year JAN - 2015
Make / Model & Variant EICHER 10.75 H BUS . , CC / HP / Watt 3298
Engine No./Chassis No. E413CDFA015268 / MC2A5ERFOFA307268 LCC Including Driver 27
Type of Body NA Total Premium 37808
RTO Location MAHARASHTRA -
Lem
Total IDV 510,000.00
Relian
Manufacturer fully build in Yes Hypothecation / NA
Vehicle Category Bus Vehicle Usage Type Contract Carriage
Limited
Vehicle Usage Sub Type
Insured Declared Value ( IDV )
Chassis IDV 0.00 Non Electrical Accessories 0.00
Combay
Body IDV 0.00 CNG LPG Kit 0.00
Vehicle IDV 510,000.00 Trailer / Side Car 0.00
Electrical / Electronic Accessories 0.00 Total IDV 510,000.00
ance
Premium Summary
Own Damage - Section I Amount ( ` ) Liability - Section II Amount ( ` )
Basic OD 465.95 Basic Liability ( TPPD 1 ) 31,562.00
Covers for Lamps Tyres / Tubes Mudguards / Bonet / Side Total Basic Liability Premium 31,562.00
parts etc ( IMT - 23 ) 69.89 PA Benefits - Section III
Total Basic Own Damage Premium 535.84 Legal Liability to paid driver and / or Conductor and / or
Less cleaner 50.00
Deduct 20 % for NCB -107.17 TOTAL LIABILITY PREMIUM 31,612.00
Sub Total of Deductions -107.17 TOTAL PACKAGE PREMIUM ( Sec I + II + III ) 32,041.00
CGST ( @ 9.00 % ) 2884.00
SGST ( @ 9.00 % ) 2884.00
nc
TOTAL OWN DAMAGE PREMIUM 429.00
TOTAL PREMIUM PAYABLE ( ` ) 37,808.00
Subject to I.M.T.Endt . Nos . & Memorandum printed / herein / herein / attached / attached h hereto . IMT 40,23,21
Limi
GSTIN : 27AABCR6747B1ZG
hinted
HSN 997134 , Description services Motor vehicle Service
of
baanst
" As the GST the amount of GST will not be refunded if the policy / e is cancelled after "
forsuram
per regulation
dancer
Consolidated Stamp duty Paid vide Letter of " NO LOA / ENF - 1 / CSD / 50 / 2024 -25 / ( Validity Period to Date 20-08-2024 " at
General Stamp Office , Mumbai . ** Not Applicable for the State of Jammu & Kashmir .
thence
age
/ SAMADHAN 9326689009 sujitlolage@gmail.com ***** * 907 E
Intermediary C Inter
Intermediaryct No. E - mail ID POS UID Aadhaar No. / PAN No.
The Customer Information Sheet ( CIS ) for this product is available on our website
She
https://www.reliancegeneral.co.in/insurances/downloads.aspx
ance
Limits of liability PA for owner driver under section III CSI 0 ( a ) Under Section II ( 1 ) ( i ) of the Policy - Death of or bodily injury to any
:
person so far as it is necessary to meet the requirements of the Vehicle Act , 1988. ( b ) Under Section II ( 1 ) ( ii ) of
Gener
the Policy - Damage to property other than property belonging to e insured or held in trust or in the custody of control of
Company
the insured up to the limits specified- ( TPPD 1 Sum Insured - 7,50,000 / - , TPPD 2 Sum Insured- 6,000 / - ) / - ) .
.
6,000
Relianc
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Reliance
urance
General /
Complianc
Reliance General Insurance Company Limited . IRDAI Registration IRDAN10301 No. 103 under C An ISO 9001 : 2015 Certified Company
red-
.
Registered & Corporate ice Reliance General | Company Limited , 6th Commerz , Oberoi RGI ( Off
: , City
,
Company Limited
%
Western Express Highway Goregaon ( East ) , .
U66603MH2000PL
mited
Onal
Park
Insurance
No.
en
Trade
Business
Corporate Identification UIN IRDAN103 to Anil Ambani
: :
/
MCOM
Ventures Private Limited and used by Reliance 1310118
License
General
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GENERAL relio reliancegeneral.co.in
RELIANCE Smart
INSURANCE
022 4890 3009 →
General
Limited
74004 22200
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Limitations as to use : y covers the use only r a permit within the meaning Motor Vehicle Act , 1988 or a carriage falling
of
under sub - section ( 3 ) of Sec 66 of the Motor Vehicle Act , 1988. The Policy covers use for any purpose other than : ( a )
Organized racing ( b ) Pace making ( c ) Speed testing ( d ) Reliability trials . ( e ) Use whilst drawing a trailer except the
Personeral
towing ( other than for reward ) of any one disabled holds propelled dri vehicle .
a
of persons Any person including insured :
ally
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entitled to drive : Provided person at the time of the accident and is not disqualified from holding
driving
that a
valid
or obtaining such a license . Provided that the person holding a valid learner's license may drive the vehicle when not used
Insurance
for the transport of goods at the time of the that a person
such
tand
Compulsory Deductible under PA on for - l owner : driver : : ( i ) deductible 1000 / - ( ii ) compulsory 00 / - ( iii ) Voluntary partiductive 0 / -
Insured is not eligible for the Compulsory PA co for owner driver in this policy as the same has not been for the reasons allowed as per motor tariff and / or basis
co
insured's declaration given below :
" I / we hereby declare that I / we hold an personal accident insurance policy covering death and t disability ( total & ) and / or compulsory
accident ( CPA ) for owner driver in other vehicles ; whereby the Sum Insured limit is of Rs 1,500,000 or more in all such above mentioned conditions . "
In case you have missed it , please opt for compulsory PA cover payment of additional as applicable.Liability of insurance company shall commence from
er by
the date of receipt of such additional premium .
" It is hereby declared and agreed that all pre - existing to the vehicle having occured to the commencement of cover are excluded from the scope of the
policy " co.in
The NCB provided on Basic OD Premium Add - on wherever applicable . The policy wording with terms , conditions and are available on
www
our our website www.reliancegeneral.co.in
website
Lited
Statutory Provisions :
" As per Section 146 of the Motor Vehicle Act , 1988 it is Mandatory to have your vehicle insured against party risk . "
any
As per Section 196 of the Motor Vehicle Act , 1988 driving an uninsured vehicle is punishable with fine or Rs . 2000 and / or i up to 3 months for the first
offence I / We hereby and fine certify of Rs that . 4000 the and / or imprisonment which the certificate up to 3 months relates as well the second as this certificate offence . " of are issued irresprisonme in accordanc with the provision of Chapter X and
Chapter XI of M.V. Act , 1988 .
Note : In the event of of cheque , this policy by I automatically stands d from inception of whether a separate is sent
or not . your
pr
you transaction via crossed cheque / DD in favour of Reliance General Insurance Co. Ltd.
paying
The policy has been issued based on the information provided by you and the policy is not valid if any of the information provided is incorrect . Subject otherwise to the
terms , conditions and exclusions of the Reliance Miscellaneous and Special Types of Vehicles Package Policy Certificate Cum Policy Schedule . In witness whereof
Policy been signed at Mumbai on policy tax invoice date in lieu of Proposal / Covernote No. as mentioned in the policy .
Ranc
This ent shall be treated Invoice as per Rule 46 of the Central Goods and Services Tax Rules 2017 .
as a
Updating Registration Number of within 15 days of polic inception is MANDATORY per IRDA . Kindly provide the same to your Agent / Our Call
as
S.mp
centre / Policy issuing Branch ( Applicable for policies booked without Registration No of
IMPORTANT NOTICE : The insured is not indemnified if the vehicle is used or driven than in accordance this Schedule . Any payment made by the
CO
Company by reason of wider terms appearing in the Certificate in order to comply with the Motor Vehicle Act , s recoverable from the red . See the clause
headed ' AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY ' . For legal interpretation , English will hold good .
of provided the / terms conditions rate
/
In case a renewal the benefits under policy and or and g premium change .
,
As Highways Authority vehicle of may
policy
per ational of India kindly ensure to affixed FASTag on your
, .
the
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Clause : For resolution of any query or grievance , Insured may contact the respective branch office of the Company or may call at 02248903009 or may
write an email at rgicl.services@relianceada.com . In case the insured is not satisfied with the response of the office , insured may contact the
R
Nodal Grievance Officer of the Company at rgicl.grievances@relianceada.com . In the event of unsatisfactory response from the Nodal
Grievance Officer , insured may email to Head Grievance Officer at rgicl.headgrievances@relianceada.com . In the event of unsatisfactory
from the Head Grievance Officer he / she may subject to vested jurisdiction approach the Insurance Ombudsman for the redressal of
, , ,
grievance . Details of the of the Insurance Ombudsman are available at IRDAI www.irda.gov.in or on company website
Geneesponse
www.reliancegeneral.coOffices on www.gbic.co.in. The insured may also contact the office of the Insurance within whose
Ombudsman
territorial jurisdiction the branch or office of the Company is located .
Office of the Insurance Ombudsman , 3rd Floor , Jeevan Seva Annexe , S. V. ( W ) , Mumbai - Tel .: 022 -26106552 /
26106960 Fax : 22-26106052 Email : bimalokpal.mumbai@cioins.co.in
Note : Kindly acknowledge the this policy . In case you find variations against your or any discrepancy in the kindly contact us immediately .
medelianc
Rance
Lim
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Fast Tag ID -
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eral
The policy does not or liability for death bodily in or damage as excluded under Section 150 ( 2 ) ( ii ) and and C of the Motor Vehicles Act 1988 ( Inserted
,
Vide GSR no 164 ( f ) dated 25.02.2022 w . e . f 01.4.2022 )
In the unfortunate event of a claim , please quoting your Policy No. on 022 48903009 ( Paid ) and your claim immediately within 7days from the date of loss .
days
15
In the absence of any communication of receipt of this letter we wi that the issued policy is in order and as per your
,
proposal Conditions
of
Relic
Special as a ACE of Rs.25000 Compulsory Excess of RGICL_ORB .
ACE
Comped
:
Reliance General Insurance IRDAI Registration No. An ISO 9001 : 2015 Certified Company
within
Limited .
period
Registered & Corporate ice : Reliance General | Company Limited , IRDAN10301 6th Oberoi Commerz , Onal Business , Oberoi City , Off
ditio
Western Express Highway Goregaon ( East ) , 063 .
U66603MH2000PL
Trade
Park
en
Corporate Identification .UIN : . above belongs to Anil Ambani
No.
Ventures Pivate Limited and used by Ralance General Insurance Company Limited under License . RGIXCOM COPCV / PS / Ver . 1310118
Page 3 of 12
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---PAGE END--- RELIANCE
INSURANCE GENERAL
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Western Registered
Ventures Corporate General
Express & Corporate Insurance Relianc
Identification Company Limited
Private Highway Reliance General Insurance
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Limited Office Company surance
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and No. Goregaon : Reliance
used U66603MH2000PLC128300 ( Limited
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Company : IRDAN103RP0012V02100001 Limited Registration
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under Oberoi
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/ 310118 Anil Certified
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Ambani City Company
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Page
4
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GENERAL relic reliancegeneral.co.in
RELIANCE Smart
INSURANCE
General
022 4890 3009 →
Limited
74004 22200
Insence
Reliance
Risk Assumption Letter
General
ompany
Limited
Insurance
Dear M / S SUDEEP LOGISTICS PRIVATE LIMITED
ral
Thank you for choosing Reliance General Insurance .
Please find enclosed policy no .: 170122423400001769 which has been issued based on the details declared by the applicant .
Relianc
Insured Vehicle Details
Registration No. MH12KQ2268 Mfg . Month & Year JAN - 2015
Make / Model & Variant EICHER 10.75 H BUS . , 3298
ncompany
CC / HP / Watt
Engine No./Chassis No. E413CDFA015268 C2A5ERFOFA307268 LCC Including 27
Reliant
Type of Body NA Total Premium 37808
Limited
RTO Location MAHARASHTR Pune IDV 510000
Manufacturer fully build in Yes Hypothecation / Lease
NAG
any
Insured's Declared Value ( IDV )
Chassis IDV 0.00 Non Electrical Accessories 0.00
Com
Body IDV 0.00 Kit 0.00
Lim
51000 PG
Vehicle IDV r / Side Car 0.00
Electrical / Electronic Accessories 0.00 Total IDV 510,000.00
ted
rance
bany
Previous Policy Details
Previous Year Policy No. Period of Insurance Previous Policy - Claim Status
3871448000 29/10/2023 To : 28/10/2024 midnight Yes No
COVERS NG
YOU HAVE THE
Relianc
OPTED
Standard Vehicle Own + Third Party
FOR
General
Compos
Cover
Electrical / electronic accessories
Non - electrical accessories
Compa
fuel kits comprising LPG / CNG systems
-
Add - on Depreciatii Covers
Reliance
Nil Cover No for depreciation on vehicle parts other than tyres and s with respect of approved loss claims .
towing Charges cover for towing charges over and above the standard guideline as per the cover opted by customer ( Sum
/ )
acciderarimited
-
Rellanc
Limit of TPPD Indemnify the Insured for an additional TPPD amount opted f damage to property other than the property belonging to the
the
accomodation
instance
Insured or held in trust or in custody of Insured .
Hotel Provide allowance towards the
insure½0
Emergency vehicle met with ' stolen 200 kms away from the location
Accommodation provided in policy
to Kindly
Please take schedule
Hotel
a moment carefully check your policy mentioned above and in e policy that the same are in order . case of
.
discrepancies , please let us know immediately . You can write to us at rgicl.services@relianceada.com or call us 022 48903009 ( Paid ) for necessary
changes / rectification . In the absence of any communication from you within a period of 15 days of receipt of this letter , we will consider that the issued policy is in order
and as per proposal . Non disclosure / or misrepresentation of claims in the previous policy period c lead to cancellation of your policy or rejection of your
claims . d the insured an
and
4
d herein / of valid Pollution Under and / fitness certificate , as applicable
that
nam owner the vehicle holds a I ( PUC ) Certificate or ,
opiclianc
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
70
of
subsistence of the Policy . the Company reserves the right to take appropriate action in case of any discrepancy in the PUC or fitness certificate . )
ce General Insurance Co. Ltd.
Reliant
Gener
Insur
Company
Signatory
CoAuthorised
Relianc
General
Reliance
Limited
Insurance
Reliance
General
Limited
Insurance
Company
Relianc
Reliance
General
urance
CO
Company
Limited
*
Reliance General Insurance Company Limited . IRDAN10301 RGI An ISO 9001 : 2015 Certified Company
Limited
IRDAI Registration No. 103
/
Limited
.
Registered & Corporate ice Reliance General | Company Limited , 6th Oberoi Commerz , Oberoi ( Off
: U66603MH2000PL , City
,
East ) , Mumbai -
under
Western Express Highway Goregaon ( 063 . . Insurance
No.
mited
Onal
Park
/
/
en
&
Trade
Business
Corporate Identification UIN : to Anil Ambani
Company
MCOM
pany
Vectures Private Limited and used by Reliance General 1310118
License
Page 5 of 12
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GENERAL relic reliancegeneral.co.in
RELIANCE Smart
INSURANCE
General
022 4890 3009 >
74004 22200
Limited
Insence
rance
neral
pany
Reliance
Know your policy
Remember to carefully go through the Risk Assumption Letter and confirm your personal as well as your vehicle details .
nited
In case of discrepancy in the policy details kindly revert within 15 days from the policy start date on 022 48903009 ( Paid ) or visit a of our branches .
elianc
,
addy Kindly r to the Key Feature Document and Policy Wording at www.reliancegeneral.co.in to understand your policy better and lan more about the policy coverages ,
à covers and Policy Exclusion This document is a statement of the specific provisions that form the Terms and Conditions of this Policy .
.
What documents do you require for making any change to your policy
1. Changes in vehicle make & model / cubic capacity / seating capacity / engine & chassis no./year of facturistration n Cation / address
Documents required : Letter for change , policy copy and registration certificate copy along with additional cheque if applicable
Premium , .
2. Changes in electrical and non electrical accessories / CNG / LPG kit G
Documents required : Letter for policy copy , invoice copy of accessories , endorsed istrar stra certificate copy ( for à kit ) and cheque for
:
premium .
ease
Hire /
details
3. Changes in purcha
financier
Documents required : Letter for change , policy copy , endorsed registration certificate copy no objection certificate from financier ( not mandatory for deletion , if
registration certificate copy is endorsed ) .
How to register a Claim - Cashless
C Ou
F ט×
Report vehicle Claim registration Survey , Document verification , Cashless Amount Vehicle
at Network Garage by Network Garage Loss Assessment & Re - inspection Confirmation Delivery
How to register a Claim - Reimbursement
nc
TY
Registration Report Vehicle Survey , Document Vehicle Submission of Claim Settlement
of Claim at Garage verification , Loss Assessment Delivery Original Repair Bills + to Customer
and Re - inspection Payment Receipt
What documents do you require to register a Claim
1 . form duly filled and signed Company stamp in case of company registered vehicles )
23 Registration
2 . c
Relianc
3. Driving License of the the time of loss
General
4 . Policy copy
Company
Vehicle fitness certificate
Limited
5 .
6 . Vehicle route permit
7 . Vehicle carriage permit
8 . Road tax copy
Reliance
9 . Load Challan ( if applicable )
ompany
Limited
Insurance
Note : 1. As soon as a claim occurs , please intimate immediately to our call centre 022 48903009 ( Paid ) . in intimation would the violation of policy
So
?
condition
2. Any additional document will be informed
Relianc
if
.
,
ited
Gene
amp
How to renew your policy conveniently Payment Modes
Internet banking
C
www .
Cheque / DD
Visit reliancegeneral.co.in Call 022 4890 3009 ( Paid ) Submit a cheque / DD along with signed Renewal Credit / Debit Card
and renew online and renew Notice to branch / agent and renew
anc
The content on this page is for additional information & Should not be considered as part of the policy document / Schedule
uns
Con
Reliance General Insurance An ISO 9001 : 2015 Certified
Limit
Company Limited . IRDAI Registration No. 103 / Company
Registered & Corporate ice : Reliance General | No. Company Limited , 6th Trade Oberoi Commerz , Onal Business Park Garden Company under . C City , Off
RGI
:
Western Express Highway Goregaon ( East ) , Mumbai - U66603MH2000PLC128300 063 . .
IRDAN103RP01
Imm
Oberoi
Identification No.
IRDAN1033
.
Corporate Corporate Identification UIN belongs to Anil Ambani
U66603MH2000PL
. :
UIN
Insurance
,
MCOM
Ventures Private Limited and used Reliance General 1310118
License
/
by
Limited
Page 6 of 12
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GENERAL relic reliancegeneral.co.in
RELIANCE Smart
INSURANCE
General
022 4890 3009 →
Insence
74004 22200
Limited
Reliance
urance
Proposal for POS Commercial Vehicles Package
oneral
Limited
any
( Other Motor Trade Int Risks Policy )
than
made / details stated are the minimum requirement to be furnished by a proposer .
Relianc
quer
The Insurer may seek any other as desired for under for underwriting purpose . )
General
* ( Applicable to all classes of vehicles with suitable amendments in ' Limitations as to Use ' )
Company
e
PCV GCV Trailer
For Office Use Only
Policy Number 170122423400001769
Lind
Savvion Reference No. Inspection L No.
and
Intermediary Details ( To be filled
BLOERS
Intermediary Name RANSHUR in Code
Branch Name Code
Limit
Sales Manager Name Anikesh Kailas Kolhapure Code
* POS PAN No. ***** ** 907 E * POS UID Aadhaar No.
any
oliance
AuralAN
Details ( To be filled in BLOCK LETTERS )
1 . This Proposal is for A Renewal of Policy Others ( Please specify )
2a Proposer's Full Name Mrs. SUDEEP LOGISTICS PRIVATE
.
Manny
2b Com
Relianc
. Address for where vehicle is normally kept and Used
Canted
Flat / Building / Door / B 314 PROGRESIVE MODEL COLONY
Road / Street / Sector VAIDUWADI HADAPS
Nearest
par
Reliance
Area
Limited
Insurance
City CITY
41
Relianc
MAHARASHTRA
General
Country India
Resea
Phone Mobile
Limited
Insuran
Emergency Contact No. Blood Group
Insuran½
andompany
any
Email Fax
Reliance
3 . Period of 29/10/2024 To
4 . Source of Funds Profession Salary Income
5 . Income Upto 20,000 to 1,00,000 1,00,001 and above
6 . Thaar UID No. 7. F ***** 907 E
Relianc
8. Fast Tag ID
nited
Ge
uranc
ompaq
Details of the Vehicle
Autheranc
9 . Registration Number 10. Date of Registration 12/06/2015
11. Registering & Location
-
Relian
rance
12. Year & Month of Manufacture 13. Cubic
14. Engine Number
15 . MC2A5ERFOFA307268
Gapacity
Limited
16 . of Vehicle EICHER
Gapacity
Weight
Relianc
17 . of Body / Model NA / 10.75
rance
General
Vehicle
18. Gross ( C.C. )
(
Limited
19 . Goods type ( Applicable only if GVW 7500 kgs ) Goods Hazardous Goods
+ -
non
20 . Is the Vehicle made India ? Yes
21 . Max Licensed carrying capacity ( No. of Passenger ( ) in of Passen vehicles
. case
22 . Vehicle Category Taxi
Company
Vehicle usage type ( Applicable if bus ) : Contract Carriage Stage
Vehicle usage sub type ( Applicable if Contract Carriage ) : School Bus Employee pickup Bus Others
23 Seating capacity ( Including 27
Relianc
R
CompaLimi
IRDAN10301 An ISO 9001 : 2015
Limited
Reliance General Insurance Company Limited . IRDAI Registration No. 103 Certified Company
Registered & Corporate ice Reliance General | U66603MH2000PL Company Limited , 6th Commerz , Business Oberoi ( Off
: , City
,
al
Western Express Highway Goregaon ( East ) , Mumbai No. - 063 . .
mited
Park
/
/
en
Corporate Identification .UIN : IRDAN103 Trade above belongs to Anil Ambani
Genensuan
:
Ventures Pivate Limited and used by Ralance General Insurance Company Limited under License . RGIXCOM COPCV / PS / Ver . 1310118
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GENERAL relic reliancegeneral.co.in
RELIANCE Smart
INSURANCE
General
022 4890 3009 →
Limited
Insence
74004 22200
Reliance
Details of the Vehicle Type and Use
Themeral
Sopany
24. the Vehicle is driven by Non - conventional source of power ? Yes No If yes CNG LPG
a .
Declared Value bies on Non electrical fitted fitted Electronic to the accessories vehicle Value Fuel CPG Kit Bi Total ( )
Rojanc
of vehicle Chasis to the ( )
Body vehicle ( )
R
510,000.00 0.00 0.00 510,000.00
b . Do you have a PUC ? Yes No
( Note- Warranted that the insured named d herein of the vehicle holds a valid Pollution Under Control 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 Policy Further the Company reserves the right to take appropriate action in case any discrepancy in the PUC or fitness certificate . )
.
,
25.Sistence
the
a of Driver : ( a ) Age of Driver Others
of
Physical infirmity
Relianc
( b ) the driver suffer from vision or hearing or . No
Generofantomated
If " Yes " please give
Compacted
Lim
details
Yener
Relice
( c ) Has the ever been involved for any accident or loss ? Yes No
Li
Insurance
If " give details as under including the pending prosecution , if any : -
.
Relianc
26. 20 Add On Covers ( Subject to and eligibility )
General
imited
Company
,
( a ) Easy Monthly t ( EMI ) Protection Cover : ( RGI MO - A00-00-17 - V01-14-15 )
-
%
If Yes , choose any one option ;
Relia
EMI , EMI Amount :
Limited
Insurance
Plan II - 2 EMIS , EMI Amount :
Compan
Plan III -3 EMIS , EMI
Additional Towing ì€ì€
Relianc
No
Relancap
General
( c ) Nil Depreciation No
Company
Limited
( d ) Total Cover No
( e ) Voluntary
Reliance
Deductible amount opted :
imited
Accommodatiompany
Insurance
( f ) Hotel el
Benefit Amount :
Relianc
( g ) Additional limit of N
General
ce
Reliance
Additional amount
Company
Limited
( h ) Personal Daily Cover ì€
Benefit
Reliance
( i ) Allowance Benefit
Insurance
day allowance amount opted :
Coverage Days opted :
Limited
company
Relianc
( j ) Daily Allowance
2
General
Reliance
Per day allowance amount opted :
Limited
Limited
Coverage opted :
( k ) Tools Cover
Reliance
( I ) Any other Details
Company
Limited
Company
Company
27 . vehicle fitted with any device approved by the ARAI ? Yes
If Yes , please attach certificate Installation in the Association India .
Automobile by IRDAN103Rneral
Company
Reliance Registered General & Corporate Insurance ice : Reliance Limited General . I Company Limited , 6th IRDAN10301 : Oberoi Commerz , Business , Oberoi An ISO 9001 : 2015 ( Certified City , Company Off
Western Express Highway Goregaon ( East ) , 063 .
Insurance
ssued
.
onal
Park
"
U66603MH2000PLC128300 .
en
Corporate Identification No. Trade
UIN
Identification
U66603MH2000PL
Corporate UIN above belongs to Anil Ambani
No.
:
Ventures Pivate Limited and used by Ralance General Insurance Company Limited under License . RGIXCOM COPCV / PS / Ver . 1310118
Page 8 of 12
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any
GENERAL relic reliancegeneral.co.in
RELIANCE Smart
INSURANCE
General
022 4890 3009 →
74004 22200
Limited
Insce
pany
28 . 22 Are you a member of Automobile of India ? If Yes , please submit membership copy . Yes No ì€
meliance
Listed
Insurance
29 . Whether the Vehicle is used for Driving Yes ì€ì€
30 . use of Vehicle is limited to Premises ? Yes
elianc
the commercial vehicle s also used for Private purposes ( excluding use for hire or Yes
%
31
Geral
Rehneral
Company
EConsulates
33 . Whether the Vehicle is fitted with Fibre Glass Tank ? No ì€ì€
34 . Whether the Chicle belongs to the of a Foreign Country ? No
Reliance
If so , is the element included in the IDV ?
Lin
Insurance
35 . Whether Vehicle is design for use of Blind / Handicapped / Mentally Challenged Person ? Yes No
36 . Date of purchase of the Vehicle by the Proposer 12 / Jun / 2015
any
37 . the Vehicle at the time of purchase was Second Hand
45
Risk Inclusions
38 . Do you wish to the above limits to the statutory TPPD Liability limit of No
Do you wish to ver legal liability to ?
DriveOfe
song
( a ) / Cleaner ( No. of No
Relieneral
( b ) Other ( No. of Persons ) Yes No
Liteellanc
Insurance
Iffare ( c ) paying passenger ( No. of persons ) Yes No
Cited
include ( P.A. ) Cover for paid drivers , cleaners and Yes
elianc
38 . wish to personal
you
Mon
Su
give and Capital Sum Insured ( CSI ) opted for maximum CSI available per person is 1 Lakh in the case Motorised two wheelers and 2
name
, .
lakhs for other classes of at
Cpany
ceral
39 . Personal Accident for Owner Driver . Please details of nomination
Name of the Appointee ( if
Name of the Age of Nominee Relationship Address
Nominee is Minor )
1. Personal Accident cover owner driver is compulsory for Sum Insured of for Two Wheeler , Private GCV , PCV and Misc - D
lianc
2. Compulsory PA cover owner driver cannot be granted where a vehicle is owned a company , a partnership or a similar body corporate or
where the not hold an effective license )
Geobrance
Relianter
wish to include No
Commit
Do you Yes
Name of the Appointee
Name CSI Opted of Nominee Age of ionship
( If Nominee is
ommence
L
41 . Extension of Geographical Area
Co
extension of to the following Countries required ?
1. Bangladesh
Relianc
Generator
2. Bhutan
Company
Limited
Insurance
3. Maldives
4. Nepal
Reliance
eneral
Limited
Insurance
Company
Agreement
liance
oral
Details of Hire Purchase / thecation / Lease
42 . Please state if the vehicle is Purchase Agreement Hypothecation Agreement
re
If so , give name and of concerned parties
.
erdress
43 . Full Name M / s
Bellancase
44. Address
merace
urance
Note
The Insured's Declared Value ( IDV ) of the vehicle will be deemed to be the ' SUM INSURED ' for the and it will be fixed at the commencement of
Vehicpany
of
each policy period for each insured vehicle .
e
tariff
rurance
this
The IDV of the vehicle is to be fixed on the basis of manufacturers ' listed selling price of the brand & as the vehicle proposed insurance at the commencement
Limited
emeland
of insurance depreciation as per policy wordings .
/ ,
a
Reliance General Insurance IRDAI Registration No. 103 An ISO 9001 : 2015 Certified Company
and
renewal
Western Registered Express & Corporate Highway Goregaon ice : Reliance ( East ) General , . I 063 Company . Limited , IRDAN10301 6th 103 Oberoi Commerz , Business onal , Oberoi ( City , Off
No.
Park
Trade
en
Corporate Identification .UIN : IRDAN above belongs to Anil Ambani
U66603MH2000PL
: .
Ventures Pivate Limited and used by Ralance General Insurance Company Limited under License . RGIXCOM COPCV / PS / Ver . 1310118
Page 9 of 12
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any
GENERAL reliancegeneral.co.in
relio
RELIANCE Smart
INSURANCE
General
022 4890 3009 →
74004 22200
Insence
Limited
eral
rance
Details of Previous Insurance
45 . Full Name of previous insurer KOTAK MAHINDRA GENERAL INSURANCE COMPANY LIMITED
4pany
Reliance
46 . Address
47 . Number 3871448000 Policy Expiry
Relianc
48 . of Cover Package Policy Liability only others ( to be describe )
Colanyited
49. NO CLAIM BONUS under previous policy ( % )
allowance
7
Limited
50 . Claims taken in policy No
If yes , No. of Claims Claims Amount
51 . Are you entitled to to No Claim Bonus Yes No
Reliance
mpany
If yes , please submit / attached proof
Lined
Insurance
Payment Details
Cheque DD Cheque / DD No.
/
Relinc
Cheque / DD Date Cash Credit Card
ted
Proposer's Bank Details
52 . Name of the Bank Account Holder
53 . Bank Account No .: 54. Account : Saving Current
55. Name of the
Reliance
56 . Branch
Limit
57 . MICR refund ( 9 digit MICR code number of the bank and branch appearing on the cheque issued by the
that ( 11 character code appearing on your cheque leaf
58 . the )
any
premium
due
und payment
any
/ any payment / claims be diery eeded my affresat Seed
on
to
Relianc
As per IRDAI , its mandetory that payments made to the insured are only through electronic mode .
Co
L
Infompany
Reliancensurance
General
Limited
Insurance
Company
Relianc
General
Reliance
Company
Limited
Insurance
Reliance
General
Limited
Insurance
Company
Relianc
General
Reliance
Company
Limited
Insurance
Reliance
General
Insurance
Company
Limited
Relianc
General
Reliance
Limited
Insurance
Company
Reliance
General
Limited
Company
Relianc
Reliance
urance
CO
Limited
Company
Reliance General Insurance Company Limited . IRDAN10301 RGI An ISO 9001 : 2015 Certified Company
Limited
IRDAI Registration No. 103
Insurance
/
IRDAN103Reneral Limited
.
Registered & Corporate ice Reliance General | Company Limited , 6th Oberoi Commerz , Business Oberoi Off
: U66603MH2000PL , City
,
al
-
under
Western Express Highway Goregaon ( East ) , Mumbai 063 . .
UIN Insurance
No.
mited
Park
: /
/
/
en
&
Corporate Corporate Identification Identification No. U66603MH2000PLC128300 UIN . Trade to Anil Ambani
Company
:
MCOM
pany
Ventures Private Limited and used by Reliance General 1310118
License
Page 10 of 12
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any
GENERAL relic reliancegeneral.co.in
RELIANCE Smart
INSURANCE
General
022 4890 3009 →
Insence
Limited
74004 22200
pany
Reliance
GENERAL DECLARATION :
DECeral
I understand that as per the new AML / CFT Guidelines issued Reliance General Insurance Co. Ltd will be verifying lying my details details pertaining pertaining t to KYC and PAN provided at
my
verance
the time of oposal
.
I
addrance
I further do hereby agree and consent that in the case of the event of a mismatch of information provi by me in the proposal form , identification i proof and
, , ,
proof at the time of issuance of the policy . I request Reliance General Insurance Company Limited to issue the policy with the details appearing as per my proposal
form . I will be solely responsible for any consequences arising out of the difference in detail ven by me during the verification of supporting documents provided by
me at the time of issuance of the policy or otherwise .
PEP Declaration :
Are you a Politically Exposed Person ( PEP ) ?
No
Com
If yes , mention the position held
Avance
Is of your close relation a PEP ? Yes No
omanLI
o
If yes , please mention the name relation and the position
by such member .
close
mence
I hereby declare that in if me , any of my close family attains of PEP I shall confirm the same to Reliance General
3
s or any of my r a position
Insurance Co. Ltd as mandate . I understand that is a crucial information under the PMLA Rules and AML / Guidelines and shall confirm that the answers
given by me is In case the company comes to know that this is a misrepresentation and concealment of on then the policy shall be b put on hold for
scrutiny by the pany and I shall be solely responsible for the same
.
Note :
" Politically Exposed Persons " ( PEPS ) individuals who have been entrusted with prominent c functions in a foreign cou e.g. , Heads of
are are or
Revanc
Callece
pub
States / Governments , senior politicians , senior government / judicial / military officers , senior executives of state - owned corporations , important political party officials ,
offcia
etc ( As per sub clause ( xii ) of 3 ( b ) of Chapter I of Master Direction - Know Your Customer ( KYC ) Direction , 2016 issued by Reserve Bank of India ( RBI ) .
Declaration by Proposer
I declare 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
/ We hereby that
declaration shall form the basis of the contract between me / us and RELIANCE General Insurance Company Limited . I / We also declare that , 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 . I / We hereby declare that the
contents of the form and documents have been fully explained to me / us and that I / We have fully understood the significance of the proposed contract . I / We agree to accept
a policy subject to the condition prescribed by the company . I have read and understood the brochure , prospectus , sales literature & Policy wordings and confirm to
anck
abide by the same . I / We declare that the rate of NCB stated above by me / us is correct and that no h has arisen in the expiring policy ( copy of the policy enclosed
I / We further undertake that , if this declaration is found to be incorrect , all benefits under the policy in 2ect of section I of the policy will stand forfeited I / We further
.
understand and agree that RELIANCE General Insurance will seek confirmation of above stated details from my / our previous insurers . Pending receipt of necessary
confirmation , I / We agree that , though coverage under the policy will be available to me / us , RELIANCE General Insurance will be liable to release the payment towards
any claims under section I of the policy only after a confirmation in this regard is received . In the event this declaration is found to be incorrect , any and all coverage
available under section I of the policy from the date of commencement of the policy shall stand automatically forfeited . Further , any survey arranged / allowed by
RELIANCE General Insurance of the motor vehicle , pending confirmation of the declaration from my / our previous insurers , shall be without prejudice to any of the rights
and remedies available to RELIANCE General Insurance as contained herein and under the relevant laws and regulations . I / We acknowledge and agree that , Pending
receipt of confirmation of the declaration from my / our previous insurers , the " cash - less repair facility " provided by RELIANCE General Insurance shall stand suspended .
• I / We also shall endeavour to procure the renewal notice and pass on the same to RELIANCE General Insurance immediately upon the receipt of such renewal notice .
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Mode of Payment : Secure your payment by cheque / DD favouring Reliance General Insurance CO.Ltd . This policy shall be voidable at the option of the Company in the
event of mis - representation , mis - description of nondisclosure of any material particulars by the Proposer . Any person who , knowingly and with intent to defraud the
Insurance Company or other persons , files a proposal fo insurance containing any false information , or conceals for the purpose of misleading , information , information
concerning any fact material thereto , commits a fraudulent act which will render the policy voidable at the company's sole discretion and result in a denial of insurance
benefits .. I / We here by state that the above mentioned address shall be taken as address on record for the purpose of GST . âš« I / We hereby confirm that the contents of the
proposal form and fully explained to me / us and I / We fully understood the significance of the proposed contract .
have
been
This proposal form wa completed by
Kcted
Rent
cura
documents
You can support our Go Green Initiative by saying " No " to Policy kit , Renewal Notice and Communications hard copy . We will be sending you a
digitally signed soft copy on your registered Email ID & Mobile number .
Go Green Hard copy required No
Relianc
anc
Name
Date : 19 Oct 2024 19 Oct 2024 12:58
Limited
companynited
Signature Signature of Proposer & Company Seal
pany
Gelianceneral
Prohibition of Rebates - Section 41 of the Insurance Act , 1938 as amended by Insurance Laws ( Amendment ) Act , 2015
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 in India any rebate of the whole or part of the commission payable or rebate of the premium shown on the
r property , any polic
th
nor shall any person taking out or renewing or continuing a accept any rebate , except such rebate as may be allowed in accordance with the published
prospectuses or tables of
Reneral
lick
ver
General
Insurance
An ISO 9001 : 2015 Certified
Lim
Reliance Limited . IRDAI Registration No. 103 Company
Western Registered Express & Corporate Highway vice , Goregaon : Reliance ( East ) General , Mumbai I - U66603MH2000PL 400 063 Company . Limited , IRDAN103RP01 6th Oberoi Commerz , Onal Business , Oberoi ( City , Off
No.
Trade
en
Corporate Identification VIN above belongs to Anil Ambani
Park
: .
Ventures Pivate Limited and used by Ralance General Insurance Company Limited under License . RGIXCOM COPCV / PS / Ver . 1310118
Page 11 of 12
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---PAGE END--- RELIANCE
2 . INSURANCE GENERAL
I confirm Supporting Any
Name person
Place the making neral Ins Live ace C
( In Date case of IRDAI above Confirmation signature default Smart
* Agent
The Mandatory of in
/
Vide policy Direct Broker tobe of complying
GSR does details of Agent
no Bus the
Relianc to Insuran registered with pany Limited
164 not be Name / Broker the
( f ) cover filled ☠provisions
dated & Mr. owner
25.02.2022 liability Signature / SM
☠/ CSO
for of of
death of Mrs. the this
w , CSO vehicle section
.
Reliance General Insurance e . f bodily / SM Limite proposed Reliance General
01.4.2022 to shall
injury be be
) or taken for liable
damage ) insurance for
a
as penalty
excluded which reliancegeneral.co.in
Reliance General Insurance Company Limited Reliance Gene rance any
under may
Section extend 022
150 to ten 74004 4890
( 2 ) lakh
( ii ) and rupees nited 22200 3009
urat Signature Compa â‘¢ lian
Reliance General Insurance Company Limited Reliance General (
iii .
) : O
b
and of
C of IRDAI
the Agent
Motor
/
Vehicles Broker
Company Limited Reliance General Insurance Company nite Reline
Reliance General Insurance
Act
1988
( Inserted
Reliance General Insurance Company Limited Reliance General Insurance Company Limited Relianc
Registered Reliance
Corporate Western General
Ventures Express &
Private Identification Corporate Insurance
Highway Reliance General Insurance Company Limited Relianc
Limited Office Company surance Company Limited
,
and No. Goregaon : Reliance
used U66603MH2000PLC128300 ( Limited
by East General
) .
Reliance ,
Mumbai
General - Insurance Limited Reliance General Insurance Company Limited Relianc
400
Insurance . UIN 063 . Company IRDAI
Company : IRDAN103RP0012V02100001 Limited Registration
,
6th
Limited Floor No. Insurance Company Limited Relianc
103 General
,
under Oberoi
License . Trade Commerz
.
RGI logo , International
/ MCOM
al displayed 0 Company Limited Reliance
/ CO
/ PCV above Business An ISO
/ PS
/ Ver belongs Park 9001
. , : 2015
1.3 / to Anil Oberoi
310118 Garden Certified
Dhirubhai Relianc
Ambani City Company
, Off
Page
12
of
12
ance
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