Mycar Polic

Digitally signed by
Reliance General
Insurance Company
Limited
Date: 2022.04.22
SID04222
2311
Reliance Private Car Package Policy- Schedule
https://
Policy Number: 141522223110053032 Proposal/Covernote No: R12042250606
2311
Insured Name :MR.KESHAVA KALYA Period of Insurance: From 00:00 Hrs on 01-May-2022 to 23:59 Hrs of 30-Apr-
0 2023
Communication Address & Place of Supply :NO 228 B, SHIVALAYA, 3RD A Policy Issuing Branch : NO.28, 5TH FLOOR, SOUTHERN PORTION EAST
MAIN ROAD,RAJARAJESHWARI WING, CENTENARY BUILDING, M.G. ROAD,,
LAYOUT,NAGADEVANAHALLI,BANGALORE BANGALORE,,KARNATAKA,
SOUTH,,BANGALORE,,KARNATAKA,,INDIA,560056 560001
Mobile No :9663367231 Tax Invoice No. & Date :R12042250606 & 22 Apr 2022 12:49
Email-ID : [email protected] GSTIN/UIN & Place of Supply: KARNATAKA

Insured's Blood group :
Insured Vehicle Details
Registration No. KA41MB0133 Mfg. Month & Year SEP-2017
Make / Model & Variant Volkswagen / Vento / 1.5 Comfortline All Star CC / HP / Watt 1498
Engine No./Chassis No. CWX143134 / MEXK1660XHT065990 Seating Capacity Including Driver 5
Geographical Extension INDIA LCC Excluding Driver 4
RTO Location KARNATAKA - Bangalore Total Premium ` 13096.00
Hypothecation/LeaseFINA
NA
NCE_HIDE
Insured Declared Value (IDV)

Vehicle IDV ` 647935 CNG / LPG Kit ` 0.0
Electrical / Electronic Accessories ` 0.0 Trailer / Side Car ` 0.0
Non Electrical Accessories ` 0.0 Total IDV ` 647935.00
Premium Summary
Own Damage - Section I Amount(`) Liability - Section II Amount(`)

Basic OD including Add-on 10177.44 Basic Liability (TPPD 1) 3221.00
Total Basic Own Damage Premium 10177.44 Total Basic Liability Premium 3221.00
Less PA Benefits - Section III
Anti-theft Devices (IMT-10) -132.95 0 PA cover to Owner Driver
Compulsory 375.00
Deduct 50 % for NCB -2592.49 1 Premium
Total PA 375.00
Sub Total of Deductions -2725.44 1
Legal Liability to paid driver 50.00
Add on Cover/s Opted TOTAL0LIABILITY PREMIUM 3646.00
Nil Depreciation TOTAL1PACKAGE PREMIUM (Sec I + II + III) 11098.00
TOTAL OWN DAMAGE PREMIUM 7452.00 0
CGST (@9.00 %) 999.00
1
SGST (@9.00 %) 999.00
TOTAL PREMIUM PAYABLE (`) 1 13096.00
0
Subject to I.M.T.Endt.Nos.IMT 10,15,28,22CGST
0
GSTIN :29AABCR6747B1ZC,HSN :997134,
Description of services :Motor vehicle Insurance Service
"As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th September of the next financial year"
PA-Nominee Details Name Age Relation
1 SINDHU RAVISHANKAR 33 Spouse
Consolidated Stamp duty Paid vide Letter of Authorisation "NO.LOA/CSD/300/2022/(Validity Period Dt.30/03/2022 to 30/03/2023)/1380" date 28th Mar 2022 at
General Stamp Office, Mumbai.** Not Applicable for the State of Jammu & Kashmir
[email protected]
14A07164 / Rahul Jaiswal 9886735633
om
Intermediary Code/Name Intermediary Contact No. Intermediary E-mail ID POS UID Aadhaar No. / PAN No.
Special Conditions : Additional Compulsory Excess of Rs.2500.0 RGICL_ORB.
Limits of liability : Under Section III of the policy - PA cover for owner driver CSI ` 1500000.0/-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 Motor Vehicle Act, 1988.(b) Under Section
II (1)(ii) of the Policy-Damage to property other than property belonging to the insured or held in trust or in the custody of
control of the insured up to the limits specified- (TPPD 1 Sum Insured - ` 7,50,000/-, TPPD 2 Sum Insured-` 6,000/-).
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: IRDAN103RP0010V02100001. 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/2311/PS/Ver. 1.3/010218.
Page 1 of 11
Limitations as to use : The Policy covers use for any purpose other than: (a) Hire or Reward, (b) Carriage of goods (other than samples or personal
luggage), (c) Organized racing, (d) Pace making, (e) Speed testing, (f) Reliability trials, (g) Any purpose in connection with
Motor Trade.
Persons/Classes of persons : Any person including insured:
entitled to drive Provided that a person driving holds a valid driving license at the time of the accident and is not disqualified from holding of
such a license. Provided that the person holding a valid learner’s license may drive the vehicle and that such a person
satisfies the requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.
Deductible under Section-I : (i) Compulsory deductible ` 1000.0/-(ii) Additional compulsory deductible ` 0 (iii) Voluntary deductible `/-0.0/-
*No Claim Bonus is subject to no claim on the previous policy. Benefits under the policy stands forfeited if claim is/was made in previous policy.50.0
"It is hereby declared and agreed that any damages pre-existing, any losses occurred & any Liability having been incurred, prior to the commencement of cover
under this policy are excluded from the scope of this policy."
"This policy provides you with benefit of “Anywhere Assist”."
The policy wording with detailed terms, conditions and exclusions are available on our website www.reliancegeneral.co.in.
I/We hereby certify that the Policy to which the certificate relates as well as this certificate of insurance are issued in accordance with the provision of Chapter X and
Chapter XI of M.V. Act, 1988.
Note: In the event of dishonor of cheque, this policy document automatically stands cancelled from inception irrespective of whether a separate communication is
sent or not. No Claim Bonus will be allowed, provided the policy is renewed within 90 days of the expiry of the previous policy.
*** Compulsory PA cover to Owner driver is opted for 1 year/s term with effective from 01/05/2022 to 30-04-2023.
Updating Registration Number of vehicles within 15 days of policy inception is MANDATORY as per IRDA. Kindly provide the same to your Agent/Our Call
centre/Policy issuing Branch (Applicable for policies booked without Registration No of vehicles).
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 hold good.
In case of a renewal, the benefits provided under the policy and/or terms and conditions of the policy including premium rate may be subject to change.
Grievance Clause :- For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 1800 3009 or may
write an email at [email protected]. In case the insured is not satisfied with the response of the office, insured may contact
the Nodal Grievance Officer of the Company at [email protected]. In the event of unsatisfactory response from the Nodal
Grievance Officer, insured may email to Head Grievance Officer at [email protected]. In the event of unsatisfactory
response from the Head Grievance Officer, he/she may, subject to vested jurisdiction, approach the Insurance Ombudsman for the
redressal of grievance. Details of the offices of the Insurance Ombudsman are available at IRDAI website www.irda.gov.in or on company
website www.reliancegeneral.co.in or on www.gbic.co.in. The insured may also contact the following office of the Insurance Ombudsman
within whose territorial jurisdiction the branch or office of the Company is located.Office of the Insurance Ombudsman,Jeevan Soudha
Building,PID No. 57-27-N-19 Ground Floor,19/19,24th Main Road,JP Nagar,Ist Phase, Bengaluru – 560 078. Tel.: 080 - 26652048 /
26652049 Email: [email protected]
Note: This 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. In case you
find any variations against your proposal or any discrepancy in the policy, kindly contact us immediately. Subject otherwise to the terms, conditions and exclusions
of the Reliance Motor Private Car Package Policy.
In witness whereof this Policy has been signed at Mumbai on policy tax invoice date in lieu of Proposal/Covernote No. as mentioned in the policy.
This document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services Tax Rules 2017.
In the unfortunate event of a claim, please call quoting your Policy No. on 022 48903009(Paid) and register your claim immediately within 7days from the date of
loss. You can also reach us at [email protected].
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 your
proposal.
For Reliance General Insurance Co. Ltd.
Authorised Signatory
IRDAN103RP0010V02100001/A0006V01201314
Page 2 of 11
Risk Assumption Letter
Dear Mr. KESHAVA KALYA

Thank you for choosing Reliance General Insurance.
Please find enclosed policy no.: 141522223110053032 which has been issued based on the details declared by the applicant.
Insured Vehicle Details
Registration No. KA41MB0133 Mfg. Month & Year SEP-2017
Make / Model & Variant Volkswagen/Vento / 1.5 Comfortline All Star Date of Registration 01-May-2018
Seating Capacity Including
Engine No./Chassis No. CWX143134/MEXK1660XHT065990 5
Driver
Type of Body NA CC / HP / Watt 1498
RTO Location KARNATAKA - Bangalore LCC Excluding Driver 4
Insured Declared Value (IDV)
Vehicle IDV ` 647935 CNG / LPG Kit ` 0.0
Electrical / Electronic Accessories ` 0.0 Trailer / Side ` 0.0
Non Electrical Accessories ` 0.0 Total IDV ` 647935.00
Previous Policy Details
Previous Year Policy No. Period of Insurance Previous Policy-Claim Status 0
141522123110031424 From : 01-05-2021 To : 30-Apr-2022 midnight Yes No
YOU HAVE OPTED FOR THE FOLLOWING COVERS

Standard Cover Vehicle Own Damage + Third Party Coverage
NO Electrical/electronic accessories
NO Non-electrical accessories
NO Bi-fuel kits comprising LPG/CNG systems
Add-on CoversYES
NO Nil Depreciation Cover No deduction for depreciation on vehicle parts other than tyres and tubes with respect of approved partial loss claims.
NO No deduction for depreciation, consumable on vehicle parts and covers the engine, loss of key, loss of personal
Motor Secure Plus
belongings in respect to approved partial loss claims.
No deduction for depreciation, consumable on vehicle parts and covers the engine, tyre, loss of key, loss of personal
NO Motor Secure Premium
belongings in respect to approved partial loss claims
NO NCB Retention Cover No-Claim Bonus % is retained even after a claim, which would have become 0% without this cover.
Total CoverNO Provides cover for registration charges, road tax and insurance premium (Total Cover Sum Insured -` 0.0/-)
EMI ProtectNO Pays for car EMIs for the time period during which the car is in one of our network garages for repair.
Provides allowance as per plan opted, if vehicle is in garage for more than minimum days & for initial two eligible own
Daily Allowance BenefitNO
damage claim., and in case of theft where vehicle is not found for more than 90 days.
Provides allowance as per plan opted, if vehicle is in garage for more than minimum days & for eligible own damage
Daily Allowance Benefit PlusNO
claim., and in case of theft where vehicle is not found for more than 90 days.
Return to Invoice Covers difference between IDV & purchase price of the vehicle in the event of theft, total loss/ CTL including first time
NO registration charges, road tax & applicable insurance cost.
Tyre Protector
Covers repair or replacement expenses arising out of accidental loss or damage to tyre & tubes.
NO
Rim Protector
Covers repair or replacement expenses arising out of accidental loss or damage to Rims.
NO
Loss of Personal Belongings Covers loss of personal belongings of insured or his family while such items are in vehicle at the time loss or
NO damage to the vehicle
Hospital Cash Cover
Provides hospital confinement allowance for accident or injuries sustained while driving insured vehicle.
NO
Consumable Expenses Covers expenses incurred towards consumable items due to damage to vehicle caused by perils covered. For e.g. nut &
NO bolt, screw, washers, grease etc
Engine Protector Provides coverage to internal parts of engine, gear box, transmission assembly & differential assembly due to ingress of
NO water or leakage of lubricating oil.
Key Protect Cover Provides replacement cost of keys in the event the keys are lost. It also covers replacement cost of locks if the vehicle is
NO broken into.
Emergency Hotel
Provide allowance towards the Hotel accommodation insured vehicle met with
Accommodation
accident/ stolen 200 kms away from the location provided in policy copy.
NO
Indemnify the Insured for an additional TPPD amount opted for damage to property other than
Additional Limit of TPPDNO
the property belonging to the Insured or held in trust or in custody of Insured.
Page 3 of 11
(Note- 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."
This policy provides you with benefit of “Anywhere Assist”. For more details visit www.reliancegeneral.co.in
Please take a moment to carefully check your policy details mentioned above and in the policy schedule. Kindly confirm that the same are in order. In case of
discrepancies, please let us know immediately. You can write to us at [email protected] or call us on 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 your proposal. Non disclosure and/or misrepresentation of claims in the previous policy period can lead to cancellation of your policy or rejection of
your claims.
For Reliance General Insurance Co. Ltd.
Authorised Signatory
IRDAN103RP0010V02100001/A0006V01201314
Page 4 of 11
Remember to carefully go through the Risk Assumption Letter and confirm your personal as well as your vehicle details.
In case of any discrepancy in the policy details, kindly revert within 15 days from the policy start date on 022 48903009 (Paid) or visit any of our branches.
Kindly refer to the Key Feature Document and Policy Wording at www.reliancegeneral.co.in to understand your policy better and learn more about the policy
coverages, add-on covers and Policy Exclusion. This document is a statement of the specific provisions that form the Terms and Conditions of this Policy.
1. Changes in vehicle make & model/cubic capacity/seating capacity/engine & chassis no./year of manufacture/registration no./ location/address
Documents required: Letter for change, policy copy and registration certificate copy along with additional premium cheque, if applicable.
2. Changes in electrical and non electrical accessories/CNG/LPG kit
Documents required: Letter for addition, policy copy, invoice copy of accessories, endorsed registration certificate copy (for CNG/LPG kit) and cheque for
additional premium.
3. Changes in financier details (Hypothecation/Lease/Hire purchase)
Documents required: Letter for change, policy copy, endorsed registration certificate copy and no objection certificate from financier (not mandatory for
deletion, if registration certificate copy is endorsed).
1. Claim form duly filled and signed (company stamp in case of company registered vehicles)
2. Registration copy
3. Driving License of the driver at the time of loss
4. Policy copy
Note: 1. As soon as a claim occurs, please intimate immediately at our call centre 022 48903009 (Paid)). Delay in intimation would result in the violation of policy
condition.
2. Any additional document, if required, will be informed.
Page 5 of 11
Live Smart
Name : KESHAVA KALYA
Policy no. : 141522223110053032
Policy Period : 01-May-2022 to 30-Apr-2023
Chasis No. : MEXK1660XHT065990
Vehicle No. : KA41MB0133
Emergency Contact no. :
Blood Group. : Scan QR code for
more details
http
For breakdown and claims Call 022 48903009
- All insurance contracts are based on the information provided by the insured in
the proposal form.
- Intimate claim immediately at our Paid No. 022 48903009 and provide:
1.Policy No. as mentioned on the card.
2.Place,Date & Time of Loss.
3.Name of the Driver Driving the vehicle at the time of Loss.
4.The damages suffered by the vehicle.
5.Injuries to passengers/driver/third parties if any.
6.Place when the vehicle is currently available for inspection.
IRDAI Registration No. 103

Reliance General Insurance Company Limited.
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.
RGI/MCOM/MOT-02/MOTOR CARD/Ver. 1.0/200115.
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private
Limited and used by Reliance General Insurance Company Limited under License.
Page 6 of 11
2311
Reliance Private Car Package Policy - Proposal Form

Is the Vehicle Made in India? Yes No Type of Vehicle : Two wheeler Four wheeler Three Wheeler
For Office Use Only

Policy Number 141522223110053032 Date
Savvion Reference No Inspection Lead No.
Intermediary Details (To be filled in BLOCK LETTERS)

Intermediary Name RAHUL JAISWAL Code 14A07164
Branch Name Bangalore III Code 1415
Sales Manager Name Niranjan K S Code 71000208
Details (To be filled in BLOCK LETTERS)
1. This Proposal is for A new Policy Renewal of Policy Endorsement Others (Please specify)
Mr.
2a. Proposer's Full Name Mr. Mrs. Ms. KESHAVA KALYA
2b. Address Address for Communication Address where Vehicle is Normally Kept and Used
Flat/Building/Door/Block No. No 228 B, Shivalaya, 3rd A Main
Road,rajarajeshwari Layout, Renewal
Road/Street/Sector Nagadevanahalli
Nearest Landmark
Area
City BANGALORE SOUTH,

Pin Code 560056
State KARNATAKA,
Country India
Phone Mobile 9663367231
Emergency Contact No. Blood Group
Email [email protected] Fax
3. Source of Funds Business Profession Salary Agricultural Income Savings Others

KARNATAKA
4. Monthly Income Upto ` 20,000 ` 20,001 to ` 50,000 ` 50,001 to ` 1,00,000 ` 1,00,001 and above
5. UID Aadhaar No. 6. PAN
7. Type of Cover Package Policy

8. Do you have a GST Registration Number Yes No
If Yes, please specify
9. Related Party Yes No
Page 7 of 11
Details of the Vehicle
10. Registration Number: KA41MB0133 11. Date of Registration: 01-May-2018

12. Registering Authority & Location: KARNATAKA - Bangalore
13. Year & Month of Manufacture: SEP-2017 14. Cubic Capacity: 1498
15. Engine Number: CWX143134
16. Chassis Number: MEXK1660XHT065990
17. Make of Vehicle: VOLKSWAGEN
18. Type of Body : NA 19. Seating capacity including Driver: 5 Diesel
Details of the Vehicle Type and Use
20. a. Whether the Vehicle is driven by Non-conventional source of power? Yes No If yes Bi Fuel CNG LPG
Insured's Declared
Non - electrical Electronic Side car
Value (IDV) of Value of CNG/
Policy Year accessories fitted accessories fitted (twowheeler)Traile Total Value (`)
vehicle Chassis LPG Kit Bi Fuel (`)
to the vehicle (`) to the vehicle (`) r (Pvt. Cars) (`)
Body
1st Year 647935 0.0 0.0 0.0 0.0 647935.00
2nd Year
3rd Year
b. Do you have a valid
Yes No
PUC?
(Note- Warranted that the Assured named herein/owner of the vehicle insured holds a valid Pollution Under Control (PUC) Certificate on the
date of commencement of the Policy and renews and maintains valid and effective PUC Certificate during the duration of the Policy period.
If the PUC is not found valid on the date of loss, the company shall repudiate the OD claim made under the Policy)
21. Age of Owner Driver 22. D.O.B
23. Add On Covers (Subject to availability and eligibility)
a. Nil Depreciation Cover Yes No
b. NCB Retention Cover (Applicable only for Annual Policy)
c. Easy Monthly Instalment (EMI) Protection Cover: Yes No
If Yes, please choose any one option;
Plan I - 1 EMI, EMI Amount: `________________ Plan II - 2 EMIs, EMI Amount: `______________
Plan III - 3 EMIs, EMI Amount: `_______________
NO d. Motor Secure Plus (Available for Private Cars Only)
e. Motor Secure Premium (Available for Private Cars Only)
f. Total Cover
g. Daily allowance benefits
Per Day Allowance: 0.0 Coverage Days: 0
h. Return to Invoice (Applicable only for Annual Policy)
i. Tyre Protector(Applicable only for annual Policy)

Specification of Tyres and Tubes:
j. Rim Protector(Applicable only for annual Policy)
Specification of Rims:
k. Hospital Cash Cover(Applicable only for annual Policy)
(Sum Insured: `0.0)
(No of Days: 0)
Convalescence benifit of SI:
l. Consumable
m. Engine Protect:
n. Key Protect Cover (Sum Insured: `0.0)
o. Daily Allowance Benifit Plus:
Per Day allowance amount opted: `0.0)
Coverage days Opted: 0)
p. Loss of Personal belongings (Applicable only for annual Policy)
(Sum Insured: `0.0)
q. Emergency Hotel Accomodation
Page 8 of 11
Benifit Amount : `0.0
r. Voluntary Deductable:
Voluntary Deductable amount opted: `
s. Additional limit of TPPD
Additional amount opted: `0.0
t. Any Other Details:
24. Whether the Car is Certified as Vintage Car by Vintage and Classic Car Club of India? Yes No
25. Whether the Vehicle is fitted with Fibre glass tank? 0.0 Yes No
26. Is the vehicle fitted with any Anti-theft device approved by the ARAI? Yes No
If Yes, please attach certificate of Installation in the vehicle, issued by Automobile Association of India.
27. Are you a member of Automobile Association of India ? If yes, please submit membership copy. Yes No
0.0
28. Whether the Vehicle is used for Driving Tuitions? Yes No

0
29. Whether use of Vehicle is limited to Own Premises? ( Only if not Licensed for General Road use by RTO). 0.0 Yes No
30. Whether the Vehicle belongs to the Embassy/Consulate of a Foreign Country? Yes No
If so, is the duty element included in the IDV? Yes No
31. Whether the Vehicle is design for use of Blind/Handicapped/Mentally Challenged Person? (Attach RC Copy) 0.0 Yes No
32. Date of purchase of the Vehicle by the Proposer 01-May-2018
33. Whether the Vehicle at the time of purchase was New Second Hand
Risk Inclusions
34. Please select the higher deductible if you wish to opt for over and above the compulsory deductible
Private Car :
35. Liability to third parties : The policy provides Third Party Property Damage (TPPD) of ` 1 lakh (Two wheelers) and ` 7.5 lakhs (Private car)
750000.0 Do you wish to restrict the above limits to the statutory TPPD Liability limit of ` 6000/- only ? Yes No
Legal Liability No of Person
Driver:
36. Personal Accident Cover for Owner Driver. Please give details of nomination
Name of Appointee (if
Name Name of Nominee Age of Nominee Relationship Address
Nominee is Minor)
SINDHU
33 Spouse
RAVISHANKAR
(Note: 1. Personal Accident cover for owner driver is compulsory for Sum Insured of `15,00,000/- for Two Wheeler, Private Car, GCV, PCV and
Misc-D
2. Compulsory PA cover for owner driver cannot be granted where a vehicle is owned by a company, a partnership firm or a similar body
corporate or where the owner-driver does not hold an effective driving license)
37. Extension of Geographical Area:
INDIA Whether extension of Geographical Area to the following countries required?
1. Bangladesh 2. Bhutan 3. Maldives 4. Nepal 5. Pakistan 6. Sri Lanka
Details of Hire Purchase / Hypothecation / Lease
38. Please state if the vehicle is under Hire purchase Lease Agreement Hypothecation Agreement
Renewal If so, give name and address of concerned parties.
39. Full Name M/s
40. Address
Details of Previous Insurance
41. Full Name of the previous insurer Reliance General Insurance Company Ltd.
42. Address No.28, 5th Floor, Southern Portion East Wing, Centenary Building, M.G. Road,
43. Policy Number 141522123110031424 Previous policy Expiry 30-Apr-2022
44. Type of cover: Package Policy Liability Only Other (To be describe)
NO CLAIM BONUS
45. allowed under
previous policy (%)
46. Claims taken in previous policy Yes No
Page 9 of 11
If yes, No. of Claims Claims Amount `
47. Are you entitled to No Claim Bonus Yes No
If yes, please submit/attached proof thereof
Previous Policy Claim (Only for

Previous Insurer Name
Previous Policy No. Period of Insurance SAOD)
Yes No
Payment Details
Cheque / DD Cheque / DD No.
Cheque/DD Date Cash Credit Card Others
Proposer's Bank Details

48. Name of the Bank Account Holder
49. Bank Account No.: 50. Account: Saving Current
51. Name of the Bank
52. Branch
53. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank)
54. IFSC Code (11 character code appearing on your cheque leaf)
I understand that any refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank Account.*
*As per IRDAI, its mandatory that all payments made to the insured are only through electronic mode.
AML Guidelines
"I/ We herby confirm that all premiums have been/ will be paid from bonafide sources and no premium have been/ will be paid out of the
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 the
documents to establish source of funds. The insurance company has the right to cancel the insurance contract in case I am/ have been found
guilty by any competent court of law under any of the statues, directly/ indirectly governing the prevention of Money Laundering in India.
Nationality: Indian Non- Indian, If Non Indian please specify the country
Type of
Corporations Government Non Government Organizations Society Trust
Organization :
Partnership International Organization Cooperatives Section 25 companies
Declaration by Proposer
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 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 abide by the same. • I/We
declare that the rate of NCB stated above by me/us is correct and that no claim 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 respect 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. 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. • I/We hereby confirm that the contents of the proposal form and connected documents have been fully explained to me/us and
I/We have fully understood the significance of the proposed contract.
This proposal form was completed by

You can support our Go Green Initiative by saying “No” to Policy kit, Renewal Notice and Other Communications hard copy. We
will be sending you a digitally signed soft copy on your registered Email ID & Mobile number.
Page 10 of 11
Hard copy required Yes No
Name Place :
Date : Date :
Signature Signature of Proposer & Company Seal

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 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 prospectuses or tables of the insurer.
2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh
rupees.
Supporting Confirmation of Agent/Broker/SM/CSO
I confirm the above signature to be of the registered owner of the vehicle proposed for insurance
Name of IRDAI Agent/Broker Mr. Mrs.
Place :
Date :
(In case of Direct Business, Name & Signature of CSO / SM to be taken) Signature of IRDAI Agent/Broker
Page 11 of 11

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Email-ID : [email protected] GSTIN/UIN & Place of Supply: KARNATAKA

Insured Declared Value (IDV)

Own Damage - Section I Amount(`) Liability - Section II Amount(`)

Dear Mr. KESHAVA KALYA

141522123110031424 From : 01-05-2021 To : 30-Apr-2022 midnight Yes No

YOU HAVE OPTED FOR THE FOLLOWING COVERS

For breakdown and claims Call 022 48903009

IRDAI Registration No. 103

Reliance Private Car Package Policy - Proposal Form

For Office Use Only

Intermediary Details (To be filled in BLOCK LETTERS)

Details (To be filled in BLOCK LETTERS)

City BANGALORE SOUTH,

Phone Mobile 9663367231

Emergency Contact No. Blood Group

Email [email protected] Fax

3. Source of Funds Business Profession Salary Agricultural Income Savings Others

5. UID Aadhaar No. 6. PAN

7. Type of Cover Package Policy

If Yes, please specify

9. Related Party Yes No

10. Registration Number: KA41MB0133 11. Date of Registration: 01-May-2018

i. Tyre Protector(Applicable only for annual Policy)

28. Whether the Vehicle is used for Driving Tuitions? Yes No

Details of Hire Purchase / Hypothecation / Lease

Previous Policy Claim (Only for

Proposer's Bank Details

This proposal form was completed by

Signature Signature of Proposer & Company Seal

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