Tata AIG General Insurance Company Limited

Servicing Office of Insurer: 1/F,VOLTAS HOUSE(NORTH BLOCK), OFFICE BLOCK NO 7,MAIN

ROAD,BISTIPUR,JAMSHEDPUR- 831001, Jamshedpur, Jharkhand (State Code:20) -831001, PH--
Website: www.tataaig.com
PAN: AABCT3518Q . GSTIN: 20AABCT3518Q1ZA Insurer's IRDA Registration Number: 108
Tollfree Helpline 18002667780/02266939500 Email: customersupport@tataaig.com CIN :
U85110MH2000PLC128425 UIN No: IRDAN108P0002V01200001

Auto Secure - Private Car Package Policy (UIN-IRDAN108RP0002V01200001) CUM RECEIPT

(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. 0192026799 Policy Issued On 10-DEC-2019 (12:09)

Insured Name MR. BADAL RAJ
Own Damage Period 19-DEC-2019(00:00) To 18-DEC-2020(Midnight) Motor Liability Period 19-DEC-2019(00:00) To 18-DEC-2020(Midnight)

Proposal No. & Date PRODFORD2189201, 10-DEC-2019 CPA Cover Period 19-DEC-2019(00:00) To 18-DEC-2020(Midnight)
Insured Add. S/O MANOJ KUMAR PANDEY PROMILA NIWAS IN FRONT OF S BI , DEOGHAR , JHARKHAND (State Code:20) -814112
Previous Insurer TAG Previous Policy No. 0192011255 19-DEC-2018 To 18-DEC-2019
Broker Details
IRDA Lic. No.: 375, CIN No.: U50300MH1997PLC149349 Broker Category: Composite Broker, Validity: 13-MAY-17 To 12-MAY-20
Name & Add.: TATA MOTORS INSURANCE BROKING & ADVISORY SERVICES
LTD, 1ST FLOOR, AFL HOUSE, LOK BHARATI COMPLEX, MAROL MAROSHI ROAD, ANDHERI (EAST), MUMBAI400 059, INDIA

Make Model Sub Model Cubic Capacity Manufacturing Year Seating capacity

FORD ECOSPORT 1.5 ECOSPORT DSL TIT 1498 2017 5

Body Type Registration No. RTO Invoice Date Engine No. Chassis No.

UAV JH 01 CU 4344 RANCHI 19-DEC-2017 HE41098 MAJAXXMRKAHE41098

Vehicle IDV CNG/LPG Kit Elec. Accessories Non-Elec. Accessories Total IDV

749,700 0 0 0 749,700

Schedule of Premium (Amount in Rs.)

Own Damage Premium (A)
Basic Premium Deductibles
Vehicle 9,570 Voluntary Deductibles (0) (IMT-22A) 0

Non-Elec. Accessories 0 Anti Theft Device (IMT-10) 0

Elec. Accessories (IMT-24) 0 AA Membership (IMT-8) 0

CNG/LPG Kit (IMT-25) 0 No Claim Bonus (25%) 2,393

Sub Total (Basic Premium) 9,570 Sub Total (Deductibles) 2,393

Geographical Area Extension (IMT-1) 0

IMT 23 Premium 0

Add On Coverages (NILDEP) 5248

Sub Total-Addition 14,818 Net Own Damage Premium (A) 12,425

Liability Premium (B)

Basic Third Party Liability 3221 PA Cover For 0 Persons of Rs. 200000 Each (IMT-16) 0
Third Party Liability For Bi-Fuel Kit 0 PA cover for Paid Driver of Rs 2,00,000 (IMT± 0
Third Party Liability For Geographical Area Extension 0 Legal Liability For Paid Driver (IMT-28) 50
PA Cover For Owner Driver Of Rs. 1500000 (IMT-15)
450 Legal Liability for Employees (for 0 persons) (IMT± 0

Net Liability Premium (B) 3721

Note: 1.Warning that in case of dishonour of the premium cheque, this document stands
automatically cancelled 'ab-initio Total Premium (A+B) 16146
2.Consolidated stamp duty paid to state exchequer CGST (9%) 1454
3.The policy is subject to compulsory deductible of Rs.1000 (IMT-22) SGST (9%) 1454

5.Add-on: NILDEP(Nil Depreciation:5248)

6.The insurance company will display terms & conditions on its website www.tataaig.com which can
be accessed by you online.
*Subject to IMT Endt. Nos.& Memorandum:7,22,28 Gross Premium Paid 19054
0
Nominee Details
Name of Nominee Age Relationship with Insured Name of Appointee Relationship with Nominee
PRATIBHA RAJ 37 SPOUSE --N.A-- --N.A--
Payment Details : Cheque No.: 961628, Cheque Date: 10-DEC-2019, Bank Name: STATE BANK OF INDIA, Bank City: JAMSHEDPUR
Hypothecation Details: STATE BANK OF INDIA - DEOGHAR - DEOGHAR
MISP Name: JAYSHREE MOTORS PVT LTD, MISP PAN No: AABCJ2880K, MISP Code: MISP/AABCJ2880K
SAC:997134, Description of Service :Motor Vehicle Insurance Services, Place of Supply :JHARKHAND(State Code:20), Receipt No/Invoice No:0192026799
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 Motor
Vehicle Act, 1988
For & On Behalf of Tata AIG General Insurance Company Limited

Dealer Code : JAYSHREE FORD (JAMSHEDPUR) - 9XZ743V00

Authorized Signatory
In case of any claim or assistance required please contact our help line at 1800-258-2545 and you may also reach us at fordinsurance@tmibasl.com
 Tata AIG General Insurance Company Limited
Servicing Office of Insurer: 1/F,VOLTAS HOUSE(NORTH BLOCK), OFFICE BLOCK NO 7,MAIN
ROAD,BISTIPUR,JAMSHEDPUR- 831001, Jamshedpur, Jharkhand (State Code:20) -831001, PH--
Website: www.tataaig.com
PAN: AABCT3518Q . GSTIN: 20AABCT3518Q1ZA Insurer's IRDA Registration Number: 108
Tollfree Helpline 18002667780/02266939500 Email: customersupport@tataaig.com CIN :
U85110MH2000PLC128425 UIN No: IRDAN108P0002V01200001

Auto Secure - Private Car Package Policy (UIN-IRDAN108RP0002V01200001) CUM RECEIPT

(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. 0192026799 Policy Issued On 10-DEC-2019 (12:09)

Insured Name MR. BADAL RAJ
Own Damage Period 19-DEC-2019(00:00) To 18-DEC-2020(Midnight) Motor Liability Period 19-DEC-2019(00:00) To 18-DEC-2020(Midnight)

Limitations as to use: The policy covers use of the vehicle for any purpose other than (1) Hire or Reward (2) Carriage of
goods (other than samples or personal luggage) (3) Organized racing (4) Pace making (5) Speed testing (6) Reliability trials (7)
Any purpose in connection with motor trade.

Driver¶s Clause: Any person including the insured: 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 license. Provided also that the person holding an
effective learners license may also drive the vehicle & that such a person satisfies the requirements of Rule 3 of the Central
Motor Vehicle Rules, 1989.

Limits of Liability Clause:Under Section II-1(i) of the policy-Death of or bodily injury: Such amount as is necessary to meet
the requirements of the Motor Vehicle Act 1988.Under Section II-1 (ii) of the policy-Damage to third party property is
Rs.7.5lakhs PA Cover Under Section III for Owner-Driver is Rs. 1500000

Important Notice: The insured is not indemnified if the vehicle is used or driven otherwise than in accordance with the
schedule. Any payment made by the company by reasons 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 ³AVOIDANCE OF CERTAIN TERMS &
RIGHT OF RECOVERY´For legal interpretation English version will hold good.

Note: This Schedule, the attached Policy and Endorsements mentioned herein above shall read together and word or
expression to which a specific meaning has been attached in any part of this policy or of the Schedule shall bear the same
meaning wherever it may appear. Any amendments/modifications/alterations made on this system generated policy document
is not valid and Company shall not be liable for any liability whatsoever arising from such changes. Any changes required to
be made in the policy once issued would be valid and effective, only after written request is made to the Company and
Company accepts the requested amendments/modifications/alterations and records the same through separate endorsement to
be issued by the company.
In Witness whereoff this policy has been signed at RANCHI on 10-DEC-2019 12:09
 Tata AIG General Insurance Company Limited
Servicing Office of Insurer: 1/F,VOLTAS HOUSE(NORTH BLOCK), OFFICE BLOCK NO 7,MAIN
ROAD,BISTIPUR,JAMSHEDPUR- 831001, Jamshedpur, Jharkhand (State Code:20) -831001, PH--
Website: www.tataaig.com
PAN: AABCT3518Q . GSTIN: 20AABCT3518Q1ZA Insurer's IRDA Registration Number: 108
Tollfree Helpline 18002667780/02266939500 Email: customersupport@tataaig.com CIN :
U85110MH2000PLC128425 UIN No: IRDAN108P0002V01200001

Auto Secure - Private Car Package Policy (UIN-IRDAN108RP0002V01200001) CUM RECEIPT

(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. 0192026799 Policy Issued On 10-DEC-2019 (12:09)

Insured Name MR. BADAL RAJ
Own Damage Period 19-DEC-2019(00:00) To 18-DEC-2020(Midnight) Motor Liability Period 19-DEC-2019(00:00) To 18-DEC-2020(Midnight)

PRIVATE CAR PACKAGE POLICY: ADD ON COVERS

TA01-Depreciation Re-imbursement (UIN IRDAN108A0001V01200910)

This cover is applicable if it is shown on Your schedule.

What is Covered:

We will pay you the amount of depreciation deducted on the value of parts replaced under own damage claim, lodged under
section 1 (own damage) of the policy. We will pay for the unlimited claims reported to Us during the Period of insurance.

Special Conditions applicable to this cover in addition to the General Conditions:

A claim where replacement of any part is not involved and no depreciation is deducted under own damage claim, will not be
considered as claim under this cover.

Vehicle is repaired at any of our Authorised Garage/Authorised workshop/Authorised service station.