CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

Chola MS Issuing Office Address : Proposal No. E4991581

KHAMMAM CIE Intermediary Code 201204002988
15-9-533, KAVIRAJ NAGAR, Contract No.
WYRA ROAD, KHAMMAM. Loan Application No.
KHAMMAM H.O MOTOR INSURANCE Agreement No.
KHAMMAM
TELANGANA PROPOSAL POSP Name:
507001 FUNDED POSP PAN No:
This is only a quote/proposal and not a POSP Aadhar No:
valid policy certificate
Proposal Type : New Vehicle Type of Vehicle : Miscellaneous [UIN No. IRDAN123P0007V02100001]
1.Name of the Insured CHEEKATI SRI DIVYA
Vehicle Registration Address S/O BALAKRISHNA,1-72,MODDULAGUDEM
Area DAMMAPETA S.O City: KHAMMAM
State TELANGANA Pin Code: 507306
Financier Type: Hypothecation Financier Name: L AND T FINANCE LTD

2.Registration Mark,Number and Description of the Vehicle Insured. Date of Registration 02 Feb 2019
Registration No. NEW Place of Registration SATHUPALLY
Engine No. NJD5FCE0241 Chassis No. MBNSFAJYBJND01998
Type of
Make MAHINDRA Model 475 - YUVO Variant YUVO TRACTOR Fuel Used DIESEL
Body
Gross Licensed Carrying Capacity
Vehicle Public /
Cubic Year of Licensed Total Seating
Weight Private
Capacity Manufacture Passenger Driver and Others Capacity
(GVW) Carrier
in kilos Carrying Capacity Including Driver

714 2019 0 PUBLIC 0 1 0

3.Effective Date & Time of Commencement of Insurance for the purpose of the Act. From 02 Feb 2019 00:00 Hrs
4.Date of Expiry of Insurance Midnight of 01 Feb 2020
Value of Chassis(Rs.) Value of Body(Rs.) For Vehicle(Rs.) For Trailer(Rs.) Value of CNG/LPG (Rs.)
670,000.00 0.00 670,000.00 0.00 0.00
Non Electrical Accessories (Rs.) Electrical / Electronic Accessories (Rs.) Total Value (Rs.)
0.00 0.00 670,000.00

PREVIOUS INSURANCE PARTICULARS(If Applicable)

Name of Previous Insured :
Policy No: Period From : To:
Type of Earlier Policy
Previous Policy
Past Claim History Number of Claims Made
Claim Paid Amount (Rs.) 0.00
Are you entitled for No Claims Bonus(NCB) No If Yes,then NCB %

Net Premium (Rs.) 12,309.00

GST (Rs.) 2,216.00
Total Premium (Rs.) 14,525.00
IMT Nos:21,40,7
Warranty
Special Conditions
Compulsory Excess (Rs.) 1,000.00
Additional Imposed Excess (Rs.) 0
Date of Issue 01 Feb 2019 Time 17:54 Hrs Place KHAMMAM CIE

Declaration:I / We desire to insure with Cholamandalam MS General Insurance Company Limited ("Company") and in this regard
hereby declare that the statements made by me / us in the proposal form are true and complete to the best of my / our knowledge and
belief. I / We hereby agree that this declaration shall form the basis of the contract between me / us and the company. I / We also
declare that if alteration / addition is carried out after the submission of this proposal; the same shall be conveyed to the Company
immediately. I / We have understood the covers being offered under this policy and am / are aware of the applicable terms and
conditions. I / We are aware that mere remittance of payment does not guarantee acceptance of this risk, which decision shall be made
by the Company. I / We agree to the Company taking appropriate measures to capture the voice log for all such telephonic transaction
carried out by me / us in accordance with procedures / regulations, internal or external. This cover is valid in India only.
I further agree that the details stated in the Cover Note be taken as part of this Proposal.
Declaration for No Claim Bonus (NCB)*(if NCB confirmation is not submitted but NCB claimed).
I /We declare that the rate of NCB of 0 claimed by me/us is corrected and that NO CLAIM has arisen in the expiring Policy Period(Copy
of Policy enclosed). I/We further undertake that if this declaration is found incorrect, all benefits under the Policy in respect of Section -
1 (own damage) of the Policy will stand forfeited.

Signature of the Proposer: Date: Place: