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Date : 06/02/2018

Policy No : FCV/SA392276/U3/01/005782

Client ID : 7581941

MR RAM JAG SINGH


KACHHAWAN

JAUNPUR 222002
UP
Contact Number : 9792834164
Email Id :
PESARAKGSG@KGSGBANK.COM

Dear MR RAM JAG SINGH

Welcome to Bharti AXA General Insurance Co. Ltd

Congratulations! You have made the right choice by selecting the Bharti AXA Smart Drive Commercial Vehicle Insurance Policy. Your Policy No ( FCV/SA392276/
U3/01/005782) will be your friend in need. Bharti AXA, with its world-class service, will reach out to you with a range of benefits, including a fast, fair and friendly claims-
settlement experience. We will be at your side, providing quality solutions and convenience at every step. By going in for this policy, you have bought yourself peace of mind!

The policy guidelines and the details of your insurance coverage are available in the enclosed policy document. Should you have any questions, please contact your Bharti
AXA insurance advisor or call our toll free number 1 800 103 2292. You can also e-mail us at customer.service@bharti-axagi.co.in or register your query in the support
section at www.bharti-axagi.co.in. We are there to help you.

We thank you for reposing faith in Bharti AXA General Insurance Co. Ltd and look forward to adding value to our relationship by providing more services and benefits in the
years to come.

Should you require any assistance or clarification on your insurance or any information pertaining to our other products, you can call us on 1 800 103 2292 or get in touch
with
KASHI GOMTI SAMYUT GRAMIN(U3000447) at 2220752
Warm regards,

Authorized Signatory

Bharti AXA GENERAL INSURANCE COMPANY LTD


1st Floor, Ferns Icon, Survey No.28, Doddanakundi, Bangalore 560037. INDIA. IRDA Regn.No.139
Tel: 080 40260100 Fax: 80 40260101 Email: Customer.service@bharti-axagi.co.in

For redressal of your grievance, if any, you may approach any one of the offices- 1.Policy issuing office 2.Corporate Office. In case, you are not satisfied with our own grievance redressal mechanism; you
may also approach Insurance Ombudsman. Details of Insurance Ombudsman offices are available at IRDA website: www.irda.gov.in, or on the website of General Insurance Council: www.gicouncil.in or
on the company website www.bharti-axagi.co.in

Tax Invoice will be followed after the Policy Certificate


Bharti AXA General Insurance Company Limited, Plot No. 22E, Second Floor, Civil Lines Smart Drive Commercial Vehicle Insurance Policy, CERTIFICATE OF INSURANCE AND SCHEDULE, NEW
BUSINESS, ORIGINAL
Form 51 of the Central Motor Vehicle Rules ,1989
Certificate / Policy No : FCV/SA392276/U3/01/005782 Account Number : U3000447
Policy type : Miscellaneous Vehicle- Misc - COMPREHENSIVEINSURANCE POLICY
Period of Insurance : From 20:00Hours on 30/01/2018To Midnight on 29/01/2019
Premium Paid (incl. S. Tax) : INR 7992.14
: MR RAM JAG SINGH
Policy holder's Name
:
Address : KACHHAWAN
:
:
: JAUNPUR 222002
: UP
Under Hire purchase/Hypothecation/Lease with : KGSG BANK , PESARA JAUNPUR
Geographical Area : INDIA
Agent Details
Agent Name : KASHI GOMTI SAMYUT GRAMIN
Tel No - Mobile No : 2220752
Regn.No : UP62X5705 Place of Regn : JAUNPUR
Make / Model : SONALIKA - 740 - DI STD
Year of Manufacture : 2011 Body Type :
Seating Cap. (Incl.Driver) :2 Engine C.C :
Public / private Carrier :
Chassis No. : C2145113 Engine No. : 3100EC03H215797
IDV of the Vehicle : INR INR 150000.00
IDV-Trailer :
Bi-Fuel(CNG/LPG) :
Total Insured Declared Value of the Vehicle : INR 150000.0
Schedule of Premium
A)Own Damage Premium B) Liability premium
Premium for (Vehicle and non Electrical Accessories) : INR 1875.00 Basic : INR 4892.00
Trailer : INR 0
CNG/LPG Kit (IMT 25) : INR 0 Restricted TPPD : INR 0
Trailer : INR 0 Comp. PA : INR 100
IMT - 23 : INR 0
Overturning : INR 0 No. of Passengers :
Own Premises : INR 0
NCB 0% : INR 0 CNG / LPG(IMT 25) : INR 0
Load /Discount : INR -93 LL others : INR 0
LL Non-Fare : INR 0
A. Total Own Damage premium : INR 1781.0 B. Total Liability Premium : INR 4992.0
Net Annual
: INR 6773.0
Premium (A+B)
GST : INR 1219.14
Total Annual Premium : INR 7992.14
Driver's clause: Persons or Classes of person entitled to drive
Any person including the insured : Provided that a person driving holds an effective driving license at the time of the accident and is not disqualified from holding or obtaining such a license.Provided also that the person
holding an effective Learner's License may also drive the vehicle when not used for transport of goods/passengers at the time of accident and that such a person satisfies the requirements of Rule 3 of the central Motor
Vehicle Rules , 1989
Limitation As to Use
The Policy covers use only for carriage of goods within the meaning of Motor Vehicles Act.Policy does not cover: 1)Use for Organised racing ,pace making,reliability trial,speed testing. 2)Use whilst drawing a trailer except
towing(other than for reward)of any one disabled mechanically propelled vehicle. 3)Use for carrying passangers in vehicles,except employees(other than driver)not exceeding the no.Permitted in registration document and
coming under purview of workmen's Comp Act 1923
Limits of Liability
Under Section II-1 (i) of the policy (Death or bodily injury) : such amount as is necessary to meet the requirements of the Motor Vehicles Act, 1988.
Under Section II-1 (ii) of the policy
(Damage to third party Property) : INR 750000
P.A Cover for Owner - Driver Under Section
III: CSI : INR 200000
Deductable under Section-I
Compulsory Deductible 0.5 % of IDV of the vehicle subject to a minimum of INR 2000.00
Name of Nominee : MRS SINGH Age of Nominee : 38
Driver Nominee Relationship : WIFE Name of Appointee :
Appointee Nominee Relationship :
Subject to Indian Motor Tariff Endorsement (nos)
IMT21-
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 XI of Motor Vehicle Act, 1988. In witness of this policy
has been signed at _______________ on _______________ in lieu of covernote no. dated
Receipt No. : 2806162
Service Tax Registration no. : AADCB2008DST001
BHARTI AXA GENERAL INSURANCE COMPANY LTD.

Authorized Signatory

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's Act , 1988 is recoverable from the insured. See the clause headed "AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY"
The 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.
Issued By - KASHI GOMTI SAMYUT GRAMIN On 30/01/2018 IP Address - 10.92.89.12
This motor policy is generated and issued online therefore the stamp duty payable on this policy is paid separately.

Bharti AXA GENERAL INSURANCE COMPANY LTD


1st Floor, Ferns Icon, Survey No.28, Doddanakundi, Bangalore 560037. INDIA. IRDA Regn.No.139
Tel: 080 40260100 Fax: 80 40260101 Email: Customer.service@bharti-axagi.co.in

For redressal of your grievance, if any, you may approach any one of the offices- 1.Policy issuing office 2.Corporate Office. In case, you are not satisfied with our own grievance redressal mechanism; you
may also approach Insurance Ombudsman. Details of Insurance Ombudsman offices are available at IRDA website: www.irda.gov.in, or on the website of General Insurance Council: www.gicouncil.in or
on the company website www.bharti-axagi.co.in

Tax Invoice will be followed after the Policy Certificate

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