The New India Assurance Co. Ltd.

Servicing Office of Insurer: DO 122200, NEW INDIA CENTRE, 1ST FLR, 17-A COOPERAGE ROAD, Mumbai,
Maharashtra (State Code:27) -400001, PH-022-22821458 Website: http://newindia.co.in
PAN: AAACN4165C , GSTIN: 27AAACN4165C3ZP Insurer's IRDA Registration Number:190
Tollfree Helpline 1800-209-1415 Email: nia.121404@newindia.co.in CIN : U9999 MH1919 GOI 000526

POS - PRIVATE CAR-PACKAGE POLICY-CERTIFICATE CUM POLICY SCHEDULE

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

Policy No 12220031171350098074 Proposal No. & Date PPVBU3936279, 24-MAR-2018

Policy Issued On 24-MAR-2018 (20:27) Period of Insurance 28-MAR-2018(00:00) To 27-MAR-2019(Midnight)

Insured Name Ms. FATIMA KHAN
Insured Add. D/O LATE TAHIR ALI KHAN 55 ZAKHIRA QILA NEAR JAMA MASJID , BAREILLY , UTTAR PRADESH (State Code:09) -243003
Previous Insurer NIA Previous Policy No. 12220031160350034242 28-MAR-2017 To 27-MAR-2018
Broker Details
IRDA Lic. No.: 375, CIN No.: U50300MH1997PLC149349 Broker Category: Direct General 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), MUMBAI 400 059, INDIA

Make Model Sub Model Cubic Capacity Manufacturing Year Seating capacity

TATA MOTORS TATA TIAGO TIAGO XT 1.2 P 1199 2017 5

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

HATCHBACK UP 25 BW 8387 BAREILLY 28-MAR-2017 REVTRN02BSYK07080 MAT626282HKB09676

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

393,790 0 0 0 393,790

Schedule of Premium (Amount in Rs.)

Own Damage Premium (A) Liability Premium (B)
Basic Premium Basic Third Party Liability 2,863

Vehicle 7,540 Third Party Liability For Bi-Fuel Kit 0

Non-Elec. Accessories 0 Third Party Liability For Geographical Area Extension 0

Elec. Accessories (IMT-24) 0 PA Cover For Owner Driver Of Rs. 2 Lakh (IMT-15) 100

CNG/LPG Kit (IMT-25) 0 PA Cover For 5 Persons of Rs. 100000 Each (IMT-16) 250
Sub Total (Basic Premium) 7,540 PA cover for Paid Driver of Rs 2,00,000 (IMT± 0

Add On Coverages (Nil Dep) 1,969 Legal Liability For Paid Driver (IMT-28) 50

Geographical Area Extension (IMT-1) 0 Legal Liability for Employees (for 0 persons) (IMT± 0

IMT 23 Premium 0 Net Liability Premium (B) 3,263

Sub Total-Addition 9,509 Total Premium (A+B) 12,772

Deductibles IGST (18%) 2299

Voluntary Deductibles (0) (IMT-22A) 0 Gross Premium Paid 15,071
Note: 1.Warning that in case of dishonour of the premium cheque, this document stands automatically
Anti Theft Device (IMT-10) 0 cancelled 'ab-initio

AA Membership (IMT-8) 0 2.Consolidated stamp duty paid to state exchequer

3.The policy is subject to compulsory deductible of Rs.1000 (IMT-22)
No Claim Bonus (0%) 0

Sub Total (Deductibles) 0 5.Add-on: Nil Depreciation:1969

6.The insurance company will display terms & conditions on its website http://newindia.co.in which can
be accessed by you online.
Net Own Damage Premium (A) 9,509 *Subject to IMT Endt. Nos.& Memorandum:16,22,28,23
Nominee Details
Name of Nominee Age Relationship with Insured Name of Appointee Relationship with Nominee
ZAINAB KHAN 27 SISTER --N.A-- --N.A--
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 Mo
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. 2.0lakhs.
Payment Details : UTR No.: 5856101262080830, Payment Date: 24-MAR-2018, Bank Name: HDFC BANK LTD, Bank City:
Hypothecation Details: ----NA----
POSP Name: SANJIT PRABHAKAR, POSP Aadhaar Number: 721933900197, POSP PAN Number: AHXPP7676D
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 NOIDA on 24-MAR-2018 20:27
SAC:997134, Description of Service :Motor Vehicle Insurance Services, Place of Supply :UTTAR PRADESH(State Code:09), Receipt No/Invoice No:23170064679
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 The New India Assurance Co. Ltd.

Dealer Code : AYUSH MOTORSINDIA PVT LTD(NOIDA)(TASC) - 308496000

In case of any claim or assistance required please contact our help line at 1800 209 0060 and you may also reach us at support@tatamotorsinsurancebrokers.com
 PRIVATE CAR PACKAGE POLICY: ADD ON COVERS

A. Endorsement Wordings

Notwithstanding anything to the contrary contained in the policy, and provided additional premium has been paid, it is hereby understood and agreed
that in the event of a Partial Loss Claim for damages to the vehicle insured under the policy where liability is admitted, the insurer will indemnify the
insured the full value of expenses incurred for replacement of damaged parts of insured vehicle without application of depreciation thereon.

It is also agreed and understood that the cover specified able will be applicable for only 2 Claims during a Policy Period. Subject otherwise to the
terms, conditions, limitations and exceptions of the policy.