HDFC ERGO General Insurance Company Limited

Servicing Office: HDFC ERGO GENERAL INSURANCE COMPANY LIMITED 1ST FLOOR, SCO 11, CHOTI BARANDARI ,
PATIALA, PUNJAB -147001
Proposal Form
PAN: AABCL5045N, GSTIN: 03AABCL5045N1ZI, CIN: U66030MH2007PLC177117, IRDAI Reg. No.: 146

Proposal No: HIIB12633678 Proposal Date: 06-Dec-2024 (17:20)

Proposer Name: MR. HARDIK J MOREY Previous Policy No: HIB/56108178
Vehicle Class: PRIVATE Previous Insurer: IFFCO Tokio General Insurance Company Limited.
Period of Own Damage: 20-DEC-2024 (00:00) To 19-DEC-2025 (1 YEAR)
#36 KHUDA ALI SHER,SECTOR-7 C/O # 47 Period of Liability Cover: NA
Proposer Address: PARADISE PALM,KHARAR,POST OFFICE KHARAR ,
CHANDIGARH, CHANDIGARH-160001 Period of Compulsory
Personal Accident Cover: NA To NA
Proposer Type PAN GSTIN Name Age Relation
Proposer Details: Nominee Details
INDIVIDUAL ******722R NA NA 0 NA
Previous TP Details
TP Insurance Company Name: The New India Assurance Company Limited. TP Policy No: 11300031220950006345
TP Risk Inception Date: 19-Dec-2022 TP Risk Expiry Date: 18-Dec-2025
Vehicle Details
Make Model Sub Model Cubic Capacity Manufacturing Year Seating Capacity
HYUNDAI ALL NEW I20 I20 SPORTZ 1.2 KAPPA MT 1197 2022 5
Registration Date Registration No. RTO Hypothecation/Lease* Engine No. VIN / Chassis No.
03-MAR-2023 CH-01-CN-1187 CHANDIGARH NO G4LFNM372669 MALBH512LNM191518
Invoice Value Vehicle IDV Elec. Accessories Non-Elec. Accessories BI Fuel Kit Total IDV
766625 613300 0 0 0 613300
Schedule of Premium (Amount in Rs.)
Own Damage Premium (A) Amount Liability Premium (B) Amount
Basic Own Damage Premium Basic Third Party Liability 0
Vehicle 6850 Bi-Fuel Kit 0
Non-Elec. Accessories (IMT-24) 0 Geographical Area Extension (IMT-1) 0
Elec. Accessories (IMT-24) 0 Sub Total (Third Party Liability Premium) 0
Bi-Fuel Kit (IMT-25) 0 Personal Accident (PA) Cover
Sub Total (Basic Premium) 6850 Compulsory PA Cover for Owner Driver Rs.0 (IMT-15) 0
Geographical Area Extension (IMT-1) 0 PA Cover for (0) Unnamed Passengers Rs.0 Each (IMT-16) 0
IMT 58 Premium 0 PA Cover for Paid Driver Rs. 2 Lac (IMT-17) 0
Sub Total 6850 Sub Total PA Cover 0
Discounts/Deductibles Legal Liability
Voluntary Deductible (IMT-22A) (0) 0 Paid Driver (IMT-28) 0
Anti-Theft Device (IMT-10) 172 Employees(IMT-29) (for 0 persons) 0
AA Membership (IMT-8) 0 Sub Total (Legal Liability) 0
No Claim Bonus – (0%) 0 Net liability Premium (B) 0
Handicapped Discount (IMT-12) 0 Total Premium (A+B) 10657
Sub Total (Discounts/Deductibles) 172 IGST (18%) 1919
Add-on Coverage (ZD,CM,KP,PB) 3979
Net Own Damage Premium (A) 10657 Gross Premium Paid 12576
Add-on Cover Opted in the Policy: ZERO DEPRECIATION,CONSUMABLES,KEY PROTECT,PERSONAL BELONGING.
SAC: 997134, Description of Service: Motor Vehicle Insurance Services, Place of Supply: CHANDIGARH (State Code: 04)
*Hypothecation Details: ----NA---- Payment Mode:ONLINE
Break in Insurance Declaration “I/We hereby Declare and Undertake

That, the vehicle proposed to be insured had, during the period in which it was not covered by valid and effective insurance policy issued by any insurer/s, had NOT met with any accident (*Select the
appropriate check box and provide relevant information against selected entry)

That, the vehicle proposed to be insured had, during the period in which it was not covered by valid and effective insurance policy issued by any insurer/s, met with an accident on DD/MM/YYYY at
DD/MM/YYYY Add more date/s with time if vehicle had met with an accident more than once)
I/we understand that all and/or any kind of liabilities arising out of accident/s which had occurred prior to risk inception date and time as mentioned in the Policy Document issued by HDFC ERGO General
Insurance Company Limited. in consideration of these presents will be completely out of ambit of said Policy and said Company will not be in any manner liable or held responsible, therefore.
I/we further undertake that if this declaration and/or any of its part is found to be incorrect in any manner, all the benefits under the Policy will then stand forfeited and the contract of insurance will be treated as
void ab-initio”.
NCB Declaration I / We declare that the rate of NCB claimed by me/us is correct and that no claim has arisen in the expiring policy period (copy of the policy enclosed) I/We further undertake that if this
declaration is found to be incorrect, all benefits under policy respect of Section I of the policy will be forfeited.
Declaration “I am/we are aware that the complete terms and conditions of this insurance policy are available at the official website of the insurer http://www.hdfcergo.com. I/We hereby consent to receive only
the certificate and schedule of insurance upon undertaking of the insurer that the complete policy terms & conditions will be made available free of cost upon my/our request”. I hereby declare and confirm that
the PUC certificate of the vehicle proposed for insurance is valid as on date. I hereby declare and confirm that the Fastage of the vehicle proposed for insurance is affix as on date.
Any other Material Information Declaration and Consent I/We hereby declare that the statements, answers given by me /us in this proposal form are true to the best of my knowledge and belief and I/We
hereby agree that this declaration shall form the basis of the contract between me/us and the It is hereby understood and agreed that all statements, details and particulars provided herein above are the basis
on which this Insurance is being granted and that if, after the insurance is affected, it is found that any of the statements, answers or particulars are incorrect or untrue in any respect, the company shall have no
liability under this Insurance. I/We agree and undertake to convey to any change / alterations carried out in the risk proposed for insurance after submission of this proposal form. “I/We have insurable interest in
the subject matter of this insurance, and we hereby declare that the Cost of the same and the premium for this insurance is paid from legal sources of funds. I, the undersigned proposer hereby declares and
confirm that I have understood the features, terms and conditions of the policy and details asked contained in the proposal form. I also understand that the reply to the details asked in the proposal form, forms
the basis of the contract of insurance. If any information/statement given in proposal is found to be untrue, the policy shall be treated as void ab initio and the premium paid shall be forfeited to the Company.
Please give details if you are politically exposed person or relative of politically exposed person. ------------------------------------------------------------ Please give details if you are no profit organization. --------------------
--------------------------

I hereby agree to receive a one pager policy document I hereby confirm having a valid personal accident policy for sum Insured of minimum Rs.15 lakhs.
I hereby confirm that I have mandated Hyundai India Insurance Broking Pvt.Ltd. to place my insurance risk and have read and agreed on the terms and conditions.

Insurance Broker Name: Hyundai India Insurance Broking Pvt. Ltd. Proposer Signature & Date:
Corporate Office: 16th Floor, Building No. 9A, DLF Cybercity, Phase III, Gurugram, Haryana 122001

Broker Code: 822 (Valid UPTO:30/05/2025) MISP NAME: JOSHI AUTOMOBILES PRIVATE Proposal Form Created by:
CIN: U67200HR2021PTC098982 LIMITED
GST: 06AAGCH0310P1ZP MISP CODE: HIIB-MHY-0005
MISP Authorised Signatory
Designated Person NAME : Sanjay Minhas
INSURANCE ACT 1938, SECTION 41- PROHIBITION OF REBATES
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
Disclaimer: This Proposal is valid for today only. Price may vary subject to Terms & Conditions of Insurance Company at the time of policy issuance.