Bajaj Allianz General Insurance Company Ltd.

Registered and Head Office: Bajaj Allianz House, Airport Road, Yerwada, Pune

Transcript of Proposal for Private Car Package Policy

Dear GOURI SHANKAR KARNAWAT,

We wish to inform you that the contract under policy number 'OG-26-2302-1801-00001484' has been finalized based on the
information and declaration given by you, the transcript whereof is mentioned below. You are requested to reconfirm the same.
In case of any disagreement or objection or any changes with respect to information mentioned below, we request you to
please revert back within a period of 15 days from date of your receipt of this, failing which it will be deemed that you are
satisfied with the correctness of the details mentioned below. Kindly note that as the contents and declarations contained in this
transcript is the basis on which we have issued the policy to you, we advise you to please ensure that you have
provided/disclosed and or not withheld any material facts/information and declarations, as Policy becomes Void ab initio if
material facts are not provided/disclosed and or withheld and in such case no claim, if any, will be considered by us apart from
forfeiture of the premium.
Details provided by you:

A. Proposer details
1. Proposer Name : GOURI SHANKAR KARNAWAT
2. Proposer Address : 401 PADMAWATI APARTMENT INDORE, 36 BF SCHEME NO 54 VIJAY NAGAR
INDORE
, , INDORE, MADHYA PRADESH-452001
3. Proposer Mobile Number : 7389912336
4. Proposer Residential Number : NA
5. Proposer e-mail id : [email protected]
6. Proposer Profession : NA

B.Vehicle Details
Registration Month / Year Vehicle Vehicle Vehicle Sub Cubic Capa- Fuel Type Year of Man- Seating Ca-
Number of Regn Make Model Type city/Kilowatt ufacture pacity
MP04CM746 JUN/2014 FORD ECOSPORT 1.5 DIESEL 1498 Diesel 2014 5
3 TITANIUM
PLUS

Engine Number Chassis Number Vehicle IDV (in Electrical Non-Electrical CNG/LPG Unit Total IDV (in
Rs.) Accessories Accessories (Extra fitted) Rs.)
IDV (in Rs.) IDV (in Rs.) IDV (in Rs.)
MAJAXXMRKA MAJAXXMRKA 3,65,300.00 0 0 0 3,65,300.00
ET57317 ET57317
 C. Coverage opted

1. Period of Insurance : From 10-JUN-2025 00:01(Hrs)

To 09-JUN-2026 Midnight
2. Is your vehicle fitted with external LPG/CNG kit : No.
3. Electrical Accessories cover Opted (If Applicable) : No.
4. Non - Electrical Accessories cover Opted (If Applicable): : No.
5. Is Voluntary Excess opted : No.
Amount of voluntary excess opted : Rs.NA.
6. Whether PA cover is opted for owner-driver : No.
PA cover is exempted for owner-driver with Reason :Owner does not have Valid Driving
License
7. compulsory deductible : Rs.1,000.00
8. Is any additional compulsory deductible imposed and agreed upon : No.
Amount of additional compulsory deductible imposed : NA.
9. Whether geographical area extension is opted : No.
Details of Countries to which geographical area extension cover is given : NA.
10. Is LL to person for Paid driver/Operation/Maintenance opted : Yes.
11. Whether PA cover is opted for paid driver other than owner driver : No.
Sum Insured for Paid Driver : Rs.NA.
12. Whether PA cover is opted for passengers : Yes.
Sum Insured per Passenger : Rs.50,000
13. Is TPPD restricted to statutory limit of Rs.6,000? : No.
14. Pre Existing damages in the vehicle : NA.
15. 1 Premium for Liability coverage, quoted and agreed upon is :
16. 1 Premium for OD coverage, quoted and agreed upon is :
17. Do you have valid PUC certificate of the vehicle : NA
18. Do you have valid Fitness certificate of the vehicle : NA
19. Total Premium (excluding Goods and Service Tax (GST)) for Liability and OD coverages, quoted and agreed upon is
:
20. NCB (No Claim Bonus) claimed by you and granted by us based on your declaration of no claim during your previous
previous policy : 0 %.
21. About the last insurance company
(i) Insurance Provider : Bajaj Allianz General Insurance Co Ltd..
(ii) Previous Policy No : OG-25-2302-1801-00001217, Previous Policy Expiry Date :09-JUN-25
22. Whether your vehicle is Hypothecated and if so the details of Pledgee whose name is registered by us: No.
Name of Pledgee : NA.
23. Add on Cover(s) optedm3: No.Plan name:NA

24. To support our Go Green initiative, send policy copy link on registered mobile number / email id: YES

Please note Cover Note No. / issued to you basing on the above information.
In case of Disagreement or objection or any changes with respect to information and contents mentioned hereinabove, please
contact our toll free number & register your objections/changes/disagreement to the contents of this transcript or you may also
send us email or written correspondence at the following details within a period of 15 days from date of your receipt of this
transcript along with Policy:
I/We hereby unconditionally allow the Company to share all my / our information being collected in this proposal form or
through telephonic / email / web-inputs means or other means, as updated from time to time within group entities.
Toll free Number : 1800-102-5858,1800-209-5858
Email address : [email protected]
Website : www.bajajallianz.com
Contact our policy servicing branch at: 4th Floor,Commerce House,, 7 Race Course Road, ,, ,, Indore-452001
PH:0731-4065790.
INSURANCE ACT, 1938 SECTION 41 - PROHIBITION OF REBATES
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 a policy
accept any rebate, except such rebate as may be allowed in accordance with the published prospectus or tables of the insurer.
ANY PERSON IN BREACH OF COMPLYING WITH THE PROVISIONS OF THIS SECTION SHALL BE PUNISHABLE
WITH FINE WHICH MAY EXTEND TO RUPEES TEN LAKH.Bajaj Allianz General Insurance Co Ltd
  

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

Regd. Office & Head Office: Bajaj Allianz House, Airport Road, Yerwada,Pune-411006(India)
IRDAI Registration No. 113
Corporate Identity Number: U66010PN2000PLC015329
Certificate of Insurance ( PRIVATE CAR PACKAGE POLICY)

UIN : IRDAN113RP0025V01200102
Policy Number: OG-26-2302-1801-00001484 Customer ID: 394083252
Particulars of Vehicle Insured:
Registration Number Place of Registration Engine Number Chassis Number Make & Model
MP04CM7463 MP04-BHOPAL MAJAXXM- MAJAXXMRKAET5 FORD - ECOSPORT
RKAET57317 7317

Sub Type Year of Mfg NCB % CC Seating Capacity

1.5 DIESEL TITANIUM PLUS 2014 0 1498 5

Name of Registration Authority : MP04-BHOPAL

Name and Address of Insured : GOURI SHANKAR KARNAWAT
: 401 PADMAWATI APARTMENT INDORE, 36 BF
SCHEME NO 54 VIJAY NAGAR INDORE, ,
INDORE, MADHYA PRADESH-452001
Geographical Area : .00
Business or Profession : NA
Effective date of commencement of Insurance for the purpose of act:
Policy Inception Date: From 00:01 O' Clock on 10-JUN-2025
Policy Expiry Date: Midnight on 09-JUN-2026
Persons or Class of Persons entitled to drive:
Any person including the insured:
a) 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.
b) Provided also that the person holding an effective learner's license may also drive the vehicle and that such a person satisfies
the requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.
IMT-Endorsements/Add on Package
22, 28, 16,
Beneficier Details:
Beneficier1 Beneficier2 Beneficier3 Beneficier4 Beneficier5

Limitations as to Use:
The Policy covers use for any purpose other than
a) Hire or Reward, b) Carriage of goods (other than samples or personal
luggage), c) Organized racing, d) Pace Making, e) Speed testing, f)
Reliability Trials, g) Any purpose in connection with Motor Trade
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 provi-
sions of Chapter X and Chapter XI of M.V. Act, 1988.
Policy issuing office and correspondence address for communication by holder of Certificate of Insurance for claim,
service request, notice, summons, etc:
4th Floor,Commerce House,, 7 Race Course Road, ,, ,, Indore-452001 PH:0731-4065790
Date of issue :07-JUN-2025
For & On Behalf of
Bajaj Allianz General Insurance Company Ltd.
For help and more information:
Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at
[email protected] or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 07-Jun-2025 16:24:09 PM- Silent_Printing (Web) (NA)
Authorized Signatory
  

BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED

(A Company incorporated under Indian Companies Act, 1956 and licensed by Insurance Regulatory and Development Authority of
India [IRDA] vide Reg No.113)
Regd. Office: Bajaj Allianz House, Airport Road, Yerwada,Pune-411006(India)
PRIVATE CAR PACKAGE POLICY SCHEDULE
UIN : IRDAN113RP0025V01200102
Policy issuing office and Correspondence address for communication by policyholder for claim, service request, notice, summons, etc:
4th Floor,Commerce House,, 7 Race Course Road, ,, ,, Indore-452001 PH:0731-4065790
INSURED DETAILS POLICY DETAILS
Insured Name GOURI SHANKAR KARNAWAT Policy Number OG-26-2302-1801-00001484
401 PADMAWATI APARTMENT IN- Policy Issued on 07-JUN-2025 15:59 PM
Insured DORE, 36 BF SCHEME NO 54 VIJAY
NAGAR INDORE , , INDORE, MAD- From : 10-JUN-2025 00:01 (Hrs)
Address HYA PRADESH-452001
Policy Period To : 09-JUN-2026 Midnight
Geographical India
Area Cover Note
/
Customer ID Details
394083252
Previous Policy No OG-25-2302-1801-00001217
Bank Reference
No 1 383929423/5
Invoice No
GSTIN / UIN NA Company GST No 23AABCB5730G1Z5
Place of Supply/ 23 - Madhya Pradesh
State Code/Name Company PAN AABCB5730G

Make & Mod-

Registration Number Place of Registration Engine Number Chassis Number SubType
el
1.5 DIESEL
MAJAXXM- MAJAXXMRKAE FORD - ECOS-
MP04CM7463 MP04-BHOPAL TITANIUM
RKAET57317 T57317 PORT
PLUS
Year Of Manufactur- Trailer Registra-
NCB % CC/KW Seating Capacity Hypothecation Details
ing tion Number
0 1498 5 2014 -,-
Non electrical Electrical/Elec- Value of CNG/
Vehicle IDV Value For Trailers Total Value
accessories tronic accessories LPG kit
3,65,300.00 0 0 0 0 3,65,300.00
Own Damage Premium(Rs.) Liability Premium(Rs.)
Own Damage Premium 3,884.00 Basic Third Party Liability 3,416.00
Special Discount 0.00 LL to person for Paid driver/Opera- 50.00
Total OD Premium - A 3,884.00 tion/Maintenance
Total Premium (Net Premium) (A+B) 7,475.00 PA Cover For 5 Passenger Of Rs. 50000 each 125.00
State GST (9%) 673.00 Total Act Premium - B 3,591.00
Central GST (9%) 673.00
Final Premium ( Rupees Eight Thousand Eight Hun- 8,821.00
dred Twenty One Only )
**Note: The above Total OD Premium is inclusive of all applicable Loading /Discounts viz (Automobile association membership, Voluntary Excess,
Anti Theft, Handicap Person, Driver Tuition, Fiber Glass, CNG/LPG Unit, Geographical Extension, Imported Vehicle Etc. wherever Applicable)

As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th September of the next financial year
I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under
sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.

Agency Code BAG10013246 Contact No. 9826026266/0

For help and more information:
Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at Ba-
[email protected] or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 07-Jun-2025 16:24:09 PM- Silent_Printing (Web) (NA)
  

Agency Name SHASHIKALA AGRAWAL

E-Mail ID. [email protected]
SP/POSP Code

Limitation as to Use The Policy covers use of the vehicle for any purpose other than : Hire or reward, Carriage of
goods( other than samples or personal luggage),Organised racing,Pace making, Speed testing,
Reliability trials. Any purpose in connection with Motor Trade.
Driver Any person including the insured provided that a person driving holds an effective driving li-
cense 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 the transport of goods/passengers at the time of the accident and that such a
person satisfies the requirements of Rule 3 of the Central Motor Vehicle Rules, 1989.
Limits of Liability Under section II-I(i) of the policy -> Death of or bodily injury : Such amount is necessary to meet
there requirements of the Motor Vehicles Act,1988. Under section II-I(ii) of the policy -> Dam-
age to Third Party Property : Rs. 7,50,000.00
Existing Damage Details
Nominee Details Name :NA - Relationship :NA
Subject to Warranties/ 22, 28, 16, & null & Plan Description:
IMT-Endorsements/
Add on Package
Additional Details Coinsurance Details: - . Transaction Id: -
Premium Details Receipt No. 2302-01060769, Date 07-JUN-25 ** If Premium paid through Cheque, the Policy is
void ab-initio in case of dishonour of Cheque.
Excess Details Compulsory Excess: Additional Excess: Rs.0 Voluntary Excess: Rs..00
Rs.1,000.00
Theft Excess: Rs.0
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 Act,
1988 is recoverable from the Insured. See the clause headed AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY.
It is mandatory to keep your policy with updated contact (Mobile No., Email ID and PAN Card) and bank account details, to process any of
your service requests faster and hassle-free in future.
You can update the same through Caringly yours App {Link}, WhatsApp Service { Say Hi on WhatsApp - +91 75072 45858}, Contact our
24-Hour Call Center at 1800-209-5858, 1800-102-5858, Give a Missed Call on 8080945060, SMS WORRY to 575758, Email ba-
[email protected], website {http://www.bajajallianz.com}, contact your agent or nearest branch.
Warranted that insured named herein or owner of the vehicle insured holds a valid Pollution Under Control (PUC) and / or Fitness Certificate on the date of
commencement of the Policy. If the PUC and/or Fitness Certificate is not found to be valid on the date of commencement of the Policy, the Company reserves
its right to consider the policy void ab initio.
For & On Behalf of
Bajaj Allianz General Insurance Company Ltd.

Stamp
Duty Rs.
0.25

Authorized Signatory
This document is digitally signed, hence counter signature / stamp is not required.
Consolidated Stamp Duty of Rs. 0.25/- paid for insurance policy stamps vide Order No. CSD/19/2025/816 dated 01-MAR-25 of General Stamp Office, Mumbai, India.

Principal Location : 4th Floor, Commerce House, 7 Race Course Road, Indore - 452001 PH:0731-4065790 | Services Accounting Code :
  

997134 - Motor vehicle insurance services. No reverse charge is payable on these services.

For help and more information:

Contact our 24 Hour Call Centre at 1800-102-5858, 1800-209-5858, Toll Free: 30305858( chargeable, add area code before this number in case of mobile call) Email us at Ba-
[email protected] or Visit our Website www.bajajallianz.com
Corporate Identification Number U66010PN2000PLC015329
Latest Schedule - 07-Jun-2025 16:24:09 PM- Silent_Printing (Web) (NA)
 Bajaj Allianz General Insurance Company Ltd.
4th Floor, Commerce House, 7 Race Course Road, Indore - 452001
Contact No:Contact No: 0731-4065790,4068734; Fax No: 4068626

RECEIPT

Receipt Number 2302-01060769

Receipt Date 07/06/2025
Business Channel MAENP

Received with thanks from GOURI SHANKAR KARNAWAT

(Customer ID : 394083252 ) a total sum of Rupees Eight Thousand Eight Hundred Twenty
One Only by,

Instrument Instrument No. Instrument Bank Name Branch Name Amount

Type Date
Cheque 002064 07/06/2025 ICICI BANK PATEL NAGAR 8,821

Total Amount Rs. 8,821.00

Note : Integrated Receipts: Cheque.
Issuance of this receipt does not amount to acceptance of the risk by Bajaj Allianz General In-
surance Company Limited. The insurance cover for the risk shall be as per the terms and con-
ditions of the Insurance Policy if and when issued.
* Cheque/DD/PO receipt is valid subject to realisation of the instrument.

For & on behalf of

Bajaj Allianz General Insurance Company Ltd.

Authorised Signatory

Regd.Office: Bajaj Allianz House,Airport Road, Yerwada, Pune - 411006