Cholamandalam MS General Insurance Company Limited

Registered Office: 2nd Floor, "Dare House" No.2, NSC Bose Road, Chennai - 600 001.
Toll Free: 1800 208 5544 | Ph: 044 4044 5400 | Fax: 044 4044 5500 |
PAN AABCC6633K CIN: U66030TN2001PLC047977 IRDAI Regn. No.123
REACH US THROUGH WHATSAPP 7305234433

Policy Schedule cum Certificate of Insurance

Motor Private Car Package Policy UIN IRDAN123RP0001V03100001
Policy cum Certificate Number 3362/03995003/000/00 Period of Insurance: From 00:01 hrs. on 07/06/2025 To: Midnight of 06/06/2026
Registration Address: C O ABHISHEK VERMA MATAN, PURAMOTH MOTH MOTH
Name & Communication Address: ANITA CHOUDHARY
RURAL, JHANSII UTTAR, JHANSI, UTTAR PRADESH, 284303
C O ABHISHEK VERMA MATAN, PURAMOTH MOTH MOTH RURAL, JHANSII UTTAR
Mobile/Landline No :9450269404
Email ID:[email protected]
Business / Profession: -
UP-93-JHANS
Customer ID: - EIA: - Date of Registration 09/06/2022 Place of Registration
I
GSTIN - Geographical Area: India Financier Name -
Nominee Name - Nominee Relationship - Financier Address -
PARTICULARS OF VEHICLE INSURED
Registration Mark UP93BV5385 Engine Number K15CN9036936 Chassis Number MA3BNC72SNE490299 Cubic Capacity / KW 1462

Make MARUTI SUZUKI Model ERTIGA Variant VXI Year of Manufacturing 2022

Type of Body MPV Fuel used PETROL Driver 1 Licensed passenger Carrying Capacity 7

Fast Tag No. - Colour - Contract No. - Total seating capacity including driver 7
Value of Chassis - Value of Body - For Vehicle 620000
IDV (Insured's Declared For Trailers - Non-Electrical Accessories - Value of CNG/ LPG kit -
Value) in Rupees (Rs.)
Electrical/Electronic Accessories - Total Value 620000
PREMIUM COMPUTATION TABLE
Premium Premium
A. OWN DAMAGE Sum Insured (Rs.) IMT B. LIABILITY Sum Insured (Rs.) IMT
(Rs.) (Rs.)
Basic OD 620000 19785 Basic TP 3416
CNG Kit - OD 25 0 CNG Kit - TP 25 0
Electrical or Electronic Accessories 24 0 LL to Paid Driver 28 50
Non Electrical Accessories 0 Geographical Extension - TP 1 0
Geographical Extension OD 1 0 TOTAL PREMIUM (B) 3466
Less: Anti-Theft Device 10 0 C. PERSONAL ACCIDENT (PA) COVERS
Less: No Claim Bonus Discount (0%) 0 TOTAL PREMIUM (C) 0

Less: Experience based Discount (85%) 16818

Experience based loading 0
TOTAL PREMIUM (A) 2967
Sum Insured Time Premium TOTAL PREMIUM (A+A1+B+C) 11572
A1. ADD-ON COVERS UIN Options
(Rs.) Excess (Rs.) CGST (9%) Rs. 0 SGST (9%) Rs. 0
IRDAN123RP0001V012002 IGST (18%) Rs. 2083
Waiver of depreciation 620000 100% 4030
03/A0003V02200910
TOTAL AMOUNT Rs. 13655
IRDAN123RP0001V012002 Consolidated Stamp Duty Paid Vide G.O Rt No.166, Commercial
Consumables Cover 910
03/A0008V01201213 Taxes and Registration (j1) Department, Tamil Nadu dated25/04/2025
Chola Value Added Services - IRDAN123RP0001V012002 Subject to I.M.T. Endt. Nos. and Memorandum:22,21,28
199 Compulsory deductible under Section 1: Rs.1000
Private Car 03/A0006V01201718
TOTAL PREMIUM (A1) 5139
LIMITATIONS AS TO USE: The Policy covers use of the vehicle for any purpose other than: a) Hire or Reward b) Carriage 0f 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.
1. As per Sec 147 of MV Act issued policy the premium received only to an extent of liability fixed by IRDA/Central Govt
2. Sec 150 (2) (b) that the policy is void on the ground that it was obtained by, nondisclosure of any material fact or by representation of any fact which was, false in some material particular;
i. Or
ii. (c) that there is non-receipt of premium as required under section 64VB of, the Insuracne Act, 1938.
3. No APPlication for compensation shall be entertained unless it is made within 6 Months from the date of occurrence of the Accident
4. No Sum shall be payable by an insurer incase a person driving the vehicle does not have a valid driving license or is under the influence of Alcohol or Drug.

DRIVER CLAUSE: Any person including 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 and that such a person satisfies the requirements of Rule 3 of the Central Motor Vehicles Rules
1989 as amended from time to time.
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 Vehicle Act, 1988 as amended from time to time.
Under Section II - 1(ii) of the Policy - Damage to Third Party Property - Rs.7,50,000.00 Compulsory P.A. Cover for the Owner - Driver under Section III (CSI) - Rs.15,00,000.00
Warranties: It is hereby warranted the coverage under this Policy commences only from the Risk Start time and Date as mentioned in the Policy schedule. No Liability shall attach under this Policy in
respect of any Accident/Loss prior to the time and date of commencement of Period of Insurance.
As per GR36 A, PA for Owner-driver refers to the Owner of the Insured Vehicle holding an effective driving license.
"If this policy is preceded by break-in insurance, it is expressly agreed and understood that there will be no liability for any loss or damage that has occurred prior to the date of commencement
mentioned in the schedule".
Coverage under this policy is subject to realisation of premium cheque(s). In case of dishonor of cheque(s), no separate intimation will be given and the policy stands cancelled from inception.

Refer our website www.cholainsurance.com for Policy / Add-on Wordings and the Ombudsman list. For claims Assistance Contact Toll Free: 1800 208 5544 SMS CHOLA to
56677 | Visit www.cholainsurance.com | Email [email protected]. For Roadside Assistance please contact 1800 309 3967 Disclaimer: The Company
may contact you for matters related to your policy or to provide details of products & services offered. To opt out from the facility, please register under Do Not Call section
on our website.
Cholamandalam MS General Insurance Company Limited
Registered Office: 2nd Floor, "Dare House" No.2, NSC Bose Road, Chennai - 600 001.
Toll Free: 1800 208 5544 | Ph: 044 4044 5400 | Fax: 044 4044 5500 |
PAN AABCC6633K CIN: U66030TN2001PLC047977 IRDAI Regn. No.123
REACH US THROUGH WHATSAPP 7305234433

Policy Schedule cum Certificate of Insurance

Motor Private Car Package Policy UIN IRDAN123RP0001V03100001
No Claim Bonus The insured is entitled for a No Claim Bonus (NCB) on the own damage section of the policy, if no claim is made or pending during the preceding year - 20 % No Clam is made or
pending during the Preceding Two consecutive years- 25 % No claim is made or pending during the Preceding Three consecutive years-35 % No claim is made or pending during Preceding Four
consecutive years-45 % No claim is made or pending during the Preceding Five consecutive years-50%. No Claim Bonus will only be allowed provided the policy is renewed within 90 days of the expiry
date of the previous policy.
Warranted that NCB under this Policy is based on representation regarding NCB and absence of claim under the previous Policy. If the information be found incorrect or false in any aspect, this Policy
shall be void ab initio and no benefit shall be payable by the company
PUC: This policy has been issued upon declaration by the Insured that a valid Pollution Under Control (PUC) Certificate is held on the date of commencement of the Policy. The insured undertakes to
renew and maintain a valid and effective PUC and/or fitness Certificate, as applicable, during the subsistence of the Policy.
Grievance clause: For resolution of any query or grievance, you may contact the respective branch office of the Company or may call 1800 208 5544 or may write an email to
[email protected]. If you are not satisfied with the response of the office, you may email to Grievance Officer at [email protected]. In the event of unsatisfactory
response from the Grievance Officer, you may, subject to vested jurisdiction, approach the Insurance Ombudsman for the redressal of grievance. Details of the offices of the Insurance Ombudsman are
available at IRDAI website www.irdai.gov.in or General Insurance Council:https://www.cioins.co.in/ombudsman or on company website www.cholainsurance.com
NOTE: The Policy Schedule CUM Certificate of Insurance is an important document issued based on your declaration. We request you to verify the details and ensure that everything is in order. In case
of any discrepancies, please contact us within 15 days from the date of issuance of policy.

Intermediary Name: Girnar Insurance Brokers Pvt Ltd

Contact No. 7551196989
Code: 2020777215360001

Business Location: Chennai Head Office,DARE HOUSE,2ND FLOOR,NO 2,N.S.C BOSE ROAD,CHENNAI-600001,TAMIL NADU

GST Invoice No.: 3362039950030000 | GSTIN: 33AABCC6633K1ZQ | SAC Code: 997134 | SAC Description: Motor Vehicle Insurance Services

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 as amended from time to time, is recoverable from the insured. See the
clause headed "AVOIDANCE OF CERTAIN TERMS AND RIGHT OF RECOVERY". For legal interpretation, English Version will hold good.
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 the Motor Vehicles Act, 1988 as amended from time to time.
Date and Signature of the proposal 02/06/2025. In witness where of this policy has been signed at Chennai Head Office on 02/06/2025

for Cholamandalam MS General Insurance Company Limited,

Signature Not Verified

Signed by: DS CHOLAMANDALAM MS
GENERAL INSURANCE COMPANY LIMITED 4
Reason: KANCHIPURAM SRIDHAR HARISH
Location: Chennai
02-06-2025 14:04:26

Receipt No. PY000005070634 Receipt Date: 02-06-2025 Duly Constituted Attorney(s)

Whether tax is payable under reverse charge basis - No

"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 and also as per Notification No. 13/2020-CT dated
21-03-2020. This policy schedule shall be in lieu of Tax Invoice and hence no separate GST invoice required In compliance with Rule 54(2) of CGST Rules, 2017.

Refer our website www.cholainsurance.com for Policy / Add-on Wordings and the Ombudsman list. For claims Assistance Contact Toll Free: 1800 208 5544 SMS CHOLA to
56677 | Visit www.cholainsurance.com | Email [email protected]. For Roadside Assistance please contact 1800 309 3967 Disclaimer: The Company
may contact you for matters related to your policy or to provide details of products & services offered. To opt out from the facility, please register under Do Not Call section
on our website.