Signed

by:Mr.Mukul
Kishore
Date:2015.12.31

Reliance Private Car Vehicle Certificate cum Policy Schedule

Policy / Certificate No. : 1203552311016340
Proposal /Covernote No : W12311503983
Name of Insured : MR. SWAMINATHAN R Period of Insurance : From 00:00 Hrs on 03-Jan-2016 to midnight of 02-Jan-2017
Address : Business/Occupation: Others
NO 138/A3 III MAIN ROAD SADASIVA NAGAR MADIPAKKAM , MADIPAKKAM MADIPAKKAM , Hypothecated with : Canara Bank Location : , CHENNAI
SAIDAPET - 600091 , TAMIL NADU
Contact details : 9566264809 Zone : Geographical Area : India
Email : insurance.mount@india-garage.com
Particulars of vehicle Insured :
Registration No. & Make / Model Variant Engine No. / Chassis No. Type of Body Cubic Mfg. Year Seating Capacity Net Premium Rs. IDV (Insured's Declared
Place Capacity Value) Rs.
TN-22-CR-7197 & MAHINDRA / XYLO H4 MLE4J12115 / 2179 JAN-2014 7 17131.31 713350
MEENAMBAKKAM 7STR MA1YA2MLXE2J2224
4
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.
Persons/Classes of Persons 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 and that such a person satisfies the requirements of Rule 3 of the Central
Motor Vehicles Rules, 1989
Limits of Liability : a. Under Section II-1(i) of the Policy-Death of or bodily injury to any person so far as it is necessary to meet the requirements of the Motor Vehicle Act, 1988. b. Under
Section II(1)(ii) of the Policy-Damage to property other than property belonging to the insured or held in trust or in the custody of control of the insured up to the limits specified Rs. 750000/-
PA Cover for owner-driver under Section-III CSI - Rs. 2,00,000/-
Deductible under Section-1: (i) Compulsory deductible Rs. 2000/- (ii) Additional compulsory deductible Rs. 0/-, (iii) Voluntary deductible Rs. /-

Special Conditions: __________________________________________________________________________________________________________

It is hereby declared and agreed that all pre-existing damages to the vehicle having occurred prior to the commencement of cover are excluded from the scope of the policy. Consolidated Stamp duty Paid vide
GRAS GRN No. MH003135880201516E dated 25 August 2015** ** Not Applicable for the State of Jammu & Kashmir
I/We hereby certify that the Policy to which the certificate relates as well as this certificate of insurance are issued in accordance with the provision of Chapter X and Chapter XI of M.V. Act, 1988. Note: In the event
of dishonor of cheque, this policy document automatically stands cancelled from inception irrespective of whether a separate communication is sent or not. No Claim Bonus will only be allowed, provided the policy
is renewed within 90 days of the expiry of the previous policy.
Insured's Declared Value
For the Vehicle For Trailers Electrical / Electronic Non Electrical CNG / LPG Kit Total Cover SI(Rs.) Total Value
Accessories Accessories
713350 0 0 0 0 0 713350

Schedule of Premium

A. Own Damage B. Liability

Basic OD Including Add On Where Applicable 14625.39 Basic premium including premium for TPPD Vehicle 4931
Total Net Basic Own Damage Premium(Including addon 14625 Liability Premium for Driving Tuition 0
covers as applicable.) Total 4931
Less PA Benefits
Deduct 20% for NCB 2925.08 Compulsory PA covers for owner-driver 100
Sub Total (deduction) 2925 PA for unnamed passenger (IMT-16) No of passengers: 7 CSI 350
TOTAL OWN DAMAGE PREMIUM 11700 per person: 100000
Legal Liability
Legal Liability to paid driver,cleaner & conductor (IMT-28) No. of 50
people :1
TOTAL LIABILITY PREMIUM 5431
PACKAGE PREMIUM (Total ODP + Total Liability Premium) 17131.31
Add: Service Tax @ 14% 2398.38
Add: Swachh Bharat Cess @ 0.5% 85.66
FINAL PREMIUM 19615
Subject to I.M.T.Endt.Nos. & Memorandum printed/herein/attached hereto. IMT 16, IMT 28, IMT 22| IMT 15 6HUYLFH7D[5HJLVWUDWLRQ1R$$%&5%67
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The shortfall/excess in the TP Premium will be collected/refunded after the release of the IRDA OF INDIA circular which shall be effective from 1st April, 2015
Subject to Reliance GI Endorsement Numbers printed herein/attached hereto. 0
* No Claim Bonus is subject to no claim on the previous policy Benefits under the policy stands forfeited if claim is/was made in previous policy.
The policy has been issued based on the information provided by you and the policy is not valid if any of the information provided is incorrect. Subject otherwise to the terms, conditions and exclusions of the
Reliance Private Car Policy. In witness whereof this Policy has been signed at Mumbai on 31-Dec-2015 in lieu of Cover Note No/Proposal No. W12311503983 Dated 31-Dec-2015
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 appealing in the Certificate in order to comply with For Reliance General Insurance Co. Ltd.
the Motor Vehicle Act, 1988 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. NOTE: Kindly acknowledge receipt of this policy. In
case you find any variations against your proposal or any discrepancy in the policy, kindly contact us immediately
For any assistance with claims, please contact us on 1800 3009 (toll free) or email us at rgicl.services@relianceada.com Duly Constituted Attorney(s)

Branch Issuance Office : H Block, 4th Street, Door No 12, H 2035, 15th Main Road, Anna Nagar (West), Chennai -
600040 , Tamil Nadu. Contact No.044-30925816
Intermediary Code/Name :
15C26792 / RELIANCE MONEY SOLUTIONS PVT LTD
Intermediary Contach No.:
09324579132

Insurance is the subject matter of Solicitation. IRDA of India Registration No. 103. An ISO 9001:2008 Certified Company
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Dear SWAMINATHAN R
We thank you for placing your trust with Reliance General Insurance Company Limited
We are pleased to enclose Private Car Package Policy as Proposed by you
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21/,1(352326$/)250IRUIXWXUHUHIHUHQFH*LYHQKHUHEHORZLVDQH[WUDFWRIWKHVDPHIRU\RXUUHFRUGVDQGUHIHUHQFH
(I) Details of Registered Owner/Insured
Name of the Insured SWAMINATHAN R State TAMIL NADU
Address NO 138/A3 III MAIN ROAD SADASIVA NAGAR City SAIDAPET
MADIPAKKAM MADIPAKKAM MADIPAKKAM
Landline number -
Email insurance.mount@india-garage.com Mobile number 9566264809
(II) Policy Details
Total Insured Declared Value (IDV) 713350 Total Premium amount 19615
Policy Start date 03/01/2016 Policy End date 02/01/2017
Hypothecation Type Hypothecated Name of Financial Institution Canara Bank
Address of Financial Institution , CHENNAI Renewal/Rollover/New Renewal Policy
(III) Vehicle Details
Make MAHINDRA Manufacturing Month/Year JAN-2014
Model XYLO Date of Purchase/Registration 03/01/2015
Variant H4 7STR RTO Location TAMIL NADU-MEENAMBAKKAM
Engine Number MLE4J12115 Registration number TN-22-CR-7197
Chassis Number MA1YA2MLXE2J22244 Seating Capacity Including Driver 7
Vehicle IDV 713350 Value of Electrical Accessories 0
Value of CNG/LPG KIT 0 Value of Non Electrical Accessories 0
(IV) Additonal Cover/s Opted
Electrical Accessories NO Legal Liability to Paid Driver YES
Non Electrical Accessories NO Personal Accident Cover for unnamed YES
Passengers
CNG/LPG Kit Attached NO Extension in Geographical Area NO
Is Vehicle used for Driving Tuitions NO Legal Liability to Employees NO
Fiber Glass Fuel Tank NO If Yes Extension in Geographical Area NO
Personal Accident Cover for Named NO Legal liability to Cleaner & conductor NO
Passengers
Legal liability to Non-Fare Passenger No Loading charged NO
(V) Add on Cover/s Opted
Nil Depreciation Cover NO Total Covers NO
Motor Secure Plus NO Motor Secure Premium NO
(VI) Discounts Claimed
Anti Theft Device Discount NO Automobile Association Disc NO
Voluntary Deductible Discount NO Automobile Association Membership -
number/Name
Against this discount you have accepted an additional voluntary deductible of Rs 0 against each claim
Restrict TPPD Liability To 6000 NO
(VIl) PA to Owner Driver - Nominee Details

(VlIl) Payment Details

Payment Mode Cheque/Demand Draft Bank Name HDFC Bank
Premium Amount 19615 Payment Date 30/12/2015
(lX) Previous Year Policy Details
Policy Number 1203552311000118 Previous Insurer Name Reliance General Insurance Company Ltd.
Policy End date 02/01/2016 Branch Name & Address
Claim (Yes or No) NO Current NCB % 20
NCB% for this Policy YES
Declaration
I agree that the insurance benefit available to me shall become voidable in the event of any untrue or incorrect statement, misrepresentation,non-description or non-disclosure in any particulars in the application
form / personal statement, declaration and connected documents or any material information has been withheld by me or anyone acting on my behalf to obtain insurance benefit. I hereby declare that I am not
aware of any neglect and omission or error or existence of any circumstances likely to give rise to a claim thereof. I hereby declare, incase of false declaration the Insurance Company shall have the right to cancel
the policy. The insurance company shall have the right to change the premium and conditions agreed to subject to such terms and conditions as has been communicated to me. I hereby agree that my enrollment
for insurance would be at the sole discretion of the insurance company. I declare and warrant that the information I have given in this online form will be considered as the proposal form in relation to myself (or
other person or categories of persons to be insured) and any documentation of information accompanying it or arising out of the answers I have given is complete and accurate in all respects. I understand and
agree that this online form and other information and documentation I have given or will give,relating to myself or any other person to be insured, will be the basis of any insurance that you may issue, and I also
understand the consequences of any default. I further understand that the coverage offered is subject to realization of premium payment.
Online Transaction Facility - Terms and Conditions:
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UHDGDQGXQGHUVWRRGWKHVDOLHQWIHDWXUHVWHUPVDQGFRQGLWLRQVRIWKHSROLF\DVVWDWHGLQWKHEURFKXUH
Insured Name : SWAMINATHAN R Date : 31/12/2015
The information that you give to Reliance General Insurance on this online form will be treated as the proposal form and details in any supplemental information form or documentation supplied by you or on your
behalf will influence our decision to offer insurance and the terms upon which to offer it. Further, any policy we issue will be based on what you have told us. It is therefore important that your answers are complete
and accurate in all respect.
The questions in this online form are indicative rather than exhaustive. You must provide us with all information relevant to the risk to be insured,even if it is not the subject of a question in this online form. If you
are in any doubt as to what information should be given, please email us at rgicl.services@relianceada.com. Any failure to provide us with full and accurate material information may mean that your policy can be
declared as void.
No insurance cover will be in force until we have approved it and the premium has been paid.
Statutory Warning - PROHIBITION OF REBATES (Under Section 41 of Insurance Act 1938)
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.
Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to five hundred rupees.
We hope the information shown above is found by you as correct
For detailed terms & condition (Policy Wordings) governing this policy, kindly refer our website.
In case of any query you may contact our customer care service numbers given on the face of the policy. We look forward to having a long term & fruitful relationship
Yours truly

Authorized Signatory
For Reliance General Insurance Co ltd