BHARTI AXA GENERAL INSURANCE COMPANY LTD 4th Floor, 401 &4O2, 3rd Eye situated at Panchvati

Ahmedabad_380006. Tel:+91 79 4022 9000Fax:079-4O22gOO1 Email: customer.service@bharti-axagi.co.in
rForm 51 of Ehe Central Motor Vehicle Rules, 1989
NO"

cross Roads,c. G.

Road '

^-^ CERTTFTCATE OF INSURAT{CE AND SCHEDULE NEW BUSINESS Original

SMART Motor private

Car

CERTTFTCATE/POLTCY : FPV/r0975648/7I/08/t477L!9

Account No. :

71_000187

Policy Type Period of Insurance Premium Pald (inc1. S. Tax) Name of Policy
Holder

: Private Car - Cornprehensive Ineurance policy : From 00:00 Hours on 05/08/2012 To Midnight on O4/OA/20L3 : INR 51,645.15 :
DHAVAL HASMITKHLAL SHAH

Address

: 302 SWAPANA GOKUL FLATS 58 SWASTIK SOCIETY
C G ROAD NAVRANGPURA AHMEDABAD-38OOO9 GUJARAT

Under Hire Purchase /Hypothecat ion/Leas e

:

TATA CAPIAL LIMITED

with Geographicaf Area
Regn. No.
Make/Model

: INDIA
CJOaKttl2022
MERCEDES C22O

Place of Regn.:
c1

AHMEDBAD

Year of Manufacture Seating Cap. (Tncl . Driver) Pubfic Carrier / Private Carrier Chassls No.
IDV of the Vehicle

2071
000s

Body Type Engine C. C.

SALOON

2148

Private Car
0449]-3

Engine

No

44691,6

Accessories

: rNR 2,350,000.00 Bi - Fuel (CNG/Lpc) : 0.00 IDV of Non buifd in : E]ectrical 0.00

Non-El_ectrical 0.00

Total Insured ; 2,350,000.00 Decl-ared Value of the Vehicfe Depreciation cover : 100.00 % (?) Hospital Cash : INR 1000.00/5 Cover (SI/PERSON)

Ambul-ance Charges

cover

: rNR 5ooo.oo/5
LOOO0.OO/s

(srlPERSoN)

Medical Expenses : INR
neimbursement.
(SIlPERSON)

Schedule of Premium

A.

Own Damage Premium non

Accessories
NCB

Premium on Vehicle and Electrical-

: INR 80,840.00 : INR L5,168.00

B. Liability Basic

Premium

:

INR 2, 853 . 00

20.00?

Add: Legal : Liability to Paid Driver as per Endt. IMT 28

INR s0.00

BHARTTAXAGENER.ALTNSURANCECOMPANYLTD
1st Floor,Ferns lcon, Survey No.28, Doddanakundi village K.R.Puram Hobli Bangalore - 37 Toll Free No: Tel: 91 80 40260100 Fax: 80 40260101 Email: customer.service@bharii-axagi.co.in

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