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PACKAGE POLICY - ENDORSEMENT SCHEDULE

Attached to and forming part of Policy No Endorsement No : 001 : 10003/31/13/349760 Endorsement Date : 28/10/2012

Endorsement Effective Insured's Code Insured's Name Address

From 00:00 On 28/10/2012 To Midnight Of 27/10/2013 Issue Office Code : 10003 Issue Office Name : Head Office - III Address : E - 8, RIICO INDUSTRIAL AREA SITA PURA JAIPUR RAJASTHAN 302022

: 5161159 : BABU SINGH : HANUMAN CHOWK RAUINDORE

Dev.Officer Total Premium

: NB0000000300 : 4,443

Broker Details

Type of Endorsement :

LC0000000002 M/S.R S I B P Ltd. Contact No: Change in NCB

Collection No & Dt : BG Co Insurance Details :

ENDORSEMENT NCB RECOVER SCHEDULEOF PREMIUM Cover Description Original Sum Insured Endorsement Sum Insured Revised Sum Insured Endorsement Premium -3,953.63 9,18,540 9,18,540 3,953.63 3,954.00 489.00 4,443.00 : Rs 4,443 ( INDIAN RUPEES Four thousand four hundred forty-three only )

LESS :NO CLAIM BONUS-GR27 OD TOTAL TOTAL PREMIUM ADD :SERVICE TAX TOTAL AMOUNT Total Amount in figures and words

The Insurance under this policy / endorsement is subject to following terms,conditions,waranties & clauses specified in the policy / endorsement: All other terms/conditions/waranties/clauses in the policy remain unaltered

Place : Date

: JAIPUR : 13/10/2012

For and on behalf of SHRIRAM GENERAL INSURANCE COMPANY LTD.

All the Amounts mentioned in this policy are in INDIAN RUPEES

Authorised Signatory
Service Tax Reg. No. AAKCS2509KST001 Page 1 of 2

Attached to and forming part of policy number 10003/31/13/349760 Waranted that in case of dishounour of premium cheque(s) the company shall not be liable under the endorsement and the endorsement shall be void ab initio In witness whereof the undersigned begin authorised by and on behalf of the company has herein to set his hands.

Entered By

SVS0V081 SVS0V081

Examined By :

Place : Date

: JAIPUR : 13/10/2012

For and on behalf of SHRIRAM GENERAL INSURANCE COMPANY LTD.

All the Amounts mentioned in this policy are in INDIAN RUPEES

Authorised Signatory
Service Tax Reg. No. AAKCS2509KST001 Page 2 of 2