Reliance PKG POL-LMV 4W>6 &3W>17 PASCAP Endorsement Schedule

Policy Servicing Branch Office:

Policy Issuing Office:

Reliance General
Insurance Co. Ltd., 570,
Naigaum Cross Road,
Next to Royal
Industrial Estate,
Wadala (W), Mumbai
400031

Reliance General Insurance Co. Ltd,

Old No 15, New No 29, 3rd Floor, North Usman Road,T Nagar,
Chennai
CHENNAI

CHEN
NAI
TAMIL
NADU
60001
7

Name of the Insured

Mr. JAGADHEESWARI G

Correspondence Address of the Insured

438A,RAILWAY QTRS,PILKINGTON ROAD,

AYANAVARAM,CHENNAI
TAMIL NADU - 600023
India
Policy Period: From 23/04/2016 to 22/04/2017

Policy No: 1201562312004623

Endorsement No. 21001
Endorsement Effective Date: 03/08/2016
Type of Endorsement: Nil
Vehicle Make

Vehicle Model

Engine No./Chassis No.

Registration Number

HYUNDAI

I 10 MAGNA 1/S

247755 / 890899

TN-02-AS-1013

Premium Details
Policy Premium (Including
all previous
Endorsement/s)
Premium relating to this
Endorsement
Final Premium after
Endorsement

Service Tax

Net Premium

Swachh Bharat Cess

Total Premium

10108.00

1465.66

50.54

11624.2

0.00

0.00

0.00

0.00

10108.00

1465.66

50.54

11624.2

Service Tax Reg.No. AABCR 6747 BST 001

Category-General Insurance Business Service 00440005
Note: In the event of dishonor of the cheque, this endorsement automatically stands cancelled from inception, irrespective of whether a
separate communication is sent or not.

In witness whereof this policy has been signed at CHENNAI on 19/09/2016. For any assistance with claims, please contact us
on 1800 3009 (toll free) or email us at services.rgicl@rcap.co.in

For and on behalf of Reliance General

Insurance Company Limited

IntermediaryName&Code

15A25495/VMANIKANDAPRABU

IntermediaryContactNo:

08608911114/8608911114
Authorize
d
Signatory

Registered Office: Reliance Centre, 19, Walchand Hirachand Marg,Ballard Estate ,Mumbai - 400 001