Cholamandalam MS General Insurance Co. Ltd.

DARE HOUSE, 2, NSC BOSE ROAD PARRYS CHENNAI - 600001,TAMIL NADU

IRDA Registration Number: 123

Broker Details
TATA MOTORS INSURANCE BROKING AND ADVISORY SERVICES LTD, 1ST FLOOR, AFL HOUSE, LOK
BHARATI COMPLEX, MAROL MAROSHI ROAD, ANDHERI (EAST), MUMBAI 400 059, INDIA, 022– CIN Number: U50300MH1997PLC149349
62379515
License Validity: 13-MAY-20 To 12-MAY-
Category: Composite Broker IRDAI Lic. No: 375
23
Proposal Details
Period of Compulsory PA
Proposal No. Cover Type. COMPREHENSIVE Own Damage Period 24-Feb-2021 To Motor Liability Period 24-
Cover 24-Feb-2021 To
PPVBU9950078 PACKAGE POLICY 23-Feb-2022 Feb-2021 To 23-Feb-2022
23-Feb-2022
Proposer Details
Address of the Proposer
Proposer Type Proposer Name Vehicle Usage
A-9, NEW MIG FLATS, MAYUR VIHAR PHASE - 3. DELHI DELHI
Individual Mr. SUBRATA KUMAR DAS Private
110096
Nominee Details
Nominee Name Nominee Age Nominee Gender Relationship with Insured Name of Appointee Appointee Relation
BANDANA MALAKAR 34 Female SPOUSE --N.A-- --N.A--
Vehicle Details
Invoice Date Chassis No. Engine No. Make Model & Variant CC
22-Feb-2018 MAT626283JKB15239 REVTRN02BRYK12738 TIAGO TIAGO XZA 1.2 P 1199
Place of Registration Registration No. Invoice Value Year of Manufacture Seating Capacity
DELHI DL-2C-AY-4085 660000 2018 5
Other Details
Branch/Office of HP/Lease/Hire
HP/Lease/Hire Pur. Agreement with Agreement Type Loan Account/Contract No
Purchaser
AXIS BANK LTD Hypothecation 4466464665645
NOIDA - NOIDA
Insured Declared Value (IDV)
Vehicle Electrical Accessories Non-Electrical Accessories CNG/LPG Total IDV
396000 0 0 0 396000
Premium Calculation
A.Own Damage Premium
Basic Premium Amount (Rs.) Deductibles Amount (Rs.)
Vehicle 3901 Voluntary Discounts Rs. (0) 0
Non Electrical Accessories 0 Anti Theft Device 0
Electrical Accessories 0 AA Membership 0
Bi Fuel Kit 0 NCB (25%) 976
Sub Total (Basic Premium) 3901 Handicapped Discount (0%) 0
Geographical Area Extension 0 Sub Total (Discounts) 976
IMT 23 Premium 0
Sub Total 3901
Add-Ons 2178 Net Own Damage Premium(A) 5103
B. Liability Premium
Basic Third Party Liability Premium (including TPPD) 3221 PA cover for Paid Driver (200000) 0
Third Party Liability For Bi-Fuel Kit 0 PA Cover (200000 Per Person) for 0 Persons 0
Third Party Liability For Geographical Area Extension 0 Compulsory PA Cover for Owner Driver (1500000) 325
Sub Total (Third Party Liability) 3221 Sub Total (PA Cover) 325
Paid Driver 50
Employees (for 0 persons) 0
Sub Total (Legal Liability) 50
Net Liability Premium(B) 3596

Total Premium 8699

IGST Premium (18%) 1566

Total GST Premium (18%) 1566

Gross Premium 10265
Add-on: Nil Depreciation
Payment Details ( MULTIPLE PAYMENT MODE )
MISP Details
MISP Name:
MISP Code: MISP Pan No:
SRILAKSHMI AUTO ENTERPRISES INDIA
TMIBASL/MISP/ABACS7516F ABACS7516F
PVT LTD
Declaration I/ we hereby declare and state that the above statements made by me/ us are true and complete. No part of it is false. I/ we desire to effect an
insurance as describe herein with Cholamandalam MS General Insurance Co. Ltd. and I/ we agree that this proposal and declarations shall be the basis of
contract between me/ us and the Cholamandalam MS General Insurance Co. Ltd. and I/ we agree to accept the policy subject to the condition specified by the
Insurance Company.
I/ we agree to receive the policy document (without enclosing the terms and conditions of policy) from the company and authorise the company to display Terms
and Conditions of the policy on its website that enables access by me.
I hereby confirm that I have mandated to place my insurance cover and have read and agreed on the terms and conditions and also give my unconditional
consent for receiving a call from TATA MOTORS INSURANCE BROKING AND ADVISORY SERVICES LTD or its affiliated entities on my number even if the number is
enrolled under NDNC/DND registry

Date: 11-Feb-2021
Proposer Signature/ Thumb Impression
INSURANCE ACT 1938, SECTION 41- PROHIBITION OF REBATES
1.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.
2.Any person making default in complying with the provisions of this section shall be liable for a penalty, which may extend to ten lakhs.