LIBERTY GENERAL INSURANCE LIMITED

PRIVATE CAR POLICY - BUNDLED COVER

CERTIFICATE OF INSURANCE CUM POLICY SCHEDULE
IMPORTANT - 1) The Validity of this Certificate of Insurance cum Schedule is subject to realization of the premium cheque.
2) No Claim Bonus will only be allowed provided the Policy is renewed within 90 days of the expiry date of the previous policy.
3) In the event of misrepresentation, fraud or non-disclosure of material facts, the company reserves the right to cancel the policy from inception.
Policy Issuing Office 10th Floor, Tower A Peninsula Business Park, Ganpath Rao Kadam Marg Lower Parel MUMBAI MAHARASHTRA - 400013 Phone: +91 22 6700 1313
Fax: +91 22 6700 1606
Policy Servicing Office 10th floor, Tower A, Peninsula Business Park, Ganpat Rao Kadam Marg, Lower Parel, MUMBAI MAHARASHTRA 400013 PH: +91 22 67001313 FAX:
+91 0 0
BaCo_LOGO Period of insurance
(Section I - Own Damage) From 12:25 Hrs of 21/10/2021 To Midnight of
20/10/2022
(Section II - Liability) From 12:25 Hrs of 21/10/2021 To Midnight of 20/10/2024
(Section III - PA OWNER-DRIVER ) From 12:25 Hrs of 21/10/2021 To Midnight
Policy No 2011-100000-21-7800895-00-000 of 20/10/2022
Geographical Area India
Insured ABHISHEK TRIPATHI
Address LUCKNOW
LUCKNOW UTTAR PRADESH 226001 Policy Issued On 21/10/2021
Covernote No/Ecovernote No 201110000021780089500000
Contact Number (M) +917007090486 Customer ID 4108129044 Covernote Date
GSTIN No/State Name NA/UTTAR PRADESH RTO Location MUMBAI Zone Zone-A
UIN CODES IRDAN150RP0004V01201819
Customer UIN

Agent Name PolicyBazaar Insurance WA Pvt Ltd

Agent Code IMD1046412 Agent Contact No 8800556374
INSURED MOTOR VEHICLE DETAILS AND PREMIUM COMPUTATION
Licensed Carrying
Registration Year of Trailer Trailer Chassis Trailer
Engine No. Chassis No. Make/Model/Type of Body CC/HP/GVW capacity including
Mark & No. Manufacture Driver
Registration No. No. IDV

NEW 2021 434R54T5 QWE345XDS MARUTI/SWIFT VXI/2 1298 5

Section I - OWN DAMAGE (A) Section II - LIABILITY (B)
Own Damage Premium on vehicle and accessories Third Party Premium
Basic Cover Basic Cover

Basic - OD 17,275.64 Basic - TP 9,534.00

TOTAL OWN-DAMAGE PREMIUM (A) 17,275.64 TOTAL LIABILITY PREMIUM (B) 9,534.00

Section I - ADD ON COVERS (C) Section III- PA OWNER-DRIVER (D)

Roadside Assistance IRDAN150RP0004V01201819/A0026V01201819 249.00 PA Owner Driver (1 Year From Date of Inception) 375.00

TOTAL ADD-ON COVER PREMIUM (C) 249.00 Net Premium(A+B+C+D) Taxable Value 27,434.00

IGST(18% - UTTAR PRADESH) 4,938.12

TOTAL POLICY PREMIUM 32,372.00

Hire Purchase/ Lease /Hypothecated with NA

LIMITATION AS TO USE : The Policy covers use of vehicle for any purpose other than: a) Hire or Reward b)Carriage of goods(other than sample of
personal luggage) c) Organized racing d)Pace Making e)Speed Testing f)Reliability Trial g)Use in connection with motor trade.
DRIVERS CLAUSE
Persons or Classes of Person 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 Vehicle Rules, 1989.
LIMITS OF LIABILITY
Deductible Compulsory Deductible: Rs 1000/-, Under Section II-I (i) such amount necessary to Under Section II-I 750,000.00 P.A. cover for 1500000
under Voluntary Deductible: Rs 0/-, of the policy (Death of meet the requirements of (ii) of the policy owner- Driver
section - I Imposed Excess : Rs 0/-. or bodily injury): motor vechile Act,1988 (Damage to third under section
Additional excess : Rs /- party property) III : CSI
Theft excess : Rs /-
Subject to I.M.T Endorsement Nos. AD05,IMT 22
NOMINATION DETAILS

Name of the Nominee Relationship with Insured Name of Appointee (if nominee is minor) Relationship with the Nominee

I/We hereby certify that the Policy to which this Certificate relates as well as this Certificate of Insurance are issued in accordance with the provisions of chapter X and chapter
XI of M.V. Act, 1988.
In witness whereof this Policy has been signed at Mumbai on 21/10/2021
Receipt No: 10210000021100061689
In case of Claims, Please contact us at : Toll Free No - 18002665844,
email id - care@libertyinsurance.in
Date of Issue : 21/10/2021
Place : Mumbai

Consolidated Stamp duty has been paid as per letter of Authorization no. For Liberty General Insurance Limited
CSD/305/2021/1234 Dated 26/03/2021 issued by Main Stamp Office, Mumbai. ** Not
Applicable for the State of Jammu & Kashmir.
Invoice No. 2721011000530032
Branch GSTIN No : 27AABCL9950A1ZL
SAC Code : 997134; Description of Service : General
Insurance Service; Place of Supply : UTTAR PRADESH/09
IRDA Regn. No. 150
CIN No. U66000MH2010PLC209656
Tax is not payable under reverse charge by the recipient Authorised Signatory

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
% DSUnknown
q
1G
1g
0.1 0 0 0.1 9 0 cm
0 J 0 j 4 M []0 d
1i
0g
313 292 m
313 404 325 453 432 529 c
478 561 504 597 504 645 c
504 736 440 760 391 760 c
286 760 271 681 265 626 c
265 625 l
100 625 l
100 828 253 898 381 898 c
451 898 679 878 679 650 c
679 555 628 499 538 435 c
488 399 467 376 467 292 c
313 292 l
h
308 214 170 -164 re
f
0.44 G
1.2 w
1 1 0.4 rg
287 318 m
287 430 299 479 406 555 c
451 587 478 623 478 671 c

appearing in the certificate in order to comply with the Motor Vehicle Act, 1988 is recoverable from the Insured. See the clause headed "AVOIDANCE OF CERTAIN TERMS AND
478 762 414 786 365 786 c
260 786 245 707 239 652 c
239 651 l
74 651 l
74 854 227 924 355 924 c
425 924 653 904 653 676 c
653 581 602 525 512 461 c
462 425 441 402 441 318 c
287 318 l
h
282 240 170 -164 re
B
Q

RIGHT OF RECOVERY". For legal interpretation English version will be good. Digitally signed by: SACHIN JOSHI
Date: 2021-10-21 13:54:24 IST