Gopal Singh

CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED
Registered Office: 2nd Floor "DARE HOUSE", 2, N.S.C. Bose Road, Chennai ‐ 600 001.
Toll free: 1800 208 5544, T: +91(0) 44 4044 5400, F: +91(0) 44 4044 5550
E‐mail: customercare@cholams.murugappa.com; website: cholainsurance.com
IRDAI Regn. No.123 PAN AABCC6633K CIN: U66030TN2001PLC047977
Motor Two ‐ Wheelers Policy Bundled ‐ Schedule cum Certificate of Insurance
[UIN: IRDAN123RP0003V02202122]
Policy cum Certificate Number: 3397/03765488/000/00
Name & Registration Address:
Name & Communication Address: GOPAL SINGH
C/O GURVESH S/O SALEKH CHAND R/O‐ NARSAN KALAN
C/O GURVESH S/O SALEKH CHAND R/O‐ NARSAN KALAN ROORKEE
ROORKEE
,GURKUL NARSAN S.O,HARIDWAR,UTTARAKHAND,PIN ‐ 247670
,GURKUL NARSAN S.O,HARIDWAR,UTTARAKHAND PIN ‐
Mobile: 7505803981 |Landline: 91‐ |Mail:
247670
YASHHONDANARSAN@GMAIL.COM
Mobile: 7505803981,Landline: 91‐
GSTIN: Customer ID: 101912006459 Geographical Area: India Business / Profession: Individual
Period of Insurance for OD(Own Damage) : From 08/07/2022 15:39 hours to midnight on 07/07/2023
Period of Insurance for TP(Third Party) : From 08/07/2022 15:39 hours to midnight on 07/07/2027
Period of Insurance for CPA(Compulsory Personal Accident Owner Driver):
From 08/07/2022 15:39 hours to midnight on 07/07/2027
PARTICULARS OF VEHICLE INSURED
Registration
Date of Registration 08/07/2022 Place of Registration ROORKEE NEW
Mark
Make HONDA Model ACTIVA 6G Variant DLX BS VI
Year of Manufacture 2022 Type of Body SOLO Fuel Used PETROL
Cubic Capacity 110 Engine No. JF91EG7137963 Chassis No. ME4JF91ACNG137527
K.Watts 0 Licensed passenger Carrying Capacity 2
Total Seating Capacity Including Driver 2 Driver 0
Vehicle Colour ‐
IDV (Insured's Declared Value)
1st Year: 2nd Year: 3rd Year: 4th Year: 5th Year:
IDV ( .)
67,004 0 0 0 0
Non‐Electrical Electrical/Electronic
For Vehicle ( .) 67,004 0 0
Accessories ( .) Accessories ( .)
Value of CNG/LPG Kit ( .) 0 Total Value ( .) 67,004 Contract No: ‐
A1.OWN DAMAGE
Sum
No.of 1st year 2nd year 3rd year 4th year 5th year Total
Insured IMT Premium Premium Premium Premium Premium Premium
Persons
( .) ( .) ( .) ( .) ( .) ( .) ( .)
Basic OD 67,004.00 1123 0* 0* 0* 0* 1123
Electrical or Electronic Accessories 24 0 0 0 0 0 0
Non Electrical or Electronic Accessories 0 0 0 0 0 0
TOTAL 1123 0 0 0 0 1123
Less:
Bonus Discount(%) 0
Refer website for policy wordings and detailed Terms & Conditions, Exclusions and the Ombudsman list.
Call Toll Free: 1800 208 5544 | SMS CHOLA to 56677 | Visit www.cholainsurance.com | Email customercare@cholams.murugappa.com
Disclaimer: The company may contact you for matters related to your policy or to provide details of products & services offered. To opt out from the facility, please register
under Do Not Call section on our website.

Toll free: 1800 208 5544, T: +91(0) 44 4044 5400, F: +91(0) 44 4044 5550
[UIN: IRDAN123RP0003V02202122]
Experience Based Discount(%) 505 0 0 0 0 505
GST Discount(5%) 56 0 0 0 0 56
TOTAL PREMIUM(A1) 562 0 0 0 0 562
A2.ADD‐ON COVERS
Sum
Insured Options Premium Premium Premium Premium Premium Premium
persons
( .) ( .) ( .) ( .) .) ( .) ( .)
Full Depreciation Waiver Cover Bundled 201 0 0 0 0 201

TOTAL PREMIUM(A2) 201 0 0 0 0 201
B.LIABILITY(TP)
Sum
Persons
( .) ( .) ( .) ( .) ( .) ( .) ( .)
Basic TP 771 770 770 770 770 3851
Paid Driver 0 0 0 0 0 0
TPPD Discount 20 250.00
TOTAL PREMIUM(B) 771 770 770 770 770 3601

C.PERSONAL ACCIDENT COVERS
Sum 1st year 2nd year 3rd year 4th year 5th year Total

No.of
Persons
( .) ( .) ( .) ( .) .) ( .) ( .)
Compulsory Personal Accident(CPA)cover
0 0 0* 0* 0* 0* 0
for Owner‐Driver
Unnamed PA cover 0 16 0 0 0 0 0 0
TOTAL PREMIUM(C) 0 0 0 0 0 0
TOTAL (A1+A2+B+C) 1534 770 770 770 770 4364
CGST (0%)( .) 0
SGST (0%)( .) 0
IGST (18%)( .) 786
TOTAL CONSIDERATION AFTER TAX 5150
* This refers to NIL OD coverage for the period and NIL CPA coverage for the period
LIMITATIONS AS TO USE: The Policy covers use of the vehicle for any purpose other than: a) Hire or Reward b) Carriage of goods (Other than samples or personal
luggage) in connection with any trade or business or use for any purpose in connection with motor trade c) Organized racing d) Pace making e) Speed Testing f)
Reliability Trial g) Tuition h) Use only with side car if attached.
DRIVER CLAUSE: Any person including 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 Vehicles Rules 1989.
LIMITS OF LIABILITY: Under Section II ‐ 1(i) of the Policy ‐ Death or bodily injury such amount as is necessary to meet the requirements of the Motor Vehicle Act,
1988. Under Section II ‐ 1(ii) of the Policy ‐ Damage to Third Party Property ‐ . 6,000 P.A. Cover for the Owner cum Driver Under Section IV (CSI)‐ .0

Toll free: 1800 208 5544, T: +91(0) 44 4044 5400, F: +91(0) 44 4044 5550
[UIN: IRDAN123RP0003V02202122]
Compulsory Deductibles Under Section 1: Rs.100 Per claim
Voluntary deductibles under Section 1 Rs.0 Per claim
Subject to I.M.T. Endt. Nos. and Memorandum: 22,7 .
Coverage Under this policy is subject to realisation of premium cheque(s). Incase of dishonor of cheque(s), no separate intimation will be given and the policy
stands cancelled from inception.
Product Plan: Two Wheeler package policy with chosen Add‐on covers.
Applicable benefits:
The policy wording with detailed terms, conditions, warranties, exclusions and the list of Ombudsman details are available on our website
www.cholainsurance.com.
Date and Signature of the proposal 08/07/2022. In witness where of this policy has been signed in lieu of the Cover Note No.:‐ Date:‐
Warranties: Warranted that NCB under this Policy is based on representation regarding NCB and absence of claim under the previous Policy.If the information be
found incorrect or false in any aspect,this Policy shall be void ab initio and no benefit shall be payable by the company.
As per GR 36A,PA for Owner driver refers to the Owner of the insured vehicle holding an effective driving licence.
Sl.No. Name of the Nominee Relationship Age of the Nominee %age of share Name of the Guardian Guardian relationship with Nominee

* This refers to NIL OD coverage for the period.
No Claim Bonus will only be allowed provided the policy is renewed within 90 days of the expiry date of the previous policy. No claim bonus is applicable at the
end of the policy period.
Note: The Policy Schedule cum Certificate of Insurance is an important document issued based on your declaration. We request you to verify the details and
ensure that everything is in order. In case of any discrepancies, please contact us within 15 days from the date of issuance of policy.
Financier Name & Address: SHRI RAM CITY UNION FINANCE LTD,ROORKEE
Intermediary Name: GIRNAR INSURANCE BROKERS PRIVATE LIMITED
Code: 202077721536 Contact No: 7551196989
For Cholamandalam MS General Insurance Company Limited.
@CholaSign1
% 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
Receipt
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
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
Place: CHENNAI
282 240 170 -164 re
B
Q
No: Digitally signed by:

KANCHIPURAM
Receipt SRIDHAR HARISH
Date:08/07/2022
Date:
Duly Constituted Authority
Business Location: CANNAUGHT PLACE
NO. 39, SECOND FLOOR, SAMYAK TOWER,OPP. METRO PILLAR NO. 120,
PUSA ROAD, NEW DELHI ‐ 110 005

KAROL BAGH S.O CENTRAL DELHI DELHI
GST Invoice No: 3397383821418 | GSTIN: 07AABCC6633K5ZH | SAC Code:997134 | SAC Description: Motor vehicle insurance services
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 the Motor Vehicles Act, 1988.
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 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 RIGHT OF RECOVERY".
For Legal interpretation, English version will hold good.
Note: UIN for the add‐on covers availed under this policy are as mentioned.
Whether tax is payable under reverse charge basis - No.
Cholamandalam MS General Insurance Company Ltd.
Regd.&Head Office:Dare House,2nd Floor,No.2,N.S.C Bose Road, Chennai‐600001, India
Product Name : Motor Two - Wheelers Policy Bundled
UIN : IRDAN123RP0017V01201819
UIN for Add-on Covers
Sl.No Add on cover Name IRDA BAP UIN UIN

1 Full Depreciation Waiver Cover Bundled IRDAN123RA0046201819
2 Full Depreciation Waiver Cover for four years IRDAN123RA0046201819
3 Full Depreciation Waiver Cover for three years IRDAN123RA0046201819

Toll free: 1800 208 5544, T: +91(0) 44 4044 5400, F: +91(0) 44 4044 5550
[UIN: IRDAN123RP0003V02202122]
4 Full Depreciation Waiver Cover for five years IRDAN123RA0079201819
5 Full Depreciation Waiver Cover for two years IRDAN123RA0046201819

Gopal Singh

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Basic OD 67,004.00 1123 0* 0* 0* 0* 1123

Full Depreciation Waiver Cover Bundled 201 0 0 0 0 201

Basic TP 771 770 770 770 770 3851

TOTAL PREMIUM(B) 771 770 770 770 770 3601

Sum 1st year 2nd year 3rd year 4th year 5th year Total

No: Digitally signed by:

Sl.No Add on cover Name IRDA BAP UIN UIN

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