CAR SHIELD - PRIVATE CAR PACKAGE POLICY

PROPOSAL FORM

FOR OFFICE USE ONLY Sales Reference :

Proposal No. :QVPN107614961

Name of Intermediary: Internal agent AG Code: AG004730

IMPORTANT(All Fields are mandatory)The details provided in this proposal form is based on the details as shared by you to AG004730 and is factually correct.
❖ Please complete the form in CAPITAL LETTERS, using a black pen. ❖ The liability of the Company does not commence until the Company has accepted the Proposal Form duly
filled in all respects and the full premium is paid. For any clarification on the cover, terms, etc., please contact Royal Sundaram. ❖ All questions in the form must be answered and
it must be signed and dated. Continue on a separate sheet if necessary and attach as part of the Proposal Form. ❖ Attach latest proof of No Claim Bonus if applicable.❖ Attach any
other information material to the risk proposed. ❖ It is an offence under the Motor Vehicles Act 1988 to make a false statement or withhold any material information for the purpose of
obtaining a Certificate of Motor Insurance.

ABOUT YOURSELF
Title Mr. Mrs. Miss Others (please specify)____________________________________________________
Name: SAJITH MON R S
First Name Middle Name Last Name
Date of birth: 19/04/1992 Are you Married? Yes No
Permanent Address:

City:
State:
Pincode:
Communication Address:

City: PUNALUR
State: KERALA Pincode:
Daytime Phone(s):
STD CODE
Mobile No.: XXXXXX3042
KYC Documents (Mandatory)
Pan FORM60 PAN No. : DOB : CKYC Number :
(For Individual Customer) (For Corporate Customer)
Driving License No Passport No Aadhar Number
Principal Officer
Name as per Aadhar Passport File No
Name as per Aadhar
Aadhar Number Registration Certificate Power of Attorney to transact business
Certificate of Incorporation and Memorandum & Article of Association
Any official document identifies partners/trustee/Foundations
Voter ID Card No NREGA Job Card
Please Specify_____________________________
Resolution of Board of directors to open account/
Mobile/Telephone Bill Bank Passbook/Account Statement
Resolution of managing body of the foundations/Association
Partnership/Trust deed
Electricity Bill Ration Card Employer Certificate
PAN allotment letter
Lease Agreement with Letter from any Public
Rent Receipt Authority or from UIDAI
Activity proof 1(for sole proprietorship only)
Activity proof 2(for sole proprietorship only)
Others Please Specify__________________ Others Please Specify__________________
E-mail: S**********5@G***L.COM
Occupation: Please tick against the applicable description, if you fall under any of the below listed categories. If you fall under more than one of the listed
titles below, please tick against all the applicable heads.
Low Risk Category
Pvt. Sector Govt. Employee Self Employed RS Employee Head of the state or Government Employee - IT or ITES
Sports Persons SeniorGovernment/judicial/Military Officer Senior Executives of State - Owned Corporations Student
Retired Employee Company Owned Others (Please Specify)
High Risk Category
Film Industry Real Estate Senior Politician Important Political Party Official House Wife Jewelry Proprietor
Chit fund Proprietor Bullion Dealers Trust,Charities,NGO with Foreign Funding Others (Please Specify)

AADHAR NUMBER
a) For Individual Customer:
Name as per Aadhar:
Aadhar Number: Date of birth of Insured: Gender:
b) For Corporate Customer:
Principal Officer
Name as per Aadhar:
Aadhar Number: Date of birth of Insured: Gender:

GST NUMBER
 Name as per
GST Certificate:
Registered
GST Number:
Address as per
GST Certificate:
District and State
as per GST Certificate:

ELECTRONIC INSURANCE ACCOUNT(EIA) NUMBER

Do you have Electronic Insurance Account Yes No (If yes please provide)

Account No:
Repository Name:
Nominee Name:

Nominee Age: Nominee Relationship:

ABOUT YOUR BANK DETAILS Please attach a copy of cancelled cheque for verification of details, remittance of claim payment/refund if any.
Bank Name: Branch:
Type of Account: Saving Current Account No:
IFSC Code: MICR Code:
Customers are requested to remit the premium by way of cheque or demand draft or credit card. Cash remittance to be avoided.
UIN - IRDAN101A0001V01202021 Car Shield - Private Car Package Policy Proposal Form
ABOUT YOUR VEHICLE Please give full details:
Date of Registration : 29/04/2019 Fastag : Date of delivery of vehicle to proposer :
Registering Authority : PUNALUR

The address is same as above: Yes No (If 'No' please give full details)
Address as per:
Registration Certificate

City: PUNALUR
State: KERALA Pincode:
Period of Insurance: From 04/12/2023 To 03/12/2024
Registration No.: KL25M7980 Engine Number: XXXXXXXX0831
Make & Model: MARUTI SUZUKI,Swift ZXI + AMT - 5 Seater Chassis Number: XXXXXXXXXXXXX9745
Year of Manufacture: 2019 Cubic Capacity : 1197 Seating Capacity: 5 (including driver)

Current Ownership: New Vehicle Used Vehicle Type of fuel: Petrol Diesel CNG LPG Others_______(PleaseSpecify)
Ownership Serial Number 1 2 3 Others________________
Vehicle mostly driven on: City roads Highways Hilly areas Village roads Airport/Airside Others

Present value of your car & accessories (Please tick as appropriate.)

For extra Electronic & For extra Non-Electrical Total 'Insured's Declared Value' of
For the Car
Electrical accessories fitted to accessories fitted to the car* the car including accessories
(Insured's Declared Value)
the car*
550,908.00 0.00 0.00 550,908.00

* If extra accessories are to be insured please provide the details below (attach sheet if necessary):

SI.No. Make Model Estimated Value

If the car is fitted with a Bi-fuel system,

please state: ADD ON
1. Is the vehicle financed? Yes No

Hire Purchase Hypothecation Lease Name and Address of finance company: ___________
2. Is the car fitted with an anti-theft device approved by Automobile Research Association of India(ARAI), Pune and the installation certified by a
recognized Automobile Association? Yes No
If 'Yes' attach full details, including copies of by purchase & installation and Automobile Association approval documents.
(Please Specify)____________________________________
3. Is there any other Safety features installed in your car? ABS Airbags Others
4. Whether the vehicle is driven by non-conventional source of power? Yes No
If 'Yes' please give details_____________________________________
5. Whether the vehicle is used for driving tuitions? Yes No
If 'Yes' please give details_____________________________________
6. Whether extension of geographical area to the following countries required ? Yes No
Bangladesh, Bhutan, Maldives, Nepal, Pakistan and Sri Lanka.
If 'Yes' state the name of the countries 1)______________________________2)_______________________________3)______________________________
7. Whether use of vehicle is limited to own premises? Yes No
8. Whether vehicle is used for Commercial purposes ? Yes No
9. Whether vehicle belongs to foreign embassy / consulate ? Yes No
10. Whether the car is certified as Vintage car by Vintage and Classic Car Club of India ? Yes No
11. Whether vehicle is designed for use of Blind/ Handicapped/ mentally challenged persons and duly endorsed as such by RTA ? Yes No
12. Whether the vehicle is fitted with fibre glass tank ? Yes No
13. Are you a member of Automobile Association of India? Yes No
If 'Yes' please state a)Name of Association______________________b)Membership No.______________________c)Date of expiry__________________

BENEFITS UNDER OUR POLICY:

• Registered owner has valid driving license Yes No
• Compulsory Personal Accident (CPA) Cover For Owner Driver Yes No
* CPA cover for owner driver will expire on 03-12-2024
If Yes, Capital Sum Insured 15 lakhs (15 lakhs to 50 Lakhs) *Multiples of Lakhs
Nomination for PA Cover Age Relationship Name of the Appointee (if Nominee is a minor)
XXXXXXXXXXX

• The Standard Coverage for Third Party Property Damage is

7,50,000/-. Do you wish to restrict the same to 6,000/- only, as per Motor Vehicles Act to avail applicable discount
UIN - IRDAN102A0001V01202021 Car Shield - Private Car Package Policy Proposal Form
 • Personal Accident Cover: For a maximum capital sum insured of 2,00,000/- covering Death and Disablement benefits for:
a) Any named person other than paid driver and/or cleaner (Please enclose the details of the persons to be insured)

Name Nominee Relationship Capital Sum Insured

b) Paid driver(s)
Yes No If 'Yes' Capital Sum Insured opted ___________________________________
c) Unnamed occupants other than the insured, his paid driver and/or cleaner, limited to the registered carrying capacity of the vehicle
Yes No If 'Yes' Capital Sum Insured opted ___________________________________
Wider legal liability to paid driver Yes No •
Legal liability for your employees Yes No (Maximum restricted to seating capacity)
If 'Yes' number of employees ____
• Additional Towing charges of 500 or 1000 or 1500 opted for over and above the limit prescribed in the policy.
If you wish to include this cover, state the limits required. 1,500
PRIVATE CAR PACKAGE POLICY PROPOSAL FORM FOR ADD-ON COVERS
These covers can be opted only for vehicles that are insured under stand-alone motor own damage policy with us.
This proposal is an addendum to the stand-alone motor own damage policy - Private car proposal form insurance of your private car.
Cover Name Cover Code Description
Depreciation Waiver Clause RSMOAC001 Would you like the Depreciation applicable on parts to be waived, in case of a partial loss claim. Yes No
In the event of Breakage of Windshield Glass, would you like to avail
Windshield Glass Clause RSMOAC002
replacement without affecting your No Claim Bonus Yes No
In the event of the vehicle meeting with an accident, you may choose one of the following compensation slabs, to
reduce any inconvenience to you:
Facilities in lieu of Spare Compensation Slabs in 0 . Per day
RSMOAC003
Car Clause
Example:
150 300 500 600 750 1,000
Vehicle Replacement Would you like to insure the vehicle for its full Invoice Price inclusive of Road Tax,Registration'and insurance
Value Plus *This add on is cost Yes No
RSMOAC012
applicable for first owner
*Plan 1 *Plan 2 *Plan 3 *Plan 4
only
*Plan 1 - FullInvoice Price.
*Plan 2 - FullInvoice Price + RoadTax
*Plan 3 - Full Invoice Price + Road Tax + Registration charges
*Plan 4 - Full Invoice Price + Road Tax and registration charges + Insurance Cost
Would you like to opt for Voluntary Deductible under your policy. Yes No
Voluntary Deductible
RSMOAC006 What limit would you like to opt for: 0
Clause
1,500 2,500 5,000 7,500 10,000 15,000
Would you like to cover your Baggage against accidental damage or loss whilst being kept in the insured
Car. Yes No
Loss Of Baggage Clause RSMOAC007 What limit would you like to opt for: ( 0)
Example:
2,500 5,000 7,500 10,000
No Claim Bonus Protector
RSMOAC008 Would you like to opt for No claim bonus protector? Yes No
(Option I)
Aggravation (Damage)
Cover Clause (Without RSMOAC009 Would you like to opt for Aggravation (Damage) Cover? Yes No
Deductible)
Would you like to opt for Tyre Cover? Yes No
If Yes, please give following details
Tyre Cover Clause RSMOAC010 Make _______________ Variant_______________
Serial Nos. for all Tyres in your vehicle including spare tyre

Key Replacement Clause

RSMOAC011 Would you like to opt for Key Replacement? Yes No
(Without Deductible)
Would you like to opt for Roadside Assistance Cover
Roadside Assistance Cover Clause? Yes No
RSAMOAC014
Clause
Please select the plan PlanA PlanB
Would you like to opt Smart Save Cover ? Yes No
Smart Save RSAMOAC016 I agree to repair my vehicle at Royal Sundaram’s TRS (Trusted repair shop). I also agree for a deductible of Rs.
3000/-, for each claim, In case I could not inform the insurer of the accident/damage to the vehicle and repaired
at non-TRS.
Would you like to opt for Pay As You Drive Cover? Yes No
Pay As You Drive RSAMOAC015 Current odometer Reading 0.00.
Please capture odometer photograph, vehicle image with registration number and upload
Hybrid Electric Car Shield* Would you like to opt for Hybrid Electric Car Shield
Applicable only for Hybrid RSAMOAC017 Cover? Yes No
Vehicle Without Deductible Deductible Rs.1500 Deductible Rs.6500
I have read the literature explaining the above covers and have opted for them after fully understanding its benefits
PREVIOUS HISTORY
1. Is the car in a roadworthy condition and free from damage? Yes No If 'No' please give details
If 'No' please give full details:__________________________________________________________________________________________________________
2. Will the vehicle be used exclusively for:
a. Private, social, domestic, pleasure & professional purposes Yes No_______________________________________________________________
b. Carriage of goods other than samples or personal baggage Yes No_______________________________________________________________
3. Name and address of the previous insurer : CHOLAMANDALAM MS GENERAL INSURANCE CO. LTD. AAAAA
4. Previous Policy No: 3362/60034295/000/00 Policy period : 29-NOV-23
5.Add on covers in previous policy: DEPRECIATIONWAIVERCOVER, ENGINEPROTECTORCOVER
6. Type of cover: Liability only cover Package cover Others (specify):______________________________________________________
7. Has any insurance company ever:
a) Declined the proposal Yes No
b) Cancelled & refused to renew Yes No
(If 'Yes' reasons there of ______________________________________________________________________________________________________________
c) Imposed special condition or excess Yes No
(If 'Yes' reasons and details there of)____________________________________________________________________________________________________
UIN - IRDAN102A0001V01202021 Car Shield - Private Car Package Policy Proposal Form
DECLARATION - NO CLAIM BONUS
Are you entitled to No Claim Bonus Yes No (If 'Yes' please submit proof from your previous insurer.)
I hereby declare that I have not made claim (or) I have made claim under my previous Policy No 3362/60034295/000/00 issued
by Cholamandalam MS General Insurance Co. Ltd.I/We declare that the rate of NCB of 50% claimed by me/us is correct and that no claim has
arisen in the expiring policy period (copy of the policy enclosed). I/We further undertake that if this declaration is found to be incorrect, all benefits
under the policy in respect of Section I of the Policy will stand forfeited.

Does the vehicle have valid Pollution Under Control (PUC) Certificate? Yes No
PUC Number: ________________________________
PUC Expiry Date: ________________________________
*"In line with the Central Motor Vehicle Act, 1989 and as per the directive of Hon'ble Supreme Court of India, it is mandated that insured must produce a valid "Pollution Under control" Certificate as and when asked by
the insurer and it is the responsibility of the insured to renew the same before expiry of the validity of the PUC certificate. Absence of Valid certificate may lead to cancellation of insurance"

PAYMENT DETAILS: Please tick (✓) payment option

Cheque/DD Number ___________________________________________ Credit Card Debit Card Payzaap Paytm Bill Desk

Bank ____________________________________________________________________________________________________________________________

NEFT RS Account No ________________________________ Transaction Ref No ___________________________________________________

Date ____________________ Amount ________________________________ Cash Amount ___________________________________

*Payment must be made favouring Royal Sundaram General Insurance Co. Limited

Authorization for electronic policy fulfilment and service communication(Please read carefully and put a check mark against each before signing)

I hereby consent that the proposal status,policy details and renewal reminders may be sent to me by email and SMS.

I hereby consent to and authorize Royal Sundaram General Insurance Co.Limited(Company)to make welcome calls,service calls or any
other communication (electronic or otherwise)with respect to the proposed or existing policy of Company from time to time.

We hereby unconditionally allow the Company to share all my / our information being collected in this proposal form or through telephonic / email / web-
inputs means or other means, as updated from time to time within group entities

I hereby authorize Royal Sundaram General Insurance Co. Limited to upload/download the required KYC documents pertaining to me in/from the CKYC
portal

PREMIUM COMPUTATION SUMMARY

Basic OD Premium 10,547.00 Basic TP 3,416.00

Other OD Covers Other TP Covers 315
75
Smart Save 0.00 Total TP Premium 3,731.00
NCB( 50 %) 5,311.00 Total OD + TP Premium 14,741.80
Add on Premium 5699.8 IGST : 2,653.56
Total OD Premium 11,010.80 Premium inclusive of GST 17,395.56

COMPULSORY DEDUCTIBLE
The Policy excludes the first portion of each claim for loss or damage to the Motor Car. The amount of the Deductible is 1,000/- for cars with cubic capacity not
exceeding 1500cc and 2,000/- for cars with cubic capacity exceeding 1500cc .
ABOUT OUR POLICY
Usage of the car : The Policy covers use of the car for social, domestic and pleasure purposes and also for professional purposes of the Insured or use by the
Insured's employees for such purposes. The Policy does not cover use for hire or reward, racing, pace making, reliability trial, speed testing, the carriage of goods
(other than samples) in connection with professional purpose or use for any purpose in connection with the Motor Trade.
DECLARATION
Before signing the Declaration check your answers carefully, particularly if this Proposal Form was completed by another person on your behalf. I/we declare that
to the best of my/our knowledge and belief the answers given are true and all material information has been disclosed. I/we agree that if any answers have been
completed by any other person such person shall for that purpose be regarded as my/our agent and acting on my/our behalf and not the agent of Royal Sundaram
General Insurance Co. Limited.
I/we declare that this Proposal Form is for insurance in the normal terms and conditions of the Insurer's Policy and shall be incorporated in and form part of the
insurance contract. If any additions or alterations are carried out after the submission of this proposal form then the same would be conveyed to the Insurers
immediately. I / We agree to download the policy terms, conditions, exceptions and applicable endorsements by logging on to the website www.royalsundaram.in
(or) mail to customer.services@royalsundaram.in to obtain a hard copy of the same.
Date: 04/12/2023
Place: PUNALUR *Signature of the proposer (Vehicle Owner)
This proposal form is electronically signed by the proposer by way of
validating One Time Password(OTP) send to his/her registered mobile number
Section - 41 of Insurance Act, 1938 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 continuing the policy accept any rebate except such rebate as may be allowed in accordance with the published prospectus or tables of the Insurer.
2. If any person fails to comply with sub-regulation (1) above, he shall be liable to payment of a fine which may extend to Ten Lakh Rupees.
Insurance is the subject matter of solicitation.

Dear Customer, Thank you for choosing Royal Sundaram as the Insurer of your vehicle.We are delighted to have you as our customer. Please find enclosed Private
Car Quote No. QVPN107614961 which has been issued based on the details submitted to us by the Insurance Broker - Internal agent. The details provided in this
proposal form is based on the details as shared by you to Internal agent and is factually correct.

Royal Sundaram General Insurance Co. Limited

(Formerly known as Royal Sundaram Alliance Insurance Company Limited)
Corporate Office:Vishranthi Melaram Towers, No.2/319, Rajiv Gandhi Salai (OMR), Karapakkam, Chennai-600097.
Registered Office: 21, Patullos Road, Chennai - 600 002
Royal Sundaram IRDAI Registration No.102 | CIN:U67200TN2000PLC045611

✆ 1860 425 0000 | 1860 258 0000 ✉ customer.services@royalsundaram.in | www.royalsundaram.in

PR18166/NOV18/V1

UIN - IRDAN102A0001V01202021 Car Shield - Private Car Package Policy Proposal Form