HDFC ERGO General Insurance Company Limited

Proposal Form cum Transcript Letter For Private Car Policy - Bundled
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Vehicle Details Proposal Details

Make TOYOTA KIRLOSKAR |Proposal No 202212230092060

Model FORTUNER-2.8 LEGENDER 4x2 AT Period of From 23 Dec, 2022 16:49 hrs
|Registration No NEW Insurance To 22 Dec, 2025 23:59
RTO NOIDA GAUTAM BUDDHA NAGAR Issuance Date 26 Dec 2022
2302205135566600000
Chassis No. MBJAA3GS400579190 Invoice No. 205135566600000
MIS CLEARPACKAUTOMATION PVT LTD Cubic Capacity 2755 Seats 7 Customer ld 100000668289
|PLOT NO-10, ECOTECH-1 EXTN, GREATER NOIDA GAUTAM Year of Manufacture 2022 Body Type SUV
BUDDHA NAGAR GAUTAM BUDDHA NAGAR - 201308
UTTAR PRADESH - Tel. 9205276368 Engine No. 1GDA692864
Odometer reading:
Payment Details : HDFC POS_ CD
Email ID : dhamendra.singh@shrinkpackaging.net GSTIN :09AADCK5741J1ZA

Policy Year Policy Period For the Vehicle () Trailer (R) Non Electrical Acc. () Electrical Acc. (3)CNGILPG Kit (8) Total IDV (2)
Year 1 From 23/12/2022 To 22/12/2023 4067900 4067900

Own Damage Policy Period Liability Policy Period

From Date &Time 23/12/2022 16:49 hrs To Date & Time 22/12/2323 Midnight From Date & Time 23/12/2022 16:49 hrs ITo Date & Time 22/12/2025 Midnight
Premium Details ()
Cwn Damage Premium(a) (3) Liability Premium(b) (8)
24596
Ov:n Damage 139936 Basic Third Party Liability
139936 150
Basic Premium LL to Paid Driver (IMT-28)
97255 PA Cover for Un-Named Persons of 40000 Each (for 7 Persons) IMT-16) 420
Less: others
25166
Total· Less 97255 Net Liability Premium (b)
83434
Add on Coverages Total Package Premium (atb) 15018
Zero Deurecislion RDAN125A0021V01201415) 5288 Integrated Tar 18%
Emergency ÄsS0slance (|RDAN125A0016V01201314) 350
Engine ani Gear box Prciection (|RDAN12540004VC1201213) 2034
No Clam Bonus Protection (1RDAFiHDFCMotorAdd-ons/09-10:2) 2034
Cost of Consumables (RDAN: 25A0003V01201213) 2034
Reun lo lInvo:ce (1RDAN125-0013V01201213; 2848
Emergency Assistencs ider {(RDAN125A0016V01201314) 999
Total - Add on 15587
58268 Total Premium 98452
Net Own Darmage Premium (a)
Geographical Area |India JCompulsory Deductible(IMT-22) 2,000 Voluntary Deductible (IMT-22A)
Hypothecated(|MT-7) with:HDFC BANK LTD Noida
Agent Name :HDFC BANK LTD Agent Code :201587086428 Tel No. :91-22-61606161 POSP PAN No.: KQEPKO101E
Anti rebate clause

Prohibition of Rebates (Section 41 of Insurance Act, 1938 as amended) :1. No person shall alloworoffer to allow, either directly or indirecly,as an inducerment lo any person to lake out or renew cr
continue an insurance in respect of any kind of risk relat.ng 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, ncr shallany
person taking out or renewing or contnuing a polcy accept any rebate except such rebate as may be allowed in accordance with the published prospectuses or tables of the insurer. provided that acceplance by an
insurance agent of commission in connection with a policy of lie insurance taken out by himself on his own lfe shall not be deemed to be acceplance of a rebate of premium within the meaning of this sub-sectien if
at the time cf such acceptance he insurance ageni salisf1es the prcscribed conditions establshing that he is a bona fide insurance agent employed by the insurer.
person making defsult in conglying with the provsions cf this secton shallbe liable for apenalty which may extend to ten lakh rupees.
Terms and Conditions
hereby declare that the InsUred erson(s) isted in Proposal torm will abide to the following T&C.
11 i/We hereby declare that the statements made hy mei:s arA tniA fn the hest nf my iour knoleriga and helief and l/we hereby agree that this declaration shall fom the basis of the contracl betwecn meUs aNO
HDFCERGO General Insurance Company Limited.
2) IWe also declare that, if any additions or alterations are carried out after the subission of this proposal form, then the same would be conveyed to the insurers immediately.
3 IWe slso shallendeavor to procure the renewal notice and pass on the sanm to HDFC ERGO General Insurance itnmediately upon the receipt of such renewal notice.
4) Any person who, knowingly and wth intent to def:aud the Insurance Copany or other persons. files a proposal for insurance containing any false information, or conceals for the purpose f nisteadiig
information concerning any fact matenal thereto, commits aíraudulent act which will render the policy voidable at the Company's sole discrelion and result in adenial of insurarnce benefits.
GSTIN : Motor(Cornprehensive and TP).For policy issued in the name of corporate entiy (proprietor. HUF. partnersthip, private company etc), GSTIN is printed on the policy. basis the delails provided during rolicy
issuance.For any subsequEnt changes or additon (:e. i GSTIN not entered at the time of policy issuance )on policy schedule. changes shall be caried out through fresh policy issuance with prospechve efect.
5:1 understand ihe Proposal No. 202212230092060 is issued to me basis on above information.
6) lt hes been declared by you that you are not a Poltically Exposed Person and the source of funds to purchase this policy are from salary:business income.
Transcript Declaration : In case disagreement or objection or any other changes with respect to information and contents mentioned herein above, please contact our lollfree number and register vour ob;ectons:
changes !disaoreement to the conte nt of this transcrip! or you may also send us email or writen corespondence at the following details within aperiod of 15 days from date of your receipt ot this transcnpi along

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN :IRDAN125RPO008VO1201819. Customer Service Address:D301.3rd Floor,
CIN: U66030MH2007PLC177117. Registered &Corporate Office: 1st Floor, HDFC House. Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumtbai - 400 078.
165/166 Backbay Reclamation, H.T.Parekh Marg. Churchgate, Mumbai -400 020. Customer Service No: +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com