Bajaj Allianz General Insurance Co. Ltd.

Servicing Office of Insurer: OFFICE NO.402 to 408, 4th FLOOR TURQUOISE, C G ROA, D,PANCHWATI
CIRCLE,AHMEDABAD-380006, Ahmedabad, Gujarat (State Code:24) -382405, PH-- Website:
WWW.BAJAJALLIANZ.COM
PAN: AABCB5730G , GSTIN: 24AABCB5730G1Z3 Insurer's IRDA Registration Number:113
Tollfree Helpline 1800-209-5858 Email: bagichelp@bajajallianz.co.in CIN : U66010PN2000PLC015329
MISC-D PACKAGE POLICY-CERTIFICATE CUM POLICY SCHEDULE
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. TBZ/PCVBU5409283 Policy Issued On 04-MAR-2021 (17:18)

Insured Name M/S INNOVATIVE ENGINEERS
Own Damage Period 04-MAR-2021(17:18) To 03-MAR-2022(Midnight) Motor Liability Period 04-MAR-2021(17:18) To 03-MAR-2022(Midnight)

Proposal No. & Date PCVBU5409283, 04-MAR-2021

Insured Add. 310, SUPER PLAZA, SANDESH PRESS ROAD, OPP. ANAND HARI TOWER, VASTRAPUR, BODAKDEV,, AHMEDABAD , GUJARAT (State Code:24) -
380054 GSTIN - 24AAEFI6090G1ZG
Previous Insurer NA Previous Policy No. NA

Broker Details
IRDA Lic. No.: 375, CIN No.: U50300MH1997PLC149349 Category: Composite Broker, Validity: 13-MAY-20 To 12-MAY-23
Name & Add.: TATA MOTORS INSURANCE BROKING AND ADVISORY SERVICES LTD, 1ST FLOOR, AFL HOUSE, LOK BHARTI COMPLEX, MAROL MAROSHI ROAD, ANDHERI
(EAST), MUMBAI - 400 059

Make Model Sub Model Cubic Capacity Manufacturing Year Seating capacity
SIGNA 2821.K
TATA MOTORS TATA SIGNA 2821 5005 2021 2
BSVI,39W7CUM TM
Registration No. RTO Invoice Date GVW Chassis No. Engine No.
NEW AHMEDABAD 04-MAR-2021 28000 MAT797031M2A00784 5LNGDICR22AYX100256
Vehicle Type Vehicle Sub Class Built Type IDV of Chassis IDVof Body Elec. Accessories
MISC-D TRANSIT MIXER Fully Built 3,542,118 0 0
Non-Elec. Accessories CNG/LPG Kit IDV of Trailer Total IDV
0 0 0 3,542,118
Schedule of Premium (Amount in Rs.)
Own Damage Premium (A)
Basic Premium Deductibles
Vehicle 14,754 Voluntary Deductibles (0) (IMT-22A) 0
Additional GVW Loading 0 Anti Theft Device (IMT-10) 0
Trailer 0 AA Membership (IMT-8) 0
Non-Elec. Accessories 0 No Claim Bonus (0%) 0
Elec. Accessories (IMT-24) 0 Sub Total (Deductibles) 0
CNG/LPG Kit (IMT-25) 0
Sub Total (Basic Premium) 14,754
Add On Coverages (Refer Note 6) 15,940
Geographical Area Extension (IMT-1) 0
IMT -23 2,214
IMT -34 0
Overturn Cover 6199
Sub Total-Addition 39,107 Net Own Damage Premium (A) 39,107
Liability Premium (B)
Basic Third Party Liability 6,847 PA Cover For 0 Persons of Rs. 200000 Each (IMT-16) 0
Third Party Liability For Bi-Fuel Kit 0 Legal Liability For Paid Driver (IMT-28) 0
Legal Liability For Cleaner / Conductor / Helper (for 0 persons)
Third Party Liability For Geographical Area Extension 0 0
(IMT± 
Third Party Liability For IMT -34 0 Legal Liability For 0 Non Fare Paying Passenger 0
Third Party Liability For Trailer 0 Legal Liability for Employees (for 0 persons) 0
PA Cover For Owner Driver Of Rs. 0 (IMT-15) 0
PA Cover For Cleaner / Conductor / Helper 200000
120
Each (IMT-17)
PA cover for Paid Driver of Rs 200000 (IMT± 120 Net Liability Premium (B) 7087
Note: 1. In case of dishonour of the premium cheque, this document stands automatically cancelled 'ab-
initio Total Premium (A+B) 46194
2.Consolidated stamp duty paid to state exchequer. CGST (9%) 4158
3.The policy is subject to compulsory deductible of Rs.17711 IMT 21 SGST (9%) 4158
4.Geographical Area-India
5.The insurance company will display terms & conditions on its website
WWW.BAJAJALLIANZ.COM which can be Gross Premium Paid 54510
accessed by you online.
6.Add-on: NIL DEP MISC D(Nil Depreciation:15940)
*Subject to IMT Endt. Nos.& Memorandum:7,17,21,23,47
0
Payment Details : Cheque No.: 110099214714, Cheque Date: 04-MAR-2021, Bank Name: NON-CUG HDFC CCAVENUE, Bank City:
Hypothecation Details: ICICI BANK LTD - AHMEDABAD
MISP Name: GALLOPS AUTOLINK PVT LTD, MISP PAN No: AAGCG1239E, MISP Code: TMIBASL/MISP/AAGCG1239E
SAC:997134, Description of Service :Motor Vehicle Insurance Services, Place of Supply :GUJARAT(State Code:24), Receipt No/Invoice No:TBZ/PCVBU5409283
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 Motor Vehicle
Act, 1988
For & On Behalf of Bajaj Allianz General Insurance Co. Ltd.

Authorized Signatory
In case of any claim or assistance required please contact our help line at 1800 209 0060 and you may reach us at support@tatamotorsinsurancebrokers.com .
 Bajaj Allianz General Insurance Co. Ltd.
Servicing Office of Insurer: OFFICE NO.402 to 408, 4th FLOOR TURQUOISE, C G ROA, D,PANCHWATI
CIRCLE,AHMEDABAD-380006, Ahmedabad, Gujarat (State Code:24) -382405, PH-- Website:
WWW.BAJAJALLIANZ.COM
PAN: AABCB5730G , GSTIN: 24AABCB5730G1Z3 Insurer's IRDA Registration Number:113
Tollfree Helpline 1800-209-5858 Email: bagichelp@bajajallianz.co.in CIN : U66010PN2000PLC015329
MISC-D PACKAGE POLICY-CERTIFICATE CUM POLICY SCHEDULE
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. TBZ/PCVBU5409283 Policy Issued On 04-MAR-2021 (17:18)

Insured Name M/S INNOVATIVE ENGINEERS
Own Damage Period 04-MAR-2021(17:18) To 03-MAR-2022(Midnight) Motor Liability Period 04-MAR-2021(17:18) To 03-MAR-2022(Midnight)

No Claim Bonus: The insured is entitled for a No Claim Bonus (NCB) on the own damage section of the policy, if no claim is made
or pending during the preceding year(s)-20%, preceding two consecutive years-25%, preceding three consecutive years-35%,
preceding four consecutive years-45%, preceding five consecutive years-50% of NCB on OD Premium. NCB is allowed provided
the policy is renewed within 90 days of the expiry date of the previous policy.

Limitations as to use:

Driver¶s 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 Learners
license may also drive the vehicle when not used for the transport of passengers at the time of accident and that such a person
satisfies the requirements of Rule 3 of the Central Motor Vehicles Rules, 1989.

Limits of Liability Clause:Under Section II-1(i) of the policy-Death of 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 is Rs.7.5lakhs PA
Cover Under Section III for Owner-Driver is Rs. 0.

Important Notice:The insured is not indemnified if the vehicle is used or driven otherwise than in accordance with the schedule.
Any payment made by the company by reasons 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 ³AVOIDANCE OF CERTAIN TERMS & RIGHT OF
RECOVERY´For legal interpretation English version will hold good
Note: This Schedule, the attached Policy and Endorsements mentioned herein above shall read together and word or expression to
which a specific meaning has been attached in any part of this policy or of the Schedule shall bear the same meaning wherever it
may appear. Any amendments/modifications/alterations made on this system generated policy document is not valid and Company
shall not be liable for any liability whatsoever arising from such changes. Any changes required to be made in the policy once issued
would be valid and effective, only after written request is made to the Company and Company accepts the requested
amendments/modifications/alterations and records the same through separate endorsement to be issued by the company.
In Witness whereoff this policy has been signed at AHMEDABAD on 04-MAR-2021 17:18

Disclaimer: The Compulsory Personal Accident cover has not been opted in this policy as the vehicle to be insured is not owned by
an individual.
 Bajaj Allianz General Insurance Co. Ltd.
Servicing Office of Insurer: OFFICE NO.402 to 408, 4th FLOOR TURQUOISE, C G ROA, D,PANCHWATI
CIRCLE,AHMEDABAD-380006, Ahmedabad, Gujarat (State Code:24) -382405, PH-- Website:
WWW.BAJAJALLIANZ.COM
PAN: AABCB5730G , GSTIN: 24AABCB5730G1Z3 Insurer's IRDA Registration Number:113
Tollfree Helpline 1800-209-5858 Email: bagichelp@bajajallianz.co.in CIN : U66010PN2000PLC015329
MISC-D PACKAGE POLICY-CERTIFICATE CUM POLICY SCHEDULE
(FORM 51 OF THE CENTRAL MOTOR VEHICLE RULES, 1989)

Policy No. TBZ/PCVBU5409283 Policy Issued On 04-MAR-2021 (17:18)

Insured Name M/S INNOVATIVE ENGINEERS
Own Damage Period 04-MAR-2021(17:18) To 03-MAR-2022(Midnight) Motor Liability Period 04-MAR-2021(17:18) To 03-MAR-2022(Midnight)

MISC-D: ADD ON COVERS