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Proposal Preview

Bajaj Allianz General Insurance Co. Ltd.

1st Floor, GE Plaza, Airport Road, Yerawada, PUNE - ,MAHARASHTRA

Proposal Details
Proposal No. P4849900 Policy Effective Date 05-Sep-2015 Policy Expiry Date 04-Sep-2016
Proposer Details
Proposer Name Address of the Proposer
Proposer Type Vehicle class
M/S BAY DATACOM 27, NAKODA NAGAR, RAKAMPUR ROAD UDAIPUR RAJASTHAN
Corporate Private
SOLUTION PVT LTD., 313001
Vehicle Details
Invoice Date Chassis No. Engine No. Make Model & Variant CC
05-Sep-2013 MALA151ALDM215198 G3HADM189192 EONDLITE + BSIV 814
Place of Registration Registration No. Invoice Value Year of Manufacture Seating Capacity
UDAIPUR RJ-27-CD-4137 300000 2013 5
Insured Declared Value (IDV)
Vehicle Electrical Accessories Non-Electrical Accessories CNG/LPG Total IDV
210000 0 0 0 210000
Other Details
HP/Lease/Hire Pur. Agreement with Branch/Office of HP/Lease/Hire Purchaser Agreement Type
-- - --
Premium Calculation
A.Own Damage Premium Amount (Rs.) B. Liability Premium Amount (Rs.)
Basic Premium Third Party Liability
Vehicle 4149 Basic Third Party Liability Premium (including TPPD) 1468
Non Electrical Accessories 0 Sub Total (Third Party Liability) 1468
Electrical Accessories 0 PA Cover
Bi Fuel Kit 0 Compulsory PA Cover for Owner Driver (200000) 0
Sub Total (Basic Premium) 4149 PA cover for Paid Driver (200000) 0
Geographical Area Extension 0 PA Cover (100000 Per Person) for 5 Persons 250
Sub Total 4149 Sub Total (PA Cover) 250
Discounts Legal Liability
Voluntary Discounts RS. (0) 0 Paid Driver 50
Anti Theft Device 0 Employees (for 0 persons) 0
AA Membership 0 Sub Total (Legal Liability) 50
NCB (20%) 830 Net Liability Premium(B) 1768
Sub Total (Discounts) 830 Total Premium (A + B) 5087
Add-Ons 0 Service Tax (14%) 713
Net Own Damage Premium(A) 3319 Gross Premium 5800

Declaration I/ we hereby declare and state that the above statements made by me/ us are true and complete. No part of it is false. I/ we desire to effect an
insurance as describe herein with Bajaj Allianz General Insurance Co. Ltd. and I/ we agree that this proposal and declarations shall be the basis of contract
between me/ us and the Bajaj Allianz General Insurance Co. Ltd. and I/ we agree to accept the policy subject to the condition specified by the Insurance
Company.
I/ we agree to receive the policy document (without enclosing the terms and conditions of policy) from the company and authorise the company to display
Terms and Conditions of the policy on its website that enables access by me.

I hereby confirm that I have mandated Aditya Birla Insurance Brokers Ltd. to place my insurance cover and have read and agreed on the terms and conditions
and also give my unconditional consent for receiving a call from Aditya Birla Insurance Brokers or its affiliated entities on my number even if the number is
enrolled under NDNC/DND registry
Date: 24-Jul-2015

Proposer Signature
ProposalFormCompletedby:

Signature / Stamp of Dealer

INSURANCE ACT 1938, SECTION 41- 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 or 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 renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the
prospectus or tables of the insurer.
2.Any person making default in complying with the provisions of the section shall be punishable with fine, which may extend to five hundred rupees.

http://121.242.235.226/lv/Policy/VSProposalPreviewFW.aspx 24-Jul-15